Thrombophlebitis Authors Ryan Nipp MD Level Basic Academic

Thrombophlebitis Author(s): Ryan Nipp, MD Level: Basic Academic Affiliation : Duke University Internal Medicine Residency Version No: 1. 0 Submitted: March 2012 Editors’ Review:

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3 Financial Disclosures (past 3 years) • No Disclosures

4 Learning Objectives • Know the definition of thrombophlebitis • Understand how a thrombus forms • Recognize how thrombophlebitis presents • Identify the appropriate diagnosis strategy • Have a broad differential diagnosis • Learn how to prevent this problem • Appreciate the treatment options

5 Outline • What is thrombophlebitis? • Risk Factors • Virchow's Triad • History and Physical Exam • Diagnosis and Differential Diagnosis • Prevention and Treatment

6 What is it? • Thrombophlebitis - inflammation due to a blood clot in the vein • Usually occurs in veins of the legs • Superficial thrombophlebitis occurs in veins just under the skin • The area is usually reddened, tender, and warm to the touch and can be painful

7 Risk Factors • Inactivity : recent injury, surgery, prolonged sitting, recent travel • Pregnancy or recent childbirth • Oral contraceptive use or estrogen therapy • Cancer • Stroke or other diseases that limit movement • Familial clotting disorders (thrombophilia) • Central venous catheters (used for injection or medications or for dialysis)

8 Virchow's Triad Venous Stasis CLOT Hypercoagulable State Vascular Wall Injury

9 History • Gradual onset • Local tenderness • Erythema along path of vein • Trauma at the site • Recent Travel • Hormone Use • Tobacco Use • Coagulopathy in the Family

10 Physical Exam 1. Visual Inspection - erythema, edema, and pain 2. Palpation - firm, thick, thrombosed vein 3. Percussion - Propagation of a palpable pulse wave suggests that a fluid-filled vessel with open or incompetent valves connects the two locations

11 Diagnosis • Physical Exam • Elevated D-dimer • Ultrasound • If pulmonary embolism is suspected, computed tomography (CT)

12 Differential Diagnosis • DVT (deep venous thrombosis – Blood clot usually in the large veins in the lower leg and thigh • Venous Insufficiency • Cellulitis • Lymphedema • Tendonitis • Varicosities Buerger's disease clinical features of thromboangiitis obliterans often include a triad of claudication of the affected extremity, Raynaud's phenomenon, and migratory superficial thrombophlebitis.

13 Prevention • Move your legs, especially during prolonged sitting (such as air travel) or bed rest • Use compression (strong support) stockings • Discuss your personal and family history with your doctor before considering hormone therapy

14 Treatment • Elevate the leg • Warm compresses to the area, and medication to decrease pain and inflammation • Support stockings may be worn to reduce swelling NSAIDs vs LMWH - Cochrane 2012 NSAIDs (Nonsteroidal anti-inflammatory drugs) LMWH (low-molecular-weight heparin) • DVT or pulmonary embolism anticoagulation with heparin (by injection) or warfarin • Pregnant women no warfarin, it can harm the developing fetus

15 Summary • Know the definition of thrombophlebitis • Understand how a thrombus forms • Recognize how thrombophlebitis presents • Identify the appropriate diagnosis strategy • Have a broad differential diagnosis • Learn how to prevent this problem • Appreciate the treatment options

16 Key References • Di Nisio M, Wichers IM, Middeldorp S. Cochrane Database Syst Rev. 2012 Mar 14; 3: CD 004982. Treatment for superficial thrombophlebitis of the leg. • JAMA. 2011 Apr 6; 305(13): 1372. JAMA patient page. Thrombophlebitis. Torpy JM, Burke AE, Golub RM.

17 Acknowledgements

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