Thrombophlebitis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Synonyms and Keywords: White Leg; phlebitis

Overview

Thrombophlebitis is inflammation of a vein, usually associated with the formation of a thrombus within the superficial venous system. It can occur in any superficial venous system, but most commonly in the lower limbs. Symptoms of thrombophlebitis include pain along the course of the vein, redness, itching and swelling around the site of thrombophlebitis. The treatment of thrombophlebitis consists of compression stockings, analgesia, as well as anticoagulants. The most feared complications are DVT and PE.

Historical Perspective

  • In 1913, Burnham AC discussed thrombophlebitis in postoperative patients.[1]
  • Historically, the treatment of thrombophlebitis was purely surgical and consisted of removal of the thrombosed vein.[2]

Classification

Thrombophlebitis can be classified according to the cause into:[3]

Type of Thrombophlebitis Description
Sterile Most common type of thrombophlebitis
Traumatic Associated with the following conditions:
Infective Mostly due to prolonged IV cannulation
Migratory Recurrent thrombophlebitis at various sites. Associated with an underlying malignancy, most commonly adenocarcinoma of the pancreas

Thrombophlebitis may also be classified according to the site into:[4]

  1. Superficial thrombophlebitis of the lower limb: most common location and it involves the great and short saphenous veins.
  2. Superficial thrombophlebitis of the arms
  3. Superficial thrombophlebitis of the breast: also known as Mondor's disease
  4. Superficial thrombophlebitis of the abdominal wall

Pathophysiology

Pathogenesis

The pathogenesis of thrombophlebitis is related to 3 important factors:[3][5][6]

These 3 factors (known as Virchow's triad) predispose to thrombus formation within the veins and subsequently to thrombophlebitis.

Associated Conditions

Thrombophlebitis may be associated with the following conditions:

Causes

Common Causes

Differentiating Thrombophlebitis from other Diseases

Thrombophlebitis must be differentiated from the following conditions causing pain, swelling and palpapable mass in the extremities:[11][12][13][14]

Condition Predilection Site Pain Redness Warmth Swelling of Surrounding Tissue Itching Palpable Mass Systemic Symptoms
Varicose veins Lower limb + - - + + - -
Deep vein thrombosis Lower limb + + + + - - Systemic symptoms are present if DVT is complicated by PE. These include:
Cellulitis No sites of predilection + + + + - -
Lymphangitis Commonly the extremities + + - + - - May be accompanied by:
Lymphedema Lower limb - - - + - -
Baker's cyst Lower limb +/- - - + - Sensation of a water-filled balloon on the posterior aspect of the knee and calf -
Polyarteritis nodosa Cutaneous PAN most commonly involves

the lower limb

+ - - - - Nodules
Ruptured medial head of gastrocnemius Lower limb + - - + - Painful lump at the site of rupture -

Epidemiology and Demographics

Epidemiology

Incidence

  • The incidence of thrombophlebitis is estimated at 100 per 100,000 cases.[4][15]
  • Thrombophlebitis is 6 times more common than DVT.[4]

Demographics

Age

  • Thrombophlebitis is more common in elderly.[4]

Risk Factors

The following are associated with an increased risk of thrombophlebitis:[3][5][6][4]

Natural History, Complications and Prognosis

Natural History

Thrombophlebitis was thought of as a benign condition. However, if left untreated, thrombophlebitis can recur or extend to involve the deep venous system. DVT can still complicate 10% of cases, despite treatment.[19]

Complications

Complications of thrombophlebitis include:[3][20][21][22][23]

Prognosis

The prognosis of thrombophlebitis is generally good with medical treatment. However, despite treatment, DVT can complicate about 10% of cases of thrombophlebitis.

Screening

There are no screening recommendations for thrombophlebitis.[30]

Diagnosis

History and Symptoms

The following symptoms are often (but not always) present in patients with thrombophlebitis:[31][4][15]

Physical Examination

Examination of the skin and affected area reveals the following:[4][15][31]

Laboratory Findings

D-Dimer

D-Dimer is not a useful laboratory test in the diagnosis of isolated cases of superficial thrombophlebitis. However, it may be useful in the case of a concomitant DVT.[4]

Ultrasound

Venous Duplex Ultrasound

Although the diagnosis of thrombophlebitis is mostly clinical, venous Duplex ultrasound is considered the imaging of choice in suspected cases.[4][23] Venous Duplex ultrasound can identify the following:

Other Imaging Findings

There are no other imaging findings associated with thrombophlebitis.

Other Diagnostic Studies

There are no other diagnostic studies associated with thrombophlebitis.

Treatment

Medical Therapy

The following interventions are used as a mainstay in treatment of thrombophlebitis:[3][19][38][23]

Nonsteroidal Anti-Inflammatory Drugs

All NSAIDs have the same effect in the treatment of thrombophlebitis.[39] They are effective in reducing the pain, and decrease the extension of thrombosis.[40][15]

Anticoagulation

Topical Agents

Some topical anti-inflammatory agents (e.g. diclofenac gel) has been found to reduce the pain, and help resolution of the inflammation.

Antibiotics

When suppurative thrombophlebitis is suspected, antibiotic treatment should be started.

Surgery

Conservative measures and medical therapy are considered the first line treatment for patients with thrombophlebitis. However, patients with recurrent thrombophlebitis are candidates for surgical intervention, such as venous stripping or ligation.[4][38]

Prevention

Primary Prevention

The following preventive measures can be done to decrease the incidence of thrombophlebitis:[3][5][6][4]

Secondary Prevention

Medical therapy with anticoagulants can decrease the rate of recurrence of thrombophlebitis.


References

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  40. "A pilot randomized double-blind comparison of a low-molecular-weight heparin, a nonsteroidal anti-inflammatory agent, and placebo in the treatment of superficial vein thrombosis.". Arch Intern Med. 163 (14): 1657–63. 2003. PMID 12885680. doi:10.1001/archinte.163.14.1657.  Unknown parameter |month= ignored (help)
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