Definition
A.Superficial thrombophlebitis is inflammation of a vessel wall accompanied by blood stasis in varicose veins, which may also have clot formation in a vein close to the surface:
1.Most superficial thrombophlebitis occurs in the lower extremity but may also occur in the breast and in the penis (Mondor disease).
2.A superficial thrombophlebitis may also occur in the upper extremities and in the neck after invasive intravenous (IV) catheters used in medical procedures.
3.Generally superficial thrombophlebitis is self-limiting but may persist for a period of time (3–4 weeks or longer) before resolution.
B.Superficial phlebitis with an infection is referred to as a septic thrombophlebitis.
Incidence
A.With pregnancy, there is approximately a four- to five-fold increase of phlebitis over a nonpregnant female. Eighty percent of thromboembolic events in pregnancy are venous (0.5–2.0 per 1,000). The incidence of pulmonary embolism (PE) in pregnancy accounts for 1.1 deaths per 100,000 deliveries.
B.The prevalence of superficial thrombophlebitis ranges from 4% to 8% of patients with an indwelling catheter.
C.Superficial phlebitis after a vein radiofrequency or laser ablation is common.
Pathogenesis
A.Superficial thrombosis is caused by infection, abuse of IV drugs, chemical irritation from overuse of IV route for diagnostic tests and drugs, and/or trauma. Several episodes can signal an underlying problem, such as carcinoma of the pancreas.
B.A common cause of varicose veins is blood-flow stasis, basically due to valvular incompetence and/or dilation of the vessel lumen.
C.Thrombi in the upper extremities commonly have iatrogenic causes, such as IV catheters.
D.Thrombophlebitis during pregnancy through the first 6 weeks postpartum is linked to a reduced fibrinolytic state.
Predisposing Factors
A.Previous thrombophlebitis is the highest risk factor for recurrence.
B.Hypercoagulability such as pregnancy (50% of events) through 6 weeks postpartum (50% of events).
C.Hemoglobinopathies:
1.Factor V Leiden mutation.
2.Protein C deficiency.
3.Protein S deficiency.
4.Prothrombin gene mutation.
5.Antithrombin III deficiency.
6.Factor XII deficiency.
D.Estrogen therapy:
1.Oral contraceptives.
2.High-dose hormone replacement therapy (HRT).
E.Malignancy (especially in the tail of the pancreas).
F.Lupus, positive anticardiolipin antibody.
G.Sepsis.
H.Surgery.
I.Long bone trauma.
J.Recent IV catheter access.
K.Prolonged immobilization.
L.Obesity.
M.Varicose veins.
N.Age older than 60.
O.Stroke.
P.Myocardial infarction (MI).
Q.Family history of deep vein thrombosis (DVT).
R.Smoking.
S.Hypertension (HTN).
T.Infection.
Common Complaints
A.Warm, tender, inflamed vessel with palpable cord.
B.Redness along the course of the superficial vein.
C.Tenderness or pain localized to the affected vein.
Other Signs and Symptoms
A.Fever/no fever.
B.Localized edema.
Potential Complications
A.Superficial thrombophlebitis extending into the deep venous system:
B.DVT.
C.Conversion to suppurative thrombophlebitis:
1.Metastatic abscess formation.
2.Septicemia.
3.Septic emboli.
Subjective Data
A.Query the patient regarding onset, duration, and intensity of symptoms.
B.Ask the patient about fever or other related symptoms.
C.Obtain a thorough medical history and account of recent physical activity.
D.Ask the patient about any recent experience of any type of injury.
E.Inquire whether the patient has ever had similar symptoms or history of previous thrombophlebitis. If so, discuss previous treatment and therapy used and the results.
F.Review current medications: Prescription, over-the-counter (OTC), and herbal products:
1.Ask specifically about oral contraceptives and hormone therapy.
G.Review the patient’s occupation for sedentary lifestyle.
H.Review any recent plane travel.
I.Review history for recent invasive procedures.
Physical Examination
A.Check temperature (if indicated with inflammation), pulse, respirations, and blood pressure (BP).
B.Inspect:
1.Assess overall appearance. Evaluate for the presence of respiratory distress.
2.Inspect extremities, noting erythema and edema.
3.Assess for increased warmth over the affected vein.
C.Auscultate:
1.Auscultate heart, noting rate, rhythm, heart sounds, murmurs, and gallops.
2.Auscultate lungs for lung sounds in all fields.
D.Palpate:
1.Palpate extremities; check all pulses, including femoral, posttibial, pedal, and radial.
2.Palpate extremities for tenderness and palpable cord.
3.Palpate lymph nodes distal and proximal to the site.
4.Test for Homans’ sign in lower extremities bilaterally if DVT is suspected.
Diagnostic Tests
A.Duplex ultrasound identifies the presence, location, and extent of venous thrombosis.
B.Doppler ultrasound.
C.Laboratory tests are ordered dependent on the clinical situation:
1.Complete blood count (CBC) with differential.
2.Screening for hypercoagulability should not be considered for one episode of superficial thrombophlebitis.
3.Screening for hypercoagulability should be considered for recurrent superficial thrombophlebitis.
4.Blood cultures.
Differential Diagnoses
A.Thrombophlebitis.
B.Varicose veins.
C.Cellulitis.
D.Strained muscle.
E.Insect bites.
F.Erythema nodosum.
G.Cutaneous polyarteritis nodosa.
H.Kaposi’s sarcoma.
I.Hyperalgesic pseudothrombophlebitis.
Plan
A.General interventions:
1.Advise all patients to stop smoking.
2.
See Section III: Patient Teaching Guides “Superficial Thrombophlebitis and
Varicose Veins.”
3.Advise the patient to avoid constrictive clothing such as knee-high hosiery.
4.Prescribe supportive hose/compression stockings.
5.Have the patient apply heat and elevate extremity for varicose veins or superficial thrombophlebitis.
6.Prescribe bed rest for superficial thrombophlebitis.
7.DVT: Hospitalization is required.
8.Tell patients with thrombophlebitis to discontinue oral contraceptives and hormone replacement.
9.Alternative forms of birth control recommended by the American Congress of Obstetricians and Gynecologists (ACOG) include the following:
a.Intrauterine device (IUD), including IUDs that contain progestin.
b.Progestin-only oral contraceptives.
c.Progestin-only implants.
d.Barrier methods.
e.Surgical procedures: Vasectomy and tubal ligation.
B.Pharmaceutical therapy for superficial thrombophlebitis:
1.Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for treatment of pain. No NSAID has been identified as superior for treatment.
2.The use of anticoagulation therapy for the treatment of lower extremity superficial thrombophlebitis is controversial. Unfractionated heparin and low-molecular-weight heparin (LMWH) are both used for treatment to reduce risk of DVT and/or recurrent phlebitis.
3.The American College of Chest Physicians recommends anticoagulation for patients with lower extremity superficial thrombophlebitis at increased risk of thromboembolism. This is defined as an affected venous segment greater than or equal to 5 cm in proximity (<5 cm) to the deep venous system and positive medical risk factors. The American College of Chest Physicians’ full evidence-based clinical practice guidelines on antithrombotic therapy are available at https://journal.chestnet.org/article/S0012-3692(15)00335-9/pdf.
4.Antibiotics, if infection is suspected.
C.Surgery:
1.Biopsy.
2.Vein ablation, only if symptoms are significant and persistent.
3.Vein ligation, only if symptoms are significant and persistent.
Follow-Up
A.Schedule an appointment for patients with superficial thrombophlebitis to return in 7 to 10 days, or earlier as needed. Repeat physical examination as needed to evaluate resolution or progression of the thrombophlebitis.
B.Periodic follow-up is needed to monitor patients on anti-coagulation therapy.
C.After acute problem is resolved, consider laboratory evaluation for hypercoagulation syndrome (protein C, protein S, and antithrombin III).
D.Monitor bone loss with DEXA scan with prolonged use of heparin.
E.Screening all women for thrombophilias before starting oral contraceptives is not recommended by the ACOG.
F.Women with a history of thrombosis who have not had a complete evaluation should be tested for both antiphospholipid antibodies and inherited thrombophilias.
Emergent Issues/Instructions
A.Patients should contact the office if they have any of these symptoms:
1.Worsening pain in an arm or leg.
2.Fever over 101°F.
3.Any temperature change in a hand or foot.
4.Any change in feeling of a hand or foot.
5.Any change in the color of a hand or foot.
6.Difficulty walking.
7.Vomiting or other illness that causes you to miss more than one dose of your medications.
B.Patients should contact the office if they are experiencing any new symptom(s) not present at their last office visit.
Consultation/Referral
A.If septic thrombophlebitis or DVT is diagnosed, refer the patient to a physician.
B.Hospitalization is required to initiate heparin therapy.
C.Comanage pregnancy with an obstetrician:
1.81 mg and 325 mg tablets, taken once daily.
D.Plavix (clopidogrel bisulfate):
1.75 mg, taken once daily.
Individual Considerations
A.Pregnancy:
1.Routine anticoagulation therapy for all pregnant women is not recommended. Therapeutic anticoagulation is recommended for women with acute thromboembolism during the current pregnancy or those at high risk of thrombosis, such as women with mechanical heart valves.
2.Warfarin and NSAIDs are contraindicated.
3.Heparin is the preferred anticoagulant in pregnancy. Neither unfractionated heparin nor LMWH crosses the placenta.
4.Warfarin, LMWH, and unfractionated heparin do not accumulate in breast milk and do not induce an anticoagulant effect in the infant and therefore are considered compatible with breastfeeding.
B.Geriatrics: