الفهرس 
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Abstract
Because of complications of deep venous thrombosis as PE and postphlebitic syndrome, DVT is associated with increased morbidity and mortality. Therefore, diagnosis of DVT accurately will decrease its complications and its misdiagnosis will make patients at risk of bleeding because of anticoagulant used in treatment of DVT.
Diagnosing patients suspected to have DVT is a difficult challenge as it has non- specific symptoms and signs. Previously, the gold standard for diagnosis of DVT was venography but now it not preferred as it is expensive and invasive. On the contrary, venous ultra sound is reliable, safe and non- invasive for detecting DVT so it became the corner stone tool in diagnosis of DVT. Only 15%~28% of suspected cases with DVT have actually thrombosis with venous duplex examination. In addition, it costs money and needs a specialist to perform so anew strategy is needed for diagnosis of DVT.
D-dimer testing is the standard of care for ruling out deep vein thrombosis (DVT) in emergency department (ED) patients with a non-high pretest probability and acceptance criteria for sensitivity and negative predictive value (NPV) to exclude DVT have been provided. The clinical utility of D-dimer testing is limited by the test’s low specificity. Many patients have false positive results, and must then undergo imaging with computed tomography pulmonary angiography (CTPA) to rule out PE or venous ultrasound (US) to rule out DVT. A D-dimer assay should not be used as stand-alone test to diagnose DVT.
A newer approach for diagnosis includes a combination of D-dimer level and clinical probability score (wells score) can decrease unnecessary ultrasound examination for cases suspected to have DVT.
The aim of this current study is to reduce unnecessary venous ultrasound examination as a diagnostic tool in cases suspected to have deep venous thrombosis (DVT) in our emergency department by using d dimer and wells clinical probability score.
The study was conducted on 50 consecutive patients suspected to have DVT represented to our emergency department of Menoufia University Hospital during the period from June 2018 to June 2019 and referred to radiologist to confirm presence or absence of DVT.
Data collected from cases included demographic data as age, sex and body mass index (BMI). Data regarding past medical history, risk factors for DVT, and clinical examination of all cases were collected.
Classification of cases according to clinical probability score (wells score) into low, moderate, and high risk for DVT. Blood sample for d-dimer level for all suspected cases. Diagnosis by venous duplex whether cases have DVT (proximal or isolated distal DVT) or absence of DVT.
The result of this study showed that males represented 26 (52%), females represented 24 (48%), the mean age was (45±7.4), and the mean BMI was (28.6±3.8). Most of patients have no past history medical history representing about 20 (40%) of cases, 9 (18%) of cases had DM, 9 (18%) had HTN, 5 (10%) had CHF, 2(4%) had COPD, 1(2%) had Behcet disease, and 4(8%) had active cancer. Only 19(38%) of cases
Summary
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have DVT while the remaining 31(62%) have no DVT.
Active cancer, immobilization, and recently bedridden for ≥ 3 days, or major surgery within the previous 12 weeks requiring general or regional anesthesia were statistically significant in relation to DVT.
Oral contraception pills, hormonal replacement therapy, family history of disease, and previously documented deep vein thrombosis were statistically non-significant in relation to DVT. Localized tenderness along the distribution of the deep venous system and entire leg swelling showed significant relation with DVT. Calf swelling at least 3 cm larger than that on the asymptomatic side and pitting edema confined to the symptomatic leg showed non-significant relation with DVT.
Regarding the performance of d dimer as a predictor of DVT our results showed that at cutoff point of (≥575) for d dimer sensitivity was 94.9%, specificity was 58.2%, PPV was 58%NPV was 95%, AUC was 0.92, and CI for d-dimer score was 0.84 – 0.99.
Regarding the performance of wells score as a predictor of DVT our results showed that at cutoff point of (≥1.5) for wells score sensitivity was 94.7%, specificity was 77.4%, PPV was 72%, NPV was 96%,AUC was 0.93, and CI for was 0.86 – 0.99.
Combination of d dimer and Wells score for diagnosis of DVT showed that sensitivity was 100%, specificity was 94%, PPV was90%, NPV was 100%.
The results of this study were discussed and compared with other studies.
Recommendations: Using wells score and d dimer level in early work up of patients suspected to have DVT to decrease over using and cost of venous duple decreasing burden in our ED.