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Thrombophlebitis

Thrombophlebitides

Thrombophlebitis technically refers to the inflammation of one or more veins secondary to blood clots called thrombi. This medical condition is commonly seen in the lower extremities where it may either be superficial or deep. The medical term “thrombus” refers to a clot while “phlebitis” means inflammation of the veins.


Presentation

Patients with thrombophlebitis typically present with the following symptoms:

  • Inflammation and swelling of the affected region
  • Erythema of the affected part
  • Pain on the area of inflammation
  • Tenderness over the affected vein
  • Warmth of the superficial skin
Pain
  • Pain is one of the major disadvantages of rocuronium, which is used during induction of anesthesia. Even at subparalyzing doses, 50-100% of patients complain of intense pain.[ncbi.nlm.nih.gov]
  • […] to dissolve an existing clot You may be told to do the following: Keep pressure off the area to reduce pain and decrease the risk for further damage.[nlm.nih.gov]
Relapsing Polychondritis
  • polychondritis or granulomatous arteritis in nodular vasculitis-are actually consistent with the features of phlebitis or thrombophlebitis.[ncbi.nlm.nih.gov]
Soft Tissue Swelling
Severe Abdominal Pain
  • A 32-year-old nulligravid woman presented with fever, leukocytosis, and severe abdominal pain.[ncbi.nlm.nih.gov]
Thrombosis
  • Both superficial thrombophlebitis and deep venous thrombosis respond well to early therapeutic interventions. Deep venous thrombosis below the knee level are more prone to pulmonary embolic events which increases mortality among patients.[symptoma.com]
  • Swelling and pain in an upper extremity are suggestive of thrombosis. Pain associated with SVT is usually localized over the site of thrombosis.[emedicine.medscape.com]
  • OBJECTIVE: To analyse the differences of outcome between cryostripping and conservative therapy in the treatment of superficial vein thrombosis.[ncbi.nlm.nih.gov]
Chemosis
  • A 54-year-old man presented with palsy of the left trochlear nerve, sensory disturbance in the ophthalmic and maxillary divisions of the left trigeminal nerve, ptosis, proptosis, and chemosis after dental treatment for caries and periodontitis in the[ncbi.nlm.nih.gov]
Ptosis
  • A 54-year-old man presented with palsy of the left trochlear nerve, sensory disturbance in the ophthalmic and maxillary divisions of the left trigeminal nerve, ptosis, proptosis, and chemosis after dental treatment for caries and periodontitis in the[ncbi.nlm.nih.gov]
Visual Acuity Decreased
  • Best-corrected visual acuity decreased to 20/70 in the right eye. Repeat magnetic resonance imaging demonstrated a 1.5-cm-sized mass in the right cavernous sinus, suspicious for mycotic aneurysm.[ncbi.nlm.nih.gov]
Erythema
  • No information about risk factors leading to this withdrawal movement or pain on injection is available and whether this reaction leads to erythema or to venous sequelae (i.e. thrombosis and thrombophlebitis) has not been systematically investigated.[ncbi.nlm.nih.gov]
Warm Skin
  • When symptoms do occur, they may include: swelling in the leg red, discolored, or white skin a cord in a leg vein that can be felt rapid heart beat (tachycardia) slight fever warm skin more visible surface veins dull ache, tightness, tenderness or pain[surgery.med.miami.edu]
Cutaneous Manifestation
  • Cutaneous polyarteritis nodosa and subcutaneous thrombophlebitis are usually found in the lower legs and may present with the same cutaneous manifestation of widespread tender or painful nodular erythema.[ncbi.nlm.nih.gov]
Eruptions
  • Superficial vein thrombophlebitis is the common vascular symptom in Behçet disease and is characterized as erythema nodosum-like eruptions. Some studies have reported the presence of antiphospholipid antibodies (Abs) in patients with Behçet disease.[ncbi.nlm.nih.gov]
Penile Pain
  • A 55-year-old man started to suffer from severe penile pain 2 days after engaging in sexual intercourse in the woman-on-top position.[ncbi.nlm.nih.gov]
Neglect
  • Its initial presentation is always neglected by emergency physicians, until typical symptoms and signs are noted or thin-slice brain CT results obtained, by which time it is already too late.[ncbi.nlm.nih.gov]
Altered Mental Status
  • We report a case of a young woman without cardiovascular risk factors who was admitted to our emergency department with listlessness and altered mental status. The clinical examination revealed right lower limb swelling.[ncbi.nlm.nih.gov]

