|
|
| (29 intermediate revisions by 7 users not shown) |
| Line 1: |
Line 1: |
| {{Infobox_Disease |
| | __NOTOC__ |
| Name = {{PAGENAME}} |
| | {{Thrombophilia}} |
| Image = |
| | {{CMG}}; {{AE}} [[User:Kashish Goel|Kashish Goel, M.D.]], {{asiri}},{{M.B}}, {{MKA}}, {{S.G.}}, {{JK}} |
| Caption = |
| |
| DiseasesDB = 29080 |
| |
| ICD10 = |
| |
| ICD9 = |
| |
| ICDO = |
| |
| OMIM = 188050 |
| |
| MedlinePlus = |
| |
| eMedicineSubj = |
| |
| eMedicineTopic = |
| |
| MeshID = D019851 |
| |
| }} | |
| {{SI}} | |
| {{CMG}};'''Associate Editor(s)-In-Chief:''' [[Kashish Goel|Kashish Goel, M.D.]] | |
|
| |
|
| '''''Synonyms and Keywords:''''' Hypercoagulability, coagulability, hypercoagulable state
| | {{SK}} Hypercoagulability, coagulability, hypercoagulable state; thrombosis risk elevation; thrombotic tendency; prothrombotic state; clotting disorder; |
|
| |
|
| ==Overview== | | == [[Thrombophilia overview|Overview]] == |
| '''Thrombophilia''' is defined as an increased risk of [[thrombosis]] in the body, due to an abnormality in the system of [[coagulation]]. Thrombophilia can be inherited or acquired. More than 50% of the cases of [[thrombosis]] are associated with an underlying thrombophilia. Thrombophilias are mostly associated with venous thromboembolism like [[deep vein thrombosis]] in lower extremities or [[pulmonary embolism]]. Relatively less is known about thrombophilias that predispose to arterial thromboembolism<ref name="pmid11309638">{{cite journal |author=Seligsohn U, Lubetsky A |title=Genetic susceptibility to venous thrombosis |journal=N. Engl. J. Med. |volume=344 |issue=16 |pages=1222–31 |year=2001 |month=April |pmid=11309638 |doi=10.1056/NEJM200104193441607 |url=}}</ref>.
| |
|
| |
|
| ==Classification== | | == [[Thrombophilia historical perspective|Historical Perspective]]== |
| Thrombophilia can be classified in various forms.
| |
| * The most common classification is by the nature of the thrombosis: [[artery|arterial]], [[vein|venous]] or combined.
| |
| * Crowther & Kelton (2003) propose to classify the abnormality by the molecular deficiency, type I being the (severe) deficiencies of inhibitors, and type II being the less severe elevation of coagulation factors.<ref>{{cite journal |author=Crowther MA, Kelton JG |title=Congenital thrombophilic states associated with venous thrombosis: a qualitative overview and proposed classification system |journal=Ann. Intern. Med. |volume=138 |issue=2 |pages=128-34|year=2003 |pmid=12529095 |doi= |url=http://www.annals.org/cgi/reprint/138/2/128}}</ref>
| |
| * Inherited vs. acquired
| |
|
| |
|
| ==Pathophysiology== | | == [[Thrombophilia classification|Classification]] == |
| The Virchow's triad has been described classically as the patho-physiologic mechanism responsible for any thrombosis, which includes 3 components:
| |
| * [[Endothelial dysfunction]]
| |
| * [[Venous stasis]]
| |
| * [[Hypercoaguability]]
| |
|
| |
|
| The mechanism of thrombophilia involves affecting the pathway of thrombosis<ref name="pmid11309638">{{cite journal |author=Seligsohn U, Lubetsky A |title=Genetic susceptibility to venous thrombosis |journal=N. Engl. J. Med. |volume=344 |issue=16 |pages=1222–31 |year=2001 |month=April |pmid=11309638 |doi=10.1056/NEJM200104193441607 |url=}}</ref>:
| | == [[Thrombophilia pathophysiology|Pathophysiology]] == |
|
| |
|
| [[Image: Figure_thrombophilia_mechanism.jpg]] | | == [[Thrombophilia causes|Causes]] == |
|
| |
|
| Adapted from: N Engl J Med. 2001 Apr 19;344(16):1222-31.
