Deep Venous Thrombosis
August 17, 2010
By: Dr. Piyush Gupta (Premvilas Das)

Dear Readers,

This month I received a question concerning Deep Venous Thrombosis (DVT henceforth) or blood clots in the legs. So let’s look at this issue closely:

1. What is DVT?

As the name suggests, it refers to having abnormal clotting of blood leading to formation of blood clots or thrombus in the deep veins of the legs.

There are superficial veins in the legs which do not have the potential for developing clots. They are thinner and more superficial and can get inflamed or infected, but very infrequently form blood clots.

There are deeper veins in the legs which are thicker and are responsible for bringing the blood back from the lower extremities to the heart and are prone to developing clots under certain conditions (discussed separately). Remember, it is the deep veins in the legs which have the potential to form blood clots and not the arteries.

Arterial blood clots in legs are extremely rare and it is a limb- or life- threatening emergency. It happens under such rare circumstances that to discuss it is beyond the scope of this topic.

2. Why will anyone develop DVT?

Yes, that’s a good question. Normally deep veins in the legs serve as conduits for returning blood from the legs to the heart for circulation and in normal conditions these deep veins do their jobs very efficiently and effectively. However, certain conditions can impair the ability of these veins to do their job and some conditions predispose the blood to becoming excessively thick, increasing its viscosity and making it prone to develop clots.

Let’s review these conditions:

1. Morbid Obesity and sedentary life style:

Sitting in one position for a long time, as in the case of long distance flights, for example. For normal venous circulation, the deep veins of the legs need help from the calf muscles to push the blood upwards. People who are sedentary have a higher risk of developing clots. Also, it is advisable to periodically stretch, move your lower extremities and walk in long distance car and plane rides.

2. Post-surgery period, especially knee or hip surgeries:

Any surgery increases the risk for thrombus, especially lower extremity surgeries. Your surgeon will use a blood thinner in the perioperative period to ensure that clots don’t develop. It is also important that you undergo rehab and physical therapy as soon as possible in the post-surgery period.

3. There are certain genetic conditions which can predispose one to blood clots, especially Factor 5 mutation and absence of certain anticoagulants (blood clotting inhibitors) in the blood. . There are blood tests which can detect these. Your physician can order blood tests.

4. Lower extremity trauma: Any orthopedic injury to the lower extremity predisposes one to blood clots in the legs. Again, prompt return to mobilization and physical therapy is the key.

5. Malignancy: Cancer of any kind predisposes one to having blood clots. Ovarian, colon and pancreatic cancers are the worst offenders in this regard. Any cancers involving the pelvis, groin and lower extremities will invariably lead to blood clots in the legs.

6. Use of oral contraceptives or hormone replacement therapy: Both of these medications are a very common source of blood clots in the legs. Most physicians prescribe the lowest possible dose of these medications. People who use these drugs should refrain from smoking as smoking multiplies the risk.

7. Pregnancy or postpartum status

8. Stroke: Stroke leading to weakness or paralysis of the limbs is an independent risk factor in developing venous thrombosis.

9. Age>75

What are the symptoms of DVT and how can one know when to seek medical attention?

Most common symptoms are immediate onset of pain, swelling or discoloration of the leg or any combination of these three. It is important to remember there are many other conditions which can cause symptoms like DVT.

• Calf injury during running or sports
• Muscle strain, tear, or twisting injury to the leg
• Cellulitis — Superficial infection of the skin of lower extremities
• Gout: A condition causing deposition of uric acid in joints of lower extremities
• Varicose veins or venous insufficiency
• Knee abnormality
• Previous lower extremity surgery
• Side effects of BP medications like Norvasc.
  

Please Note: Not everyone with swelling in the legs should be alarmed that they have DVT. If you are experiencing sudden onset of swelling and pain in your lower leg, you should immediately go to the nearest emergency room or consult your family physician.

How can my doctor diagnose my condition?

The gold standard is a Doppler ultrasound of legs which can be performed non-invasively and efficiently in any emergency room and you will know in half hour or so whether you have actual thrombosis or something else.

Non-compressibility of lower extremity veins on an ultrasound will alert your physician about DVT.

How can I be treated?

If you indeed have DVT, your doctor will take a comprehensive history, order a battery of blood tests, and do further investigations to rule out the possibility of cancer. He will start you on a medication called warfarin, or Coumadin, and adjust your these medication levels to goal by drawing your blood periodically.

If this is your first episode and no cause could be ascertained, then you will be on warfarin for 6 months, but if it happens again, you might have to be on this medication for the rest of your life and get regular blood work done. Your physician might also discuss the use of a filter in your large veins to prevent the clot from traveling upstream.

What if I don’t treat it?

The thrombus in the leg can potentially travel to your lungs causing a blood clot in the lungs. This causes chest pain and shortness of breath and can be life threatening! It can also extend in the leg causing significant discomfort, pain and swelling.

