Thrombophlebitis

Differential Diagnosis

Arterial insufficiency

Arterial occlusive disease

Arthritis

Asymmetrical peripheral edema

Baker cyst

Cellulitis

Chronic venous insufficiency

Hematoma

Lipodermatosclerosis

Lymphangitis

Lymphedema

Neuritis

Postphlebitic syndrome

Tendinitis

Thrombophlebitis, septic

Varicose veins

Thrombophlebitis is an inflammation of a vein

(phlebitis) accompanied by an increased
tendency to form blood clots
(hypercoagulability), which leads to the
formation of a blood clot (thrombus) in the
vein. It can develop spontaneously or can be a
complication of an injury, a disease, or a
medical or surgical treatment.
Thrombophlebitis can be separated into two
main categories depending on the depth of the
inflamed veins containing the blood clots:
those that occur in veins just below the surface

of the skin (superficial thrombophlebitis) and

those that occur in a deep vein that usually
accompanies an artery (deep venous
thrombosis [DVT]). Although both conditions
stem from the same causes and involve a
similar physiologic process, superficial
thrombophlebitis usually is not life
threatening, while DVT is associated with
high morbidity and mortality. (Please refer to
Deep Vein Thrombosis for more specific
information). Migratory thrombophlebitis that
passes from one leg to the other is associated
with pancreatic or lung cancer, and the
diagnostic process must focus on finding a
possible malignancy. Septic thrombophlebitis
is another serious form of the condition
accompanied by infection and life-threatening
coagulation abnormalities.
Thrombus formation is part of the normal
coagulation of blood that helps prevent
bleeding when blood vessels are penetrated or
injured. However, if blood does not move
through a vessel as quickly as it should
(venous stasis, venostasis) or a vessel is
injured in some way, an inflammatory
response begins in the blood vessel, and
thrombus (clot) formation may follow. In
superficial thrombophlebitis, the inflammatory
response is followed immediately by platelet
aggregation at the site of the injury, the first
step in clot formation. A common example is
clot formation at the insertion site of an
intravenous (IV) line or as a result of trauma
to the vein. Platelet aggregation in this type of
thrombophlebitis usually can be decreased
with anti-inflammatory medications. The
treatment goal is to prevent superficial
phlebitis from progressing, and thus affecting
deeper veins and causing damage that can lead
to chronic blood flow problems in the deep
veins (deep vein insufficiency, sometimes
referred to as postphlebitic syndrome).
Deep vein thrombosis (DVT) develops as a
result of three conditions referred to as the
Virchow triad: venous stasis, injury to the
vein, and a state of hypercoagulability. A
thrombus is most likely to form in the larger
veins in the lower extremities (lower leg and
thigh). This thrombus may interfere with
circulation in the legs, and the clot may break
off and travel through the bloodstream

(embolize). The migrating thrombus

(embolus) can pass through the bloodstream to
the heart, and then lodge in an artery of the
lungs (pulmonary embolism), reducing the
flow of blood and oxygen availability and
causing shortness of breath and chest pain.
Pulmonary embolism is the most frequent and
serious complication of DVT. In individuals
with an atrial septal defect (patent foramen
ovale) or a ventricular septal defect, an
embolus of venous origin can pass through the
septal defect from the right side to the left side
of the heart, and cause a brain embolism
(stroke) called a paradoxical embolism. DVT
requires prompt treatment with anticoagulant
medications and sometimes requires surgery.
Incidence and Prevalence: The statistics on
thrombophlebitis are illusive. Few studies
examine the incidence and prevalence of
thrombophlebitis and many that do are
outdated. Surveillance of thrombophlebitis is
difficult as many cases go undiagnosed or
misdiagnosed. Approximately 65% of the
reported cases occur in women with an
average age of 60 years (Decousus; CaneroVidal). The incidence of superficial
thrombophlebitis is likely higher than DVT,
which has an estimated incidence of at least
56-160 cases per 100,000 per year or 3-11% of
the population (Decousus; Canero-Vidal). This
is about double the incidence of DVT and
pulmonary embolism combined. DVT and
related pulmonary embolism are the leading
preventable cause of death in hospitalized
individuals.

