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CLASSIC LIST

26/Sep/2017

SUPERFICIAL THROMBOPHLEBITIS

1. Definition

Superficial thrombophlebitis is thrombosis of superficial veins associated with vein wall inflammatory changes.

2. Epidemiology

Incidence:  400/100,000 annually.
Age range: Incidence higher in older ages.
Sex ratio:    Women more commonly than men
Associated disorders: More common in the obese, Pregnancy and the oral contraceptive pill

3. Aetiology

1. Varicose veins account for 80% of cases and usually following minor trauma such as a knock.

2. Intravenous indwelling catheters. This is especially likely if
a. The drugs being administered are hyperosmolar such as parental nutrition, contrast media or following sclerotherapy for varicose veins.
b. The canular is peripherally placed where blood flow is slow.
c. The cannula has been in situ for more than two days.

3. Malignancies such as those of pancreas, lung, gastrointestinal, ovary and prostate can produce a superficial thrombophlebitis, which migrates and recurs often lasting for two or so days before resolving with recanulization of the thrombus.

4. Immunological disorders such as Buerger’s disease, Bechet’s disease and Systemic lupus

5. Septic thrombophlebitis: staph. Aureus, klebsiella, Enterobacter, Proteus.

6. Haematological disorders: Thrombocythaemia, Polycythemia vera, leukaemia, lymphoma

7. Primary hypercoagulable states (thrombophylias)

4. Clinical features:

Symptoms can present relatively suddenly. They consist of a tender mass along the normal course of a subcutaneous vein, the overlying skin being erythematous and hot. The associated pain can be severe and extend along the whole course of the vein.

5. Differential diagnosis

1. Lymphangitis
2. Deep vein thrombosis
3. Erythema nodosum
4. Acute lipodermatosclerosis
5. Vasculitis, percutaneous polyarteritis nodosum, sarcoid, karposi sarcoma

6. Prognosis and complications

In its self, superficial thrombophlebitis is a benign self-limiting disorder. There are, however significant aetiological risk factors which have been outline above. Also there is a definite risk of an associated thrombosis in the deep veins.

There is an associated deep vein thrombosis in up to 25% of case of superficial thrombophlebitis. It is most common when the long saphenous leg vein; especially the thigh is involved.The incidence of concomitant pulmonary embolism in superficial thrombophlebitis is 5%.

7. Investigations

1. A duplex ultrasound scan of the related deep veins will exclude an associated deep vein thrombosis. Venography is reserved for those who have a deep vein thrombosis extending above the inguinal ligament.
2. Cancer screen. The extent and type of the search for an occult malignancy depends on the individual patient’s history. If no varicose veins are present and the superficial thrombophlebitis is migratory in nature a chest x-ray and abdominal ultrasound or CT scan possibly with an upper alimentary endoscopy is indicated.
3. Blood test: erythrocyte sedimentation ratio (ESR), C-reactive protein, Serum urea and electrolyte levels, Liver function tests, Autoantibody screen including anti-nuclear antibody levels (ANA) Blood clotting levels Thrombophylia screen (Activated protein C resistance, Antithrombin deficiency Protein C and Protein S deficiency, Lupus anticoagulant, anticardiolupin antibodies)
8. Treatment

1. Remove precipitating factors.

a. Varicose vein surgical intervention should be undertaken urgently only if the thrombus, (as identified on duplex ultrasound scan) has extended along the length of the superficial vein, in particular the long saphenous vein and may imminently extend further into the deep veins.

In such case and in cases where pulmonary embolisation has occurred only the junction between the superficial and deep venous systems should be surgically disconnected and the rest of the superficial vein not subjected to stripping or avulsions in the acute phase. In case where the superficial thrombophlebitis is not as aggressive the varicose veins should be treated once the superficial thrombophlebitis has settled, so as to prevent further episodes.

b. Indwelling catheters these should be changed every 48 hours to prevent the development of superficial thrombophlebitis. Venous cannulation of the lower extremities should be avoided. Using GTNpatches over peripheral lines reduces the incidence of TPNinfusion induced superficial thrombophlebitis. Once it has developed the offending cannular needs to be removed.

c. In haematological disorders anticoagulation may be necessary.

2. Symptomatic relief

a. Oral analgesia. Non-steroidal anti-inflammatory drugs decrease the pain and shorten the duration of symptoms, but the risk of side effects should not be forgotten.

b. Topical analgesia. Non-steroidal anti-inflammatory creams (e.g. Diclofenac cream) applied locally to the inflamed area reduce the pain and shorten the duration of symptoms. Hirudoid cream, a heparinoid ointment also shortens the duration of symptoms and can be used if anti-inflammatory creams are not tolerated.

c. Mild graduated compression stockings often offer relief of symptoms and act as prophylaxis against the development of a DVT. In the early very inflamed state however, some find the stockings difficult to tolerate.

3. Exercise. In mild cases exercise is actively encouraged. However, in case where the pain is very severe bed rest is necessary. DVT prophylaxis is ensured with subcutaneous heparin.

4. Antibiotics do not have a place in superficial thrombophlebitis. Their use is reserved for cases of superadded infections.

Summary

Superficial thrombophlebitis is in its self-a benign limiting condition, which is best, treated with simple analgesics. Although commonly associated with varicose veins it can, however, be a marker of more severe underlying disease such as a malignancy or haematological disorder. It can also be associated with deep venous thrombosis, both of which need to be treated.


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Daryll Baker is a Consultant Vascular Surgeon at the Royal Free Hospital London and Clinical Lead for North Central Region Vascular Services.

He read Medicine at Oxford University and trained in Vascular Surgery in Nottingham, London and Edinburgh. He obtained his research PhD from the University of Wales.

Contact

Wellington Hospital
34 Circus Road
London
NW8 9SG

020 7722 7370

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