Thrombophlebitis of the Superficial Veins

Introduction

Essentials of Diagnosis

• Induration, redness, and tenderness along a superficial vein.
  
• Often a history of recent intravenous line or trauma. No significant swelling of the extremity.

General Considerations

Superficial thrombophlebitis may occur spontaneously in patients with varicose veins, in pregnant or postpartum women, or in patients with thromboangiitis obliterans or Behcet's disease. It can also occur after trauma, such as a blow to the leg, or after intravenous infusion. A migratory thrombophlebitis may be a manifestation of abdominal cancer such as carcinoma of the pancreas (Trousseau's syndrome).

The long saphenous vein and its tributaries are most often involved. Superficial thrombophlebitis is associated with occult DVT in about 20% of cases. Pulmonary emboli are rare unless extension into the deep venous system occurs.

Clinical Findings

The patient usually experiences a dull pain in the region of the involved vein. Induration, redness, and tenderness correspond to dilated, thrombosed superficial veins. Edema of the extremity and deep calf tenderness are absent unless the deep veins are involved. Chills and high fever suggest septic or suppurative phlebitis, which is most often encountered as a complication of an indwelling intravenous catheter. Plastic intravenous catheters should be observed daily for signs of local inflammation and removed if a local reaction develops to avoid serious thrombotic or septic complications.

Differential Diagnosis

The linear rather than circular nature of the lesion and the distribution along the course of a superficial vein help to differentiate superficial phlebitis from cellulitis, erythema nodosum, erythema induratum, panniculitis, and fibrositis. Lymphangitis and deep thrombophlebitis must also be considered.

Treatment

The primary treatment of superficial venous thrombophlebitis is the administration of nonsteroidal anti-inflammatory drugs, local heat, and elevation. Ambulation is encouraged. In the majority of circumstances, symptoms will resolve within 7-10 days. Excision of the involved vein is recommended for symptoms that persist over 2 weeks on treatment, or for recurrent phlebitis in the same vein segment. If there is progressive proximal extension to the saphenofemoral junction or cephalic-subclavian junction, ligation and resection of the vein at the junction should be performed. Anticoagulation is reserved for rapidly progressing disease or extension into the deep system.

Septic thrombophlebitis requires treatment with intravenous antibiotics. As the causative organism is often staphylococcus or a gram-negative rod, broad-spectrum antibiotic coverage should be instituted until blood culture results become available. If rapid resolution of the phlebitis occurs, no treatment beyond a 7- to 10-day course of antibiotics is required. However, if the patient becomes septic, immediate excision of the infected vein is required.