Source: Medical Disability Advisor

Causation and Known Risk Factors
Risk factors for superficial thrombophlebitis
include an increased blood-clotting tendency,
infection in or near a vein, current or recent
pregnancy, varicose veins, chemical irritation,
and other local irritation or trauma. Prolonged
sitting, standing, or immobilization such as
bed rest at home or during hospitalization may
also increase the risk. Superficial
thrombophlebitis may occasionally be
associated with abdominal cancers (e.g.,
carcinoma of the pancreas), DVT,
inflammation, and clotting of small and

medium arteries (Buerger's disease, also called

thromboangiitis obliterans), and (rarely) with
pulmonary embolism.
Risks for DVT include prolonged sitting, bed
rest, or immobilization; recent surgery or
trauma, especially hip surgery, gynecologic
surgery, heart surgery, or fractures; childbirth
within the last 6 months; obesity; smoking;
and the use of medications such as estrogen
and birth control pills. Other risks include a
history of malignant tumor, polycythemia
vera, changes in the levels of blood clotting
factors increasing tendency to clot, mutations
in the genes for certain clotting factors,
disseminated intravascular coagulation (DIC),
and dysfibrinogenemia.
Source: Medical Disability Advisor

Diagnosis

History: Many individuals are asymptomatic.

Those with symptoms may report leg pain, leg
swelling (edema), and in superficial
thrombophlebitis tender, warm skin over the
area of the thrombosis. Redness (erythema)
may appear along a superficial vein.
Individuals also may report a history of recent
surgery, prolonged periods of bed rest,
inactivity (e.g., prolonged airplane or auto
travel), trauma, varicose veins, and previous
hypercoagulability or DVT. A family history
of thrombosed veins and/or pulmonary
embolism may also be described.
Physical exam: Skin signs may be visible and
noticeable to the touch (palpable). The area
above the superficial vein thrombosis may
appear red and feel warm with a hard, cordlike mass apparent beneath the skin, which
can be confirmatory. The area is extremely
sensitive to pressure; the individual will feel
pain during palpation or compression of the
affected area. Superficial thrombophlebitis
cannot be diagnosed solely on the basis of the
physical examination if a thrombosed vein is
not palpable, since erythema, edema, and pain
are common to many other conditions (e.g.,
obstruction, venous reflux, cardiac problems,
renal failure, infection, trauma). In cases of

suspected DVT there may be swelling, and

palpation over the veins in the groin, behind
the knee (popliteal) or inside the thigh may
reveal tenderness, and pain. Some individuals
will have calf pain when the foot is passively
moved upwards into dorsiflexion (Homan's
sign); however, this is an unreliable finding
(Tovey). A bluish discoloration of the entire
lower leg when the collateral outflow veins
are thrombosed (phlegmasia cerulea dolens),
or painful white edema (phlegmasia alba
dolens) and the absence of pulses, may be
noted in DVT. However, DVT is difficult to
diagnose on the basis of signs and symptoms
alone.

negative is good evidence that DVT is not

present.

Tests: No diagnostic procedures are generally

needed for superficial thrombophlebitis unless
an individual has a history of coagulation
disorders or previous DVT. An erythrocyte
sedimentation rate (ESR) and C-reactive
protein (CRP) may be done to determine if
inflammation is present. A complete blood
count (CBC) and peripheral smear may help to
rule out infection as a cause of symptoms.
Frequent checks of pulse, blood pressure,
temperature, skin condition, and circulation
usually are done in a hospitalized patient.

Source: Medical Disability Advisor

When DVT is suspected, a number of

diagnostic procedures may be performed in
order to rule out arterial occlusive disease,
inflammation of a lymphatic channel
(lymphangitis), infection of the subcutaneous
tissue beneath the skin (cellulitis), and muscle
inflammation (myositis). Tests may also
confirm the site and extent of venous
occlusion. Color-flow Doppler ultrasound may
be used to diagnose blood clots in the leg
veins. Plethysmography, which measures
changes in blood volume in the extremities,
also may be used to evaluate the presence of
venous obstruction. Less often, a venogram,
an x-ray of the veins following dye injection,
may be performed. As with color-flow
Doppler ultrasound, this test can identify the
location of venous obstruction in a limb.
Rarely, magnetic resonance imaging (MRI) or
computed tomography (CT) scan may be
performed. D-Dimer blood tests are performed
to measure clot-related substances in the
blood, and serve as a rapid screening test for
DVT. A high sensitivity D-Dimer test that is

If migratory thrombophlebitis is present,

diagnostic testing must include a workup for
possible malignancy. CT angiography of the
chest may be done if pulmonary embolism is
suspected as a complication of DVT.
For recurrent cases with no obvious
explanation, blood testing for clotting factor
mutations is performed (e.g., lupus
anticoagulant, factor V Leiden, protein S,
protein C, antithrombin III).