Workup

The diagnosis of thrombophlebitis is usually made clinically by the attending physician. Further tests may be required to determine whether the thrombophlebitis is superficial or deep. These include:

  • Blood tests: The determination of the levels of fibrin degradation product called D dimer could indicate the presence of a blood clot and the propensity of its recurrence.
  • Ultrasonography: Sonographic images of the affected leg or arm will reveal the blood clot that causes the phlebitis. Doppler studies with ultrasound can demonstrate the efficiency of the peripheral circulation. 
  • Computed Tomography (CT-scan): Complications of thrombophlebitis like pulmonary embolism could be investigated by the use of CT-scan imaging. 
Plasma Fibrinogen Increased
  • During pregnancy, procoagulant factors like plasma fibrinogen increases in concentration to more than twice its normal concentration. Fibrinolysis is also greatly impaired during this gestational period.[symptoma.com]

Treatment

The patients suffering from superficial thrombophlebitis may only need warm compress to relieve the discomfort and inflammation. The use of non-steroidal anti-inflammatory drugs (NSAIDs) can afford some pain control. Blood thinning medications like injectable low molecular weight heparin can effectively relieve both superficial and deep vein thrombosis [9].

Oral warfarin can prevent the formation of new clots and prevent small clots from growing. Thrombolytics like alteplase may be indicated for deep vein thrombosis and pulmonary embolism. Preventive compression stockings reduce the risk of thromboembolic recurrence in high-risk individuals. Surgical stripping of varicose veins can be performed for patients with recurrent thrombophlebitis of the lower extremities [10].

Prognosis

Both superficial thrombophlebitis and deep venous thrombosis respond well to early therapeutic interventions. Deep venous thrombosis below the knee level are more prone to pulmonary embolic events which increases mortality among patients. Patients who are incapacitated with long periods of immobility carry a higher morbidity rate.

Etiology

In general, thrombophlebitis is caused by a blood clot that initiates an inflammatory reaction. There are a number of events that lead to the formation of blood clots in the body. These include:

Epidemiology

Nations in the western hemisphere have an annual incidence of 1 case of thrombophlebitis per 1000 population [1]. The relative incidence of symptomatic thrombophlebitis only reaches 5 cases for every 10,000 individuals [2]. The precise prevalence is difficult to establish because it is grossly under reported. An Italian based study reveals that pain and edema are the two dominant symptoms of deep venous thrombosis (DVT) occurring in almost three-fourths of the cases [3].

Superficial thrombophlebitis is more prone to recurrence as compared to deep venous thrombosis. The mortality and morbidity of thrombophlebitis correlates with pulmonary embolic events. Almost a third of the patients with superficial thrombophlebitis in the lower extremities have a concurrent deep venous thrombosis [4]. There is no racial predilection to thrombophlebitis; however, women are more prone to this condition with a higher risk for those in estrogenic therapy. The mean age of onset for both superficial and deep venous thrombosis is at 66 years according to European studies [5].

Sex distribution
Age distribution

Pathophysiology

Almost two-thirds of the patients who develop thrombophlebitis have a pertinent medical history of hypercoagulable states like the inherited disease thrombophilia, which are are genetically transmitted and include specific hypercoagulable diseases like antithrombin deficiency, heparin cofactor II deficiency, thrombomodulin defiency, and tissue factor pathway inhibitor deficiency [6]. An inherent deficiency in any of the anticoagulant factors can also lead to thrombophlebitis [7]. Deficiency in protein S, anti-thrombin III and protein C renders the vascular endothelium incapacitated to self-repair during trivial vascular injuries.

