Superficial Thrombophlebitis in Emergency Medicine Clinical Presentation

Patients with superficial thrombophlebitis often give a history of a gradual onset of localized tenderness, followed by the appearance of an area of erythema along the path of a superficial vein. A history of local trauma, prior similar episodes, varicose veins, prolonged travel, hormone use, tobacco use, family history of blood coagulopathies, or enforced stasis may be given. Asking about these risk factors for hypercoagulability should be done, but the absence of identifiable risk factors has no prognostic value.

• Traumatic thrombophlebitis: Ask about trauma, needlesticks, indwelling IV catheters, drug (eg, phenytoin) or hypertonic (10% calcium chloride) solution infusion and sclerotherapy.
• Thrombosed varicose veins: Ask about history of varicose veins, previous history of thrombosed varices, and any injury to the leg with the varices. One should ascertain whether there was a thrombosed vein and timing of erythema and pain.
• Thrombosed hemorrhoids: History, as in varicose veins, should focus on previous history of thromboses, surgical intervention, and timing of symptoms.
• Other, migratory thrombophlebitis: Also known as Trousseau’s sign of malignancy, this is described as thrombophlebitis that travels, often one leg to another. It has a strong association of adenocarcinoma of the pancreas and lung, and, therefore, history should be directed toward finding malignancy.

Inspection

Visual appearance is not a reliable guide to a peripheral venous condition, because the clinical findings of venous disease (erythema, edema, and pain) are common to many other entities. Swelling may result from acute venous obstruction (as in deep vein thrombosis) or from deep or superficial venous reflux, or it may be caused by an unrelated disease condition such as hepatic insufficiency, renal failure, cardiac decompensation, infection, trauma, or environmental effects. Lymphedema may be primary or it may be secondary to overproduction of lymph due to severe venous hypertension.

Normal veins are distended visibly at the foot, ankle, and occasionally in the popliteal fossa, but not in the rest of the leg. Normal veins may be visible as a blue subdermal reticular pattern, but dilated superficial leg veins above the ankle usually are evidence of venous pathology.

Darkened, discolored, stained skin or nonhealing ulcers are typical signs of chronic venous stasis, particularly along the medial ankle and the medial lower leg. Chronic varicosities or telangiectasias also may be observed.

Palpation

Palpation of a painful or tender area may reveal a firm, thickened, thrombosed vein. Palpable thrombosed vessels are virtually always superficial.

Percussion

Perthes percussive test is a classic maneuver with high sensitivity (97%) but low specificity (20%)^[4] that tests if venous segments are interconnected. With the patient in a standing position, a vein segment is tapped at one location while an examining hand feels for a pulse wave at another location. Propagation of a palpable pulse wave suggests that a fluid-filled vessel with open or incompetent valves connects the two locations.

A pulse wave may be propagated after prolonged standing in the absence of true pathology, because prolonged standing causes even normal veins to become distended and normal valves to float open.

Perthes test is most valuable when a bulging varicosity in the lower leg has no obvious connection with a varicosity in the upper thigh. A palpable pulse wave propagation between the two vessels is proof positive of the existence of an unseen connection.

Trendelenburg test

The Trendelenburg test is a classic physical examination maneuver that helps to distinguish superficial venous reflux from incompetence of the deep vein valves.

The leg is elevated until all superficial veins have collapsed, and the point of suspected reflux from the deep system is occluded by manual compression or by a tourniquet. The patient is then asked to stand, and the distal varicosity is observed for refilling. If the distal varicosity remains mostly empty, the reflux pathway is principally through the peripheral varicosity that has been occluded.

Inability to prevent rapid filling of the varicosity despite manual occlusion of the suspected high point of reflux suggests that another reflux pathway is involved.

Rapid refilling of calf varices despite occlusion of the proximal trunk suggests deep system reflux or failure of the valves of multiple perforating veins.

The most important clinically identifiable risk factors for thrombophlebitis are a prior history of superficial phlebitis, deep vein thrombosis, and pulmonary embolism. Some common risk markers include recent surgery or pregnancy, prolonged immobilization, and underlying malignancy. Other recognized markers of risk for venous thromboembolic disease are listed here.

• AIDS (lupus anticoagulant)
• Antithrombin III deficiency
• Behçet disease
• Blood type A
• Burns
• Catheters (indwelling venous infusion catheters)
• Chemotherapy
• Congestive heart failure
• Drug abuse (intravenous [IV] drugs)
• Drug-induced lupus anticoagulant
• DVT in the past
• Estrogen replacements (high dose only)
• Fibrinogen abnormality
• Fractures
• Hemolytic anemias
• Heparin-associated thrombocytopenia
• Homocysteinemia
• Homocystinuria
• Hyperlipidemias
• Immobilization
• Malignancy
• Myocardial infarction
• Obesity
• Old age
• Oral contraceptives
• PE in the past
• Phenothiazines
• Plasminogen abnormality
• Plasminogen activator abnormality
• Polycythemia
• Postoperative
• Postpartum period
• Pregnancy
• Protein C deficiency
• Protein S deficiency
• Resistance to activated protein C
• Systemic lupus erythematosus Thrombocytosis
• Trauma
• Ulcerative colitis
• Varicose veins
• Venography
• Venous pacemakers
• Venous stasis
• Warfarin (first few days of therapy)