Treatment
The goals of treatment for superficial
thrombophlebitis are to increase comfort and
to prevent progression to DVT. Non-steroidal
anti-inflammatory drugs (NSAIDs) usually
will reverse the inflammation characteristic of
superficial thrombophlebitis and help relieve
pain. Anticoagulants (e.g., warfarin) may be
used to prevent new clot formation.
Thrombolytic therapy is used infrequently to
dissolve an existing clot. Antibiotics may be
used if an infection is present.
Compression stockings (thrombo-embolism
deterrent [TED] hose) are routinely
recommended and are able to reduce the
incidence of recurrent DVT (Kearon).
Compression also may be useful in helping to
reduce pain in some cases. Moist heat may
also be applied to decrease inflammation and
pain of superficial thrombophlebitis. The
affected limb may be elevated to reduce
edema and pain by reducing pressure on the
inflamed vein, and to decrease the risk of
further damage. However, some physicians
and recent research studies suggest that
elevation of the leg and the immobility of bed
rest promote venostasis, an important risk
factor for DVT, and therefore continued
ambulation may be recommended to limit
venostasis and clot formation. Air travel, long
car rides, and bed rest are not recommended

for people with any type of phlebitis or

increased blood clotting tendency.
Surgical intervention including clot removal
(thrombectomy), vein stripping, or vein
bypass is rarely needed in superficial
thrombophlebitis but may be considered if
anticoagulant therapy is ineffective. A
symptomatic, painful superficial vein may
instead be punctured and a clot removed
(puncture and evacuation) under local
anesthesia, providing rapid relief.
DVT requires anticoagulant therapy as soon as
possible after diagnosis is confirmed. Lowmolecular-weight heparin (LMW heparin) is
used immediately to prevent thrombus
extension, and often can decrease the risk of
thrombus formation and embolus migration. It
does not dissolve the existing clot, but
prevents extension (growth) of the clot, and
prevents recurrence of thrombosis. It is often
given simultaneously with the initiation of
warfarin therapy to reverse the
hypercoagulability until warfarin has had the
time necessary to control the
hypercoagulability. Individuals with recurrent
venous thrombosis or risk factors that are not
correctable (e.g., prior DVT, clotting factor
mutations, or advanced stage cancer) may be
candidates for longer-term anticoagulation.
Thrombolytic therapy may be given in those
with DVT to dissolve the original clot and
prevent pulmonary embolism. It does not
prevent new clot formation and must be
followed by oral anticoagulation therapy. A
"bird cage" filter may be placed in the major
vein in the abdomen (inferior vena cava) that
carries blood from the lower body to the heart
to prevent pulmonary embolism in an
individual with DVT. The procedure involves
giving local anesthesia, insertion of the cagelike filter (e.g., Greenfield filter) through the
femoral artery in the groin, and threading it
into place in the vena cava using fluoroscopy
or ultrasound images to guide the placement.
Thrombectomy is more often performed for
DVT when anticoagulant therapy is ineffective
or contraindicated.
Source: Medical Disability Advisor

Prognosis
The prognosis for superficial thrombophlebitis
is generally favorable, as this usually responds
to prompt medical treatment. Complete
recovery usually occurs within a relatively
short period with pharmacological or surgical
intervention. Recurrence is reported in 15% to
20% of patients (Gorty).
The prognosis for DVT varies based on
location. Isolated distal DVT has a generally
better prognosis compared to proximal DVT
with the exception of those with cancer
(Galanaud). Long-term complications of DVT
include venous stasis, induced skin ulceration,
and venous insufficiency in lower leg veins.
Massive pulmonary embolism (PE) is a
leading cause of death in hospitalized
individuals, accounting for 10% of hospital
deaths each year in the US (DeMonaco).
Source: Medical Disability Advisor
Complications
The most common complication of superficial
thrombophlebitis is progression to the deeper
veins, with development of DVT and
increased risk of pulmonary embolism.
Surgery, stroke, heart attack (myocardial
infarction), paralysis, high blood pressure
(hypertension), and infection are possible
complications but occur less frequently.
Venous ulceration and venous insufficiency of
the lower leg are long-term complications of
DVT. A serious, potentially fatal complication
of DVT is a pulmonary embolism, wherein the
blood clot or a piece of the clot dislodges from
its site of origin and lodges in one of the
pulmonary arteries of the lung. Hemorrhagic
complications are possible and serious in
patients receiving thrombolytic therapy and
can include cerebral hemorrhage.
Anticoagulant therapy may lead to blood
clotting problems if the dose is inappropriate
or if the individual has an allergy to the
anticoagulant medications. There is also a risk
of later recurrence of thrombophlebitis in the
same area due to scarring of the veins.