Do my family members have the risk of developing blood clots if I have the blood clot?

Only if you have one of the genetic disorders. Your physician will advise you about this and your family members might have to be tested.

What advise will you give me to prevent blood clots?

Best advise is to lose weight (yeah right), exercise regularly and be as physically active as you can. Avoid smoking, and speak to your physician before any surgical procedure about post-operative rehabilitation and physical therapy. If you know anyone with cancer, be doubly sure to discuss this with them and their oncologist.

Back to top

Gastro Esophageal Reflux Disease (GERD)

June, 2009

Hare Krishna Devotees,

Please accept my humble obeisances. All glories to Srila Prabhupada.

I thought of writing about a very common medical problem called gastro esophageal reflux disease or GERD. Many devotees suffer from it and this can become quite a problem if not treated properly and prevented by appropriate means. So, let’s start:

What is GERD?

GERD also called acid reflux or acid regurgitation is a medical condition in which the contents of the stomach along with the acid in the stomach regurgitate into the esophagus. Esophagus is a tube which connects your mouth with the stomach. There is a sphincter or a valve called the lower esophageal sphincter (LES) which prevents the food to come up from the stomach into the esophagus. GERD happens when the LES opens spontaneously or fails to close completely causing the acidic contents of stomach to regurgitate back into the esophagus. People of all ages can have GERD.

What are the symptoms of GERD?

The main symptom is frequent heartburn or a burning sensation in your chest, behind your breast or in your stomach. This happens when the refluxed acidic food touches the lining of esophagus. You might get frequent belching or an acidic taste in your mouth. Sometimes it’s called water brash. Acid in the esophagus can also cause spasm of the bronchus causing cough or asthma-like symptoms, wheezing etc. Patients who have asthma frequently report that there asthma symptoms get worse with GERD. Sometimes you may get a persistent cough at night because of GERD.

So what causes GERD?

Research has shown that in patients with GERD, LES relaxes while the food is being digested in the stomach or the esophagus is contracting. Also, some patients can have a hiatal hernia. Hiatal hernia happens when the upper part of the stomach and the LES move upward and above the diaphragm, the muscle wall that separates the chest from the stomach. Normally, the diaphragm assists the LES in keeping the food down but if the LES and upper part of the stomach moves upward, food can reflux more easily. You may have a hiatal hernia without any symptoms. Other factors which predispose one for GERD are:

1. Obesity
2. Pregnancy
3. Smoking

But the most important cause of GERD is dietary: There are certain foods which worsen acid reflux by causing the LES to relax:

1. Citrus fruits like lemons, oranges
2. Spicy foods
3. Foods rich in butter, like cakes, cookies etc, also all fried and fatty foods
4. Tomato containing foods like pizza, spaghetti, pasta sauce, chili, salsa
5. Chocolates
6. Drinks with caffeine and alcohol
7. Mint or chewing gum

In addition to this, heavy meals, meals late at night or lying down after eating predispose one to acid reflux.

So, how do we treat GERD or acid reflux?

1. If you smoke, stop. Generally this is not a issue with devotees.
2. Avoid foods which worsen reflux especially fatty, fried foods and spicy foods. Avoid all soda pop and carbonated beverages.
3. Loose weight (yeah right!!!!)
4. Wear loose fitting clothes
5. Avoid lying down for 3 hours after a meal
6. Raise the head of the bed, just using extra pillows will not help, you might have to put wooden blocks under the head end of the bed to give a 15-20 degree elevation.
7. Eat small balanced meals.
8. Medications

Medications for GERD are divided into three categories:

Antacids: like Maalox, Mylanta, Rolaids, TUMS or Alka Stelzer, they provide immediate relief and are effective, but they can have side effects like constipation or diarrhea.

H2 blockers like Pepsi, Zantac. They are available in over-the-counter (OTC) and prescription formulations. They are effective in about half the cases of acid reflux

Proton pump inhibitors: They are the strongest and most effective medications for acid reflux and work by reducing the amount of acid production in the stomach. They are very effective for healing ulcers in the stomach or esophagus and are taken for 6 weeks to heal symptoms from reflux. They are called Prilosec, which is available over the counter in America, Prevacid or Nexium and are very heavily advertised due to there high cost.

What if medications fail to relieve my symptoms?

Then I suggest that you consult with your doctor about a possible endoscopy where they look down into your esophagus or stomach with a camera and take biopsies. He might also suggest a special kind of x-ray called as barium swallow or refer you for surgery if you have a large hiatal hernia.

What are the long term complications of GERD?

Most dreadful is the possibility of esophageal cancer, but the common ones are narrowing of the esophagus secondary to chronic reflux and inflammation of the esophagus leading to pain. Please consult with your doctor if you have chronic acid reflux.

Hope this meets you all well.

Please write to me if you have any questions at pgupta@colnhc.org

Your doctor servant,
Premvilas Das
(Piyush Gupta, MD)

Back to top