| | == [[Thrombophilia differential diagnosis|Differentiating Thrombophilia from Other Diseases]] == |
|
| |
|
| ==Epidemiology and Demographics== | | == [[Thrombophilia epidemiology and demographics|Epidemiology and Demographics]]== |
| ===Prevalence of various inherited thrombophilias and their clinical impact===
| |
|
| |
|
| {| border="1" cellpadding="5" cellspacing="0" align="center" class="sortable"
| | == [[Thrombophilia risk factors|Risk Factors]] == |
| |-
| |
| ! Disorder
| |
| ! Healthy subjects/General population (%)
| |
| ! Patients with known thrombosis (%)
| |
| ! Estimated increase in thrombosis risk
| |
| |-
| |
| | [[Antithrombin deficiency]]
| |
| | 0.02
| |
| | 1 - 4
| |
| | 10 - 20X
| |
| |-
| |
| | [[Dysfibrinogenemia]]
| |
| | <1
| |
| | <1
| |
| | Variable
| |
| |-
| |
| | [[Protein C deficiency]]
| |
| | 0.2 - 0.4
| |
| | 3 - 5
| |
| | 10X
| |
| |-
| |
| | [[Protein S deficiency]]
| |
| | 0.3 - 0.13
| |
| | 2 - 4
| |
| | 10X
| |
| |-
| |
| | [[Factor V Leiden]]
| |
| | 1 - 15
| |
| | 18 - 40
| |
| | 5X
| |
| |-
| |
| | G20210A [[prothrombin]] gene mutation
| |
| | 2 - 5
| |
| | 7 - 16
| |
| | 3X
| |
| |-
| |
| | [[Hyperhomocystenemia]]
| |
| | 5
| |
| | 10
| |
| | 3X
| |
| |-
| |
| | Elevated [[factor VIII]] levels
| |
| | 11
| |
| | 25
| |
| | 5X
| |
| |-
| |
| |}
| |
|
| |
|
| The table has been adapted from Best Pract Res Clin Obstet Gynaecol. 2003 Jun;17(3):397-411<ref name="pmid12787534">{{cite journal |author=Buchanan GS, Rodgers GM, Ware Branch D |title=The inherited thrombophilias: genetics, epidemiology, and laboratory evaluation |journal=Best Pract Res Clin Obstet Gynaecol |volume=17 |issue=3 |pages=397–411 |year=2003 |month=June |pmid=12787534 |doi= |url=}}</ref> and data has been obtained from references<ref name="pmid11309638">{{cite journal |author=Seligsohn U, Lubetsky A|title=Genetic susceptibility to venous thrombosis |journal=N. Engl. J. Med. |volume=344 |issue=16 |pages=1222–31 |year=2001 |month=April |pmid=11309638|doi=10.1056/NEJM200104193441607 |url=}}</ref><ref name="pmid11702218">{{cite journal |author=Franco RF, Reitsma PH |title=Genetic risk factors of venous thrombosis |journal=Hum. Genet. |volume=109 |issue=4 |pages=369–84 |year=2001 |month=October |pmid=11702218 |doi=10.1007/s004390100593 |url=}}</ref><ref name="pmid7740487">{{cite journal |author=Haverkate F, Samama M |title=Familial dysfibrinogenemia and thrombophilia. Report on a study of the SSC Subcommittee on Fibrinogen |journal=Thromb. Haemost. |volume=73 |issue=1 |pages=151–61 |year=1995 |month=January |pmid=7740487 |doi= |url=}}</ref>.
| | == [[Thrombophilia screening|Screening]]== |
|
| |
|
| ==Causes== | | == [[Thrombophilia natural history, complications and prognosis|Natural History, Complications and Prognosis]] == |
| ===Inherited===
| |
| Common types:
| |
| * G1691A mutation in factor V gene ([[Factor V Leiden|Factor V, Leiden type]]; 5% of the population are [[heterozygous]] for FVL)
| |
| * [[Prothrombin]] (factor II) mutation (G20210A, 5'UTR)
| |
| * Homozygous C677T mutation in the [[MTHFR]] gene
| |
|
| |
|
| Rare forms:
| | == Diagnosis == |
| * [[Plasminogen]] and [[fibrinolysis]] disorders
| | [[Thrombophilia history and symptoms|History and Symptoms]] | [[Thrombophilia physical examination|Physical Examination]] | [[Thrombophilia laboratory findings|Laboratory Findings]] | [[Thrombophilia x ray|X Ray]] | [[Thrombophilia CT|CT]] | [[Thrombophilia MRI|MRI]] | [[Thrombophilia echocardiography or ultrasound|Ultrasound]] | [[Thrombophilia other imaging findings|Other Imaging Studies]] | [[Thrombophilia other diagnostic studies|Other Diagnostic Studies]] |
| * [[Paroxysmal nocturnal hemoglobinuria]]
| |
| * [[Protein C deficiency]]
| |
| * [[Protein S deficiency]]
| |
| * [[Antithrombin|Antithrombin III]] deficiency
| |
| * [[Dysfibrinogenemia]]
| |
| * Homozygous [[homocystinuria]]
| |
| * Increased levels of factor VIII, factor IX, factor XI, or [[fibrinogen]].
| |
|
| |
|
| ===Acquired=== | | == Treatment == |
| * [[Antiphospholipid antibodies]]
| |
| ** [[anti-cardiolipin antibodies]] and/or
| |
| ** [[lupus anticoagulant]]s
| |
| * [[Kidney|Renal disease]] (renal loss of antithrombin)
| |
| * High [[homocysteine]] levels due to vitamin deficiency (vitamins B6, B12 and folic acid).
| |
| * Immobility
| |
| * [[Pregnancy]] and [[puerperium]]
| |
| * [[Oral contraceptive pills]]
| |
| * [[Malignancy]]
| |
| * [[Obesity]]
| |
| * African American race
| |
| * [[Hormone replacement therapy]]
| |
| * Surgery and trauma
| |
| * Older age
| |
| * [[Myeloproliferative disorders]]
| |
| * Previous thrombosis
| |
|
| |
|
| ==Differential diagnosis of thrombophilia==
| | [[Thrombophilia medical therapy|Medical Therapy]] | [[Thrombophilia surgery|Surgery]] | [[Thrombophilia primary prevention|Primary Prevention]] | [[Thrombophilia secondary prevention|Secondary Prevention]] | [[Thrombophilia future or investigational therapies|Future or Investigational Therapies]] | [[Thrombophilia cost-effectiveness of therapy | Cost Effectiveness of Therapy]] |
| (By organ system)
| |
| {|style="width:75%; height:100px" border="1"
| |
| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
| |
| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | • [[Cerebral vein thrombosis]] • [[Acute myocardial infarction]] • [[Deep vein thrombophlebitis]] • [[Portal vein thrombosis]] • [[Pelvic thrombophlebitis]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Drug Side Effect'''
| |
| |bgcolor="Beige"| • [[Asparaginase]] • [[Bevacizumab]] • [[Combined oral contraceptive pill]] • [[Cyproterone]] • [[Diethylstilboestrol]] • [[Drospirenone]] • [[Eltrombopag]] • [[Erythropoietin]] • [[Ethinylestradiol]] • [[Fosfestrol]] • [[Granulocyte-macrophage colony stimulating factor]] • [[Heparin]] • [[Hormone replacement therapy]] • [[Lenalidomide]] • [[Peginesatide]] • [[Polyestradiol]] • [[Raloxifene]] • [[Strontium ranelate]] • [[Tamoxifen]] • [[Tobacco smoking]] • [[Tranexamic acid]] • [[Vorinostat]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Endocrine''' | |
| |bgcolor="Beige"| • [[Hyperosmolar non-ketotic diabetic coma]]
| |
| |-bgcolor="LightSteelBlue" | |
| | '''Gastroenterologic'''
| |
| |bgcolor="Beige"| • Acute [[pancreatitis]] • [[Portal hypertension]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Genetic'''
| |
| |bgcolor="Beige"| [[Congenital Dysfibrinogenemia]] • [[Factor II mutation]] • [[Hereditary thrombophlebitis]] • [[Antithrombin III deficiency]] • [[Factor V Leiden mutation]] • [[Protein C deficiency]] • [[Protein S deficiency]] • [[Klippel-Trenaunay syndrome]] • [[Klinefelter syndrome]] • [[Sickle cell disease]] • [[Carbohydrate-deficient glycoprotein syndrome type 1b]] • [[Factor XII deficiency]] • [[Haemoglobin SC disease]] • [[Hyperprothrombinemia 20210G-A]] • [[Plasminogen deficiency]] • [[Activated protein C resistance]] • [[CD59 antigen deficiency]] • [[Cystathionine beta-synthase deficiency]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Hematologic'''
| |
| |bgcolor="Beige"| • [[Polycythemia vera]] • [[Essential thrombocythemia]] • [[Myeloproliferative disease]] • [[Hyperviscosity]] syndrome • [[Paroxysmal Nocturnal Hemoglobinuria]] • [[Thrombocytosis]] • Raised homocysteine levels
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Iatrogenic'''
| |
| |bgcolor="Beige"| • Surgical complication
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Infectious Disease'''
| |
| |bgcolor="Beige"| • [[Intraperitoneal abscess]] • [[Acute peritonitis]] • [[Visceral abscess]] • [[Diverticulitis]] • [[Intravenous catheter infection]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Musculoskeletal / Ortho'''
| |
| |bgcolor="Beige"| • Orthopedic surgeries • Abdominal surgery
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Nutritional / Metabolic'''
| |
| |bgcolor="Beige"| • [[Cystathionuria]] • [[Homocystinuria]] • [[Methyltetrahydrofolate reductase deficiency]] • [[Metabolic Syndrome]] • [[Insulin resistance]] • [[Folic acid deficiency]] • [[Obesity]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Obstetric/Gynecologic''' | |
| |bgcolor="Beige"| • [[Pregnancy]] • [[Puerperium period]] • [[Ovarian hyperstimulation syndrome]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Oncologic'''
| |
| |bgcolor="Beige"| • [[Malignancy]] • [[Peritoneal metastasis]] • [[Adenocarcinoma of cecum]] • [[Adenocarcinoma of colon]] • Occult malignancy • [[Leukemia]] • [[Pancreatic cancer]] • [[Glucagonoma]] | |
| |-
| |
| |-bgcolor="LightSteelBlue"
| |
| | '''Renal / Electrolyte'''
| |
| |bgcolor="Beige"| • [[Chronic renal failure]] • [[Paroxysmal Nocturnal Hemoglobinuria]] • [[Nephrotic syndrome]]
| |
| |- | |
| |-bgcolor="LightSteelBlue"
| |
| | '''Rheum / Immune / Allergy'''
| |
| |bgcolor="Beige"| • [[Antiphospholipid Syndrome]] • [[Circulating anticoagulant]] • [[Heparin induced thrombocytopenia]] • [[Inflammatory bowel disease]] • [[Crohn's disease]]• [[Behcet disease]] • [[Hughes-Stovin syndrome]] • [[Polyarteritis Nodosa]] • [[SLE]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue" | |
| | '''Trauma'''
| |
| |bgcolor="Beige"| • [[Trauma]] • [[Abdominal trauma]]
| |
| |-
| |
| |-bgcolor="LightSteelBlue" | |
| | '''Miscellaneous'''
| |
| |bgcolor="Beige"| • [[Paraneoplastic syndrome]] • [[Hypereosinophilic syndrome]] • [[Immobility]]
| |
| |-
| |
| |}
| |
|
| |
|
| ==Laboratory testing== | | ==Case Studies== |
| ===Indications for screening===
| | :[[Thrombophilia case study one|Case #1]] |
| Routine screening is not indicated in those individuals with an obvious acquired cause. For example, if the thrombosis is due to immobilisation after recent [[orthopedic surgery]], it is unlikely that an underlying cause is found. Comprehensive testing in any patient should include complete assessment of risk factors and its effect on long-term therapy. Some of the indications of further testing may include<ref name="pmid19289024">{{cite journal |author=Foy P, Moll S |title=Thrombophilia: 2009 update |journal=Curr Treat Options Cardiovasc Med |volume=11 |issue=2 |pages=114–28 |year=2009 |month=April |pmid=19289024 |doi= |url=}}</ref><ref name="pmid11309638">{{cite journal |author=Seligsohn U, Lubetsky A |title=Genetic susceptibility to venous thrombosis |journal=N. Engl. J. Med. |volume=344 |issue=16 |pages=1222–31 |year=2001 |month=April |pmid=11309638 |doi=10.1056/NEJM200104193441607 |url=}}</ref>:
| |
| * Unexplained venous thromboembolism at an age of less than 50 years
| |
| * Recurrent spontaneous thrombosis
| |
| * Unusual sites like portal, splenic, mesenteric, hepatic or renal veins
| |
| * Family history in first-degree relatives
| |
| * Recurrent pregnancy losses<ref>Dawood, F., Farquharson, R., Quenby, S.''Recurrent miscarriage.'' Current Obstetrics & Gynaecology, 2004; 14:247-253.</ref>
| |
| * Recurrence of venous thromboembolism while adequately anticoagulated
| |
| * Warfarin-induced skin necrosis
| |
| * Unexplained arterial thromboembolism in a younger patient without significant arteriosclerosis risk factors and no cardioembolic source
| |
| | |
| ===Type of tests===
| |
| Tests for thrombophilia include [[prothrombin time]] and INR, [[partial thromboplastin time]], [[thrombin time]], [[fibrinogen]] levels, [[antiphospholipid antibody]] levels (IgG- and IgM-anticardiolipin, dilute Russell viper venom time and lupus anticoagulant), [[protein C]], [[protein S]] and [[antithrombin]] (both levels and activity), activated protein C resistance (APC resistance), [[factor V Leiden]] and [[thrombin|prothrombin]] mutation. Many laboratories add on various other tests, depending on local policy and guidelines.
| |
| | |
| | |
| ===Timing of tests===
| |
| | |
| ==Treatment==
| |
| | |
| ==References==
| |
| {{Reflist|2}}
| |
|
| |
|
| [[Category:Hematology]] | | [[Category:Hematology]] |
| | | [[Category:Disease]] |
| [[de:Thrombophilie]] | |
| [[fr:Thrombophilie]]
| |
| [[no:Trombofili]]
| |
| [[pl:Trombofilia]]
| |
| | |
| | |
| {{WH}} | | {{WH}} |
| {{WS}} | | {{WS}} |