eMedicine Specialties > Emergency Medicine > Cardiovascular
Thrombophlebitis, Superficial: Differential Diagnoses & Workup
Updated: Sep 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Differential Diagnoses
| Baker cyst | Neuritis |
| Cellulitis | Postphlebitic syndrome |
| Chronic venous insufficiency | Ruptured medial head of the
gastrocnemius |
| Deep Venous Thrombosis and
Thrombophlebitis | Tendonitis |
| Hematoma | Thrombophlebitis, Septic |
| Lipodermatosclerosis | Varicosities |
| Lymphangitis | |
| Lymphedema |
Workup
Laboratory Studies
- Blood tests rarely are helpful in the diagnosis of thrombophlebitis, except in those patients at risk for an underlying hypercoagulable state.
- Several common hypercoagulable states can be identified through laboratory studies. Some of these states include the following:
- Resistance to activated protein C (most often due to factor V Leiden)
- Protein C deficiency
- Protein S deficiency
- Antithrombin III deficiency
- Antiphospholipid antibodies
- Prothrombin gene 2010-a mutation (factor II mutation)
- The prothrombin time (PT) and activated partial thromboplastin time (aPTT) are not useful in the diagnostic evaluation of patients with suspected superficial or deep thrombophlebitis. Most patients with thrombophlebitis have a normal PT and aPTT, and active thrombophlebitis is not uncommon in patients with a therapeutically elevated INR due to warfarin therapy.
- A low white blood cell (WBC) count lowers the likelihood of an infectious process and raises the likelihood of phlebitis. An elevated WBC count is nonspecific because both normal and elevated WBC counts are common in patients with thrombophlebitis. Chronic venous insufficiency (venous congestion due to reflux) and superficial or deep vein thrombosis can mimic leg cellulitis very closely, and true cellulitis (with an elevated WBC count) is a frequent complication of both diseases.
- D-dimer is a unique degradation product produced by plasmin-mediated proteolysis of cross-linked fibrin that is often measured in the evaluation for DVT and PE. However, its use in detecting thrombophlebitis is of little clinical use.5
- In patients with migratory thrombophlebitis, a malignancy workup is appropriate.
Imaging Studies
- Proper diagnosis of venous system disease often requires both functional and anatomic information about the venous circulation.
- The functional tests (discussed below) are extremely useful as measures of whole-leg or regional venous function, but functional tests can detect only regionally significant reflux or a significant impediment to venous outflow.
- Anatomic imaging of the venous system can detect small amounts of local and regional reflux as well as obstructing and nonobstructing thrombus. Unfortunately, anatomic imaging often fails to identify important functional deficits.
- A combination of functional and semi-anatomic or anatomic techniques allows a complete understanding of most venous system pathology.
- All patients with superficial thrombophlebitis above the knee should undergo duplex ultrasonography as the initial diagnostic modality of choice to rule out DVT.
- When the patient has superficial thrombophlebitis below the knee, duplex ultrasonography is only indicated for signs and symptoms consistent with a DVT (eg, asymmetrical swelling, erythema, and pain). Superficial thrombophlebitis in lower extremity varicose veins have an extremely low incidence of DVT.6
- The diagnostic evaluation of patients with potential septic thrombophlebitis, such as phlebitis associated with an intravenous catheter site, is discussed in the article Thrombophlebitis, Septic.
- Magnetic resonance venography (MRV) is a noninvasive test that probably is more sensitive and more specific than ultrasonography in the detection of deep venous thrombophlebitis; however, this is not readily available and is not practical at most institutions.
- Invasive contrast venography, once the criterion standard for evaluation of the venous system, has fallen out of favor due to its invasiveness, use of ionizing radiation, and use of intravenous contrast. In addition, it can lead to venous scarring and thrombophlebitis.
- CT venography is a reasonable alternative to duplex ultrasonography to evaluate the iliac and pelvis venous systems.
Procedures
- Local incision and evacuation
- A painful section of a superficial vein containing a palpable intravascular coagulum may be treated by puncture incision with an 18-gauge needle and evacuation of the clot after local anesthesia. This procedure often produces marked rapid relief and rapid resolution of the inflammation.
- Puncture and evacuation is less effective in the first week after the onset of symptoms because the vessel wall is thickened and the coagulum itself is more cohesive during the early phase of a phlebitis.
More on Thrombophlebitis, Superficial |
| Overview: Thrombophlebitis, Superficial |
 Differential Diagnoses & Workup: Thrombophlebitis, Superficial |
| Treatment & Medication: Thrombophlebitis, Superficial |
| Follow-up: Thrombophlebitis, Superficial |
| References |
| « Previous Page | Next Page » |
References
Verlato F, Zucchetta P, Prandoni P, et al. An unexpectedly high rate of pulmonary embolism in patients with superficial thrombophlebitis of the thigh. J Vasc Surg. Dec 1999;30(6):1113-5. [Medline].
Wichers IM, Di Nisio M, Buller HR, Middeldorp S. Treatment of superficial vein thrombosis to prevent deep vein thrombosis and pulmonary embolism: a systematic review. Haematologica. May 2005;90(5):672-7. [Medline].
Rosendaal FR, Helmerhorst FM, Vandenbroucke JP. Oral contraceptives, hormone replacement therapy and thrombosis. Thromb Haemost. Jul 2001;86(1):112-23. [Medline].
Kim J, Richards S, Kent PJ. Clinical examination of varicose veins--a validation study. Ann R Coll Surg Engl. May 2000;82(3):171-5. [Medline].
Gillet JL, Ffrench P, Hanss M, Allaert FA, Chleir F. [Predictive value of D-dimer assay in superficial thrombophlebitis of the lower limbs]. J Mal Vasc. Apr 2007;32(2):90-5. [Medline].
Bergqvist D, Jaroszewski H. Deep vein thrombosis in patients with superficial thrombophlebitis of the leg. Br Med J (Clin Res Ed). Mar 8 1986;292(6521):658-9. [Medline].
Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev. Apr 18 2007;CD004982. [Medline].
Quenet S, Laporte S, Decousus H, Leizorovicz A, Epinat M, Mismetti P. Factors predictive of venous thrombotic complications in patients with isolated superficial vein thrombosis. J Vasc Surg. Nov 2003;38(5):944-9. [Medline].
Ascher E, Hanson JN, Salles-Cunha S, Hingorani A. Lesser saphenous vein thrombophlebitis: its natural history and implications for management. Vasc Endovascular Surg. Nov-Dec 2003;37(6):421-7. [Medline].
de Godoy JM, Braile DM. Protein S deficiency in repetitive superficial thrombophlebitis. Clin Appl Thromb Hemost. Jan 2003;9(1):61-2. [Medline].
De Maeseneer MG. Superficial thrombophlebitis of the lower limