Limb Swelling

A super athletic and fit friend just had knee surgery. Shortly after she developed exquisite pain and leg swelling, and today she’s on blood thinners to treat a deep vein thrombus (DVT), more commonly known as a clot. The hope is for the clot to fade into the night. The fear is for it to dislodge and travel north to her lungs to be renamed a pulmonary embolus (PE).

Red Flags:

• One sided limb swelling (more common in the legs)
• One sided limb pain
• Shortness of breath
• Chest pain
• Recent surgery
• Recent injury
• Recent prolonged sitting (bus, plane, train, truck, car)
• Wheel chair dependence
• Cancer
• Heart disease
• Hypertension
• Past history of DVT/PE
• Family members with “clotting problems”
• Smoking
• “Lost my warfarin.”

Happy Words

• “Bad valves in my veins and I lost my compression stockings.”
• “Both legs swell periodically after walking.”
• “I ran out of my Lasix.”
• “Gets totally better with elevation.”
• “I just got off a cruise and fell off my diet.”

You may think of your blood as a stream of oxygen delivering red cells, and pathogen battling white cells, but that’s barely the half of it. To keep the stream flowing properly your blood walks a tight rope, balanced between “thrombosis” and “thrombolysis,” or clotting and liquefying.

Forces that lead to clotting are captured by “Virchow’s Triad,” which include injury, stasis, and hypercoagulability. We’re most grateful for clot formation with injury. This is what keeps blood in your body when you cut yourself shaving or have an operation. For you mountain bikers, the clotting factors in your blood are the “Slime” of your inner tubes.

Clotting with stasis is more of a drag, but not very surprising. Think of ice forming over a river versus a pond. Simply put, high flow makes clotting less likely, and is one very good reason for daily exercise. This is why you’ll hear recommendations to take a stretch every thirty minutes or so on a flight, or have a walk at rest stops on long drives. It’s an ongoing challenge for surgeons as well, because while they’d like you to stop bleeding following their procedures, they also hate DVT/PEs.

The last one in the triad, hypercoagulability, essentially means predisposition to clotting. There are genetic conditions including Protein C or S deficiency, or Factor 5 Leiden thrombophilia, which you may have without knowing. Cancer can cause hypercoagulability as well. Believe it or not, simply eating foods high in vitamin K like green leafy veggies, can also nudge you in the direction of hypercoagulability (just don’t tell your kids).

What you can do from home with a painful, swollen leg is fairly limited. Exercise, elevation and aspirin are probably the biggest bang for buck. Compression stockings compress superficial veins in hopes of increasing flow through deeper veins. If you head to the hospital, expect a doppler ultrasound. Not every clot is equal, however. Our concern increases for clots that are in the deeper veins and for those which are larger and closer to the heart and lungs. (Backed up traffic on Route 1 in Big Sur is a lot less likely than a crash in San Jose on the 101 to cause problems on the peninsula.) Once a DVT is defined, then you’re in the realm of high dollar blood thinners including Lovenox, Coumadin, Plavix, Xarelto, etc… a deep bag of worms for some future post.

Many a med student has lost sleep over the “clotting cascade”. No need for you to do the same today, but suffice to say there’s more in the soup than just red cells and white cells.

All that being said, if you’re ever feeling nervous and want an ultrasound? We’re happy to order one for you through our friends at Selma Carlson Diagnostic Center

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