Aastha Shah
A 57-year-old male with a past medical history of HIV, hyperlipidemia (on a statin), chronic obstructive pulmonary disease (COPD), lumbar stenosis, and chronic diastolic heart failure presented with a chief complaint of pain and swelling in the right inguinal region for the past 3 days. The patient reported a similar presentation in the past, during which he was told that he had a hernia. He denies associated symptoms such as fever, chills, nausea, vomiting, abdominal distention, constipation, or urinary changes. He passed stool normally this morning and has no history of prior abdominal surgeries.
Vitals: BP: 135/84 mmHg | Pulse: 84 bpm | Temp: 97.4 °F (36.3 °C) | Resp: 16 | Wt: 75.7 kg (166 lb 14.2 oz) | SpO2: 98%
On physical examination, the patient appeared in no acute distress. Cardiovascular exam revealed a regular rate and rhythm without murmurs. Lungs were clear to auscultation and the abdomen was soft, nondistended, and non-tender. A firm, localized swelling and tenderness was noted in the right inguinal region. There was no redness, induration, or drainage at the site. No testicular swelling or tenderness was observed. The remainder of the physical exam, including neurologic and extremity exams, was unremarkable.
A bedside ultrasound was performed over the area of swelling.
Figure 1: Non-occlusive superficial venous thrombus in the right inguinal region.
Discussion
Deep vein thrombosis (DVT) is a common condition, with an annual incidence rate estimated at about 1 in 1,000 adults. The risk of DVT increases with age, and other risk factors include immobility, recent surgery, trauma, malignancy, and certain medical conditions like HIV, COPD, and heart failure, which this patient has.
The differential diagnosis for DVT includes a variety of conditions that may present with
unilateral leg pain and swelling. These include cellulitis, muscle strains, Baker's cyst, venous
insufficiency, or even superficial thrombophlebitis, which was seen in this patient. Superficial venous thrombosis (SVT) is generally considered less dangerous than DVT, as SVT does not carry the same risk of pulmonary embolism, but it can still cause significant discomfort and complications if left untreated.
On physical exam, patients with DVT typically present with unilateral leg swelling, pain, and
tenderness. Other findings can include warmth, erythema, and distended superficial veins. In this case, the patient had localized swelling and tenderness in the right inguinal region without any associated redness or warmth, which is consistent with superficial venous thrombosis rather than DVT.
Ultrasound is the gold standard for diagnosing both DVT and SVT. Bedside ultrasonography
performed by emergency physicians can achieve sensitivities of 95% and specificities of 96%, making it a highly reliable tool for assessing DVT at the point of care (1). However, variability in ultrasound protocols has been noted across institutions. As reported by the Society of Radiologists in Ultrasound, discrepancies between protocols can lead to underdiagnosis or unnecessary testing, as highlighted in one case where a patient presented with calf DVT that was missed on initial imaging but later identified during follow-up scans (2). This underscores the need for standardized, comprehensive duplex ultrasound protocols to ensure accurate diagnosis.
When performing a point-of-care ultrasound (POCUS) exam for DVT, compression should be applied to the femoral vein just above and below the saphenofemoral junction, above and below the bifurcation of the common femoral vein into the deep femoral vein and femoral vein, and to the popliteal vein extending up to the trifurcation into the calf veins (3-point compression protocol). In this patient, the femoral vein was visualized during the POCUS, but the clot was superficial and located away from the femoral vein.
Treatment for DVT typically involves anticoagulation to prevent clot extension and pulmonary embolism. For superficial venous thrombosis, treatment is less aggressive and usually involves conservative management, such as compression stockings, nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief, and in some cases, anticoagulation if the thrombus is near a deep vein or extensive. If the thrombus extends or becomes symptomatic, more aggressive measures, such as surgical intervention or thrombolytic therapy, may be required.
References:
- Baker M, Anjum F, dela Cruz J. Deep Venous Thrombosis Ultrasound Evaluation.
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK470453/. - Needleman L, Cronan JJ, Lilly MP, et al. Ultrasound for Lower Extremity Deep Venous
Thrombosis: Multidisciplinary Recommendations From the Society of Radiologists in
Ultrasound Consensus Conference. Circulation. 2018;137(14):1505-1515.
doi:10.1161/CIRCULATIONAHA.117.030687.