Low dose estrogen therapy propagates thrombosis in vascular structures [8]. When estrogens are discontinued after prolonged use, the associted thrombogenesis may take up to a week to resolve.

During pregnancy, procoagulant factors like plasma fibrinogen increases in concentration to more than twice its normal concentration. Fibrinolysis is also greatly impaired during this gestational period.

Mucin producing visceral carcinoma can trigger a hypercoagulable state in affected patients.

Prevention

High risk patients on long rides or flights should regularly move their lower extremities to prevent hemostasis and blood clot formation. Avoidance of tight clothing lowers the risk of thrombophlebitis. Regular and adequate hydration is needed to prevent hypercoagulable states. Patients prescribed with blood thinning medications must comply with it religiously to prevent thrombosis and embolic events from happening.

Summary

Thrombophlebitis occurs when blood clots start to obstruct one or more veins of the lower extremities; although thrombophlebitis can sometimes affect the superficial veins of the neck and arms.

Thrombophlebitis is often associated with long periods of inactivity, trauma and surgery. Patients with pronounced varicose veins can develop superficial thrombophlebitis. Clotting and inflammation of the deep veins is more prone to embolus formation, which can adversely be lodged to the lungs and cause life-threatening pulmonary embolism. Both superficial and deep thrombophlebitis are effectively treated with blood thinning medications.

Patient Information

Thrombophlebitis refers to the development of clots in one or more veins in the body with subsequent inflammation. This leads to pain, reddening and swelling of the affected region. Long periods of inactivity, injuries to the veins and inherited disorders of blood clotting are important risk factors for this condition. A number of medicines and surgical procedures can effectively treat this disease. Early treatment prevents the dangerous complication of dislodgement of the clot into the lungs. 

References

Article

  1. Belcaro G, Nicolaides AN, Errichi BM, Cesarone MR, De Sanctis MT, Incandela L, et al. Superficial thrombophlebitis of the legs: a randomized, controlled, follow-up study. Angiology. Jul 1999; 50(7):523-9.
  2. Agnelli G, Verso M, Ageno W, Imberti D, Moia M, Palareti G, et al. The MASTER registry on venous thromboembolism: description of the study cohort. Thromb Research. 2008; 121:605-610.
  3. Plate G, Eklöf B, Jensen R, Ohlin P. Deep venous thrombosis, pulmonary embolism and acute surgery in thrombophlebitis of the long saphenous vein. Acta Chir Scand. 1985; 151(3):241-4.
  4. Krunes U, Lindner F, Lindner R, Gnutzmann J. Genugt die klinische untersuchung einer varikophlebitis des unterschenkels? Phlebologie. 1999; 28:93-6.
  5. De Stefano V, Rossi E, Paciaroni K, Leone G. Screening for inherited thrombophilia: indications and therapeutic implications. Trends Hematol Oncol. 2002; 87:1095-1108.
  6. Buchanan GS, Rodgers GM, Branch DW. The inherited thrombophilias: genetics, epidemiology, and laboratory evaluation. Best Pract Res Clin Obst Gynecol. 2003; 138:128-34.
  7. Rick ME. Protein C and protein S. Vitamin K-dependent inhibitors of blood coagulation. JAMA. Feb 2 1990; 263(5):701-3.
  8. Kaplan NM. Cardiovascular complications of oral contraceptives. Annu Rev Med. 1978; 29:31-40.
  9. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. Feb 2012; 141(2 Suppl):e419S-94S.
  10. Beatty J, Fitridge R, Benveniste G, Greenstein D. Acute superficial venous thrombophlebitis: does emergency surgery have a role? Int Angiol. Mar 2002; 21(1):93-5.

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Last updated: 2019-07-11 21:39