Thrombophlebitis

Snapshot

• A 60-year-old woman presents to her physician’s office for a painful cord-like rash on her left calf. She reports that it is red, painful to the touch, and seems like a varicose vein. She has had multiple varicose veins in the past but nothing as painful or red as this lesion. She reports that she is currently undergoing estrogen replacement therapy, as menopause has been a difficult transition. On physical exam, there is erythema and tenderness along the cord-like lesion, which feels thick and hardened on palpation. She is counseled on the benefits of compression therapy.

Introduction

• Clinical definition
  • a thrombotic disorder characterized by thrombi and inflammation (phlebitis) in the superficial veins
• Epidemiology
  • demographics
    • women > men
    • more common in adults
  • location
    • most commonly in the lower extremities
    • can also occur at sites of trauma (e.g., sites of intravenous catheters)
  • risk factors 
    • venous stasis
    • varicose veins
    • hypercoagulable state
    • pregnancy
    • high-dose estrogen therapy
    • malignancy
    • immobilization
• Pathogenesis
  • endothelial injury can trigger thrombus formation and inflammatory response
• Associated conditions
  • migratory thrombophlebitis (Trousseau syndrome)
  • deep venous thrombosis
  • Buerger disease
• Prognosis
• self-limited, but can recur frequently

Presentation

• Symptoms
  • pain of the involved site
• Physical exam 
  • erythema and edema along the vein 
  • tenderness along the vein 
  • palpable thickened or thrombosed vein
  • visibly distended veins 
• while distended veins below the ankle are normal, it is suggestive of pathology if the distended veins are above the ankle

Imaging

• Duplex ultrasound 
  • indications
    • a confirmatory imaging test
    • to evaluate for deep venous thrombosis
  • findings
    • impaired blood flow
• lack of compressibility of the vein

Studies

• Labs
  • D-dimer is not useful in this disease
• Making the diagnosis
• based on clinical presentation

Differential

• Deep venous thrombosis
  • distinguishing factor
• thrombosed vein is typically not palpable

Treatment

• Management approach
  • pain management
  • prevent extension into deep venous system
• Conservative
  • compression
    • indication
      • for all patients
• Medical
  • anticoagulation
    • indication
      • not usually indicated unless process involves deep venous system
      • drugs
        • low molecular weight heparin
        • fondaparinux
  • nonsteroidal anti-inflammatory drugs (NSAIDs)
    • indication
• pain management only in patients who did not undergo anticoagulation

Complications

• Progression to deep venous system
  • pulmonary embolism
  • deep venous thrombosis