Deep vein throm­bo­sis less com­mon in up­per ex­trem­i­ties


DEAR DR. ROACH: I am a 55year-old male. Af­ter five or six days of think­ing I had pulled a mus­cle in my bi­cep, I was di­ag­nosed via ul­tra­sound with an un­pro­voked, ex­ten­sive deep­vein throm­bo­sis in my left up­per arm. I'm glad I made the de­ci­sion to have it checked out. I have no fam­ily history of this con­di­tion, ex­er­cise regularly, am not over­weight and have not had any re­cent surg­eries. Dur­ing my hos­pi­tal stay, I had a CAT scan of my ab­domen and pelvis, CT of my chest and an ul­tra­sound of my lower ex­trem­i­ties. These tests re­sults were all nor­mal. In ad­di­tion, many blood tests were run, and there is no in­di­ca­tion of any can­cer.

I have been tak­ing Xarelto since I was re­leased from the hos­pi­tal. The hema­tol­o­gist/on­col­o­gist in­di­cated that we might never know what caused the DVT. He said that there is an in­creased pos­si­bil­ity of another clot de­vel­op­ing in the fu­ture, so I may need to take Xarelto in­def­i­nitely.

I would like to know what caused the clot. Do you have any ad­vice/sug­ges­tions as to how to pro­ceed? Does Xarelto specif­i­cally ad­dress this con­di­tion? — B.R.

AN­SWER: A deep-vein throm­bo­sis is a blood clot. Blood clots in the up­per ex­trem­i­ties are much less com­mon than in the leg and pelvis. I'm go­ing to ex­clude blood clots re­lated to med­i­cal pro­ce­dures and de­vices in my dis­cus­sion, since these are very dif­fer­ent in cause, treat­ment and prog­no­sis.

Pri­mary (where no sec­ondary cause is iden­ti­fied) up­perex­trem­ity DVTs of­ten have an un­der­ly­ing cause. Prob­a­bly the most com­mon iden­ti­fi­able cause is tho­racic out­let ob­struc­tion, a com­pres­sion of the nerves, ar­ter­ies and es­pe­cially veins as they go through the tho­racic out­let — an anatom­i­cal space bor­dered by the spine, the first ribs and the breast­bone. Young men with large mus­cles are at high­est risk for blood clots in the sub­cla­vian veins that pass through the tho­racic out­let. Some­times, numb­ness and weak­ness are present, show­ing the nerve to be af­fected by tho­racic out­let ob­struc­tion. If there is ev­i­dence of com­pres­sion (usu­ally by X-ray), sur­gi­cal treat­ment should be con­sid­ered.

For peo­ple with­out tho­racic out­let ob­struc­tion, an iden­ti­fi­able risk fac­tor can be found in up to 60 per­cent of cases (you prob­a­bly had a search for these through the many blood tests you had), and as many as 25 per­cent will have a can­cer iden­ti­fied in the year af­ter di­ag­no­sis (which is why your doc­tor looked so care­fully for can­cer).

Most ex­perts rec­om­mend an­ti­co­ag­u­la­tion for three to six months, and 2 to 8 per­cent of peo­ple will re­cur. Xarelto (ri- varox­a­ban) is one choice, but is not nec­es­sar­ily bet­ter than other op­tions. I'm not sure why your hema­tol­o­gist is rec­om­mend­ing in­def­i­nite ther­apy.

DEAR DR. ROACH: My doc­tor states that my body could tol­er­ate 3,000 mil­ligrams per day of Tylenol. I am 87 years old and in poor health. Is he cor­rect? — R.B.

AN­SWER: Depend­ing on the ex­act rea­son for your poor health, your doc­tor prob­a­bly is right. A daily to­tal limit of 3,000 mg of ac­etaminophen (Tylenol) is gen­er­ally con­sid­ered safe for most adults. How­ever, in the pres­ence of sig­nif­i­cant liver dis­ease or in peo­ple with heavy al­co­hol use, a limit of 2,000 mg is safer.

TO READ­ERS: Ques­tions about the com­mon prob­lem of uter­ine fi­broids are an­swered in the book­let of that name. To ob­tain a copy, write: Dr. Roach — No. 1106, Box 536475, Or­lando, FL 32853-6475. En­close a check or money or­der (no cash) for $4.75 U.S./$6 Can. with the re­cip­i­ent's printed name and ad­dress. Please al­low four weeks for de­liv­ery.

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