12-15: Superficial Venous Thrombophlebitis

ESSENTIALS OF DIAGNOSIS

GENERAL CONSIDERATIONS

Short-term venous catheterization of superficial arm veins as well as the use of longer-term peripherally inserted central catheter (PICC) lines are the most common cause of superficial thrombophlebitis. Intravenous catheter sites should be observed daily for signs of local inflammation and should be removed if a local reaction develops in the vein. Serious thrombotic or septic complications can occur if this policy is not followed; S aureus is the most common pathogen. Other organisms, including fungi, may also be responsible.

Superficial thrombophlebitis may occur spontaneously, often in pregnant or postpartum women or in individuals with varicose veins, or it may be associated with trauma, as with a blow to the leg or following intravenous therapy with irritating solutions. It also may be a manifestation of systemic hypercoagulability secondary to abdominal cancer such as carcinoma of the pancreas and may be the earliest sign of these conditions. Superficial thrombophlebitis related to a PICC may be associated with occult DVT in about 20% of cases, but occult DVT is much less commonly associated with spontaneous superficial thrombophlebitis of the saphenous vein (about 5% of cases). Pulmonary emboli are exceedingly rare and occur from an associated DVT (see Chapters 9 and 14).

CLINICAL FINDINGS

A. Symptoms and Signs

In spontaneous superficial thrombophlebitis, the great saphenous vein is most often involved. The patient usually experiences a dull pain in the region of the involved vein. Local findings consist of induration, redness, and tenderness along the course of a vein. The process may be localized, or it may involve most of the great saphenous vein and its tributaries. The inflammatory reaction generally subsides in 1–2 weeks; a firm cord may remain for a much longer period. Edema of the extremity is uncommon.

Localized redness and induration at the site of a recent intravenous line requires urgent attention. Proximal extension of the induration and pain with chills and high fever suggest septic phlebitis and requires urgent treatment.

B. Imaging

Duplex ultrasound of the involved extremity is the standard of care to establish the extent of superficial thrombophlebitis and detect the presence of DVT.

DIFFERENTIAL DIAGNOSIS

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

TREATMENT

For focal, spontaneous thrombophlebitis not near the saphenofemoral junction, local heat and NSAIDs are usually effective in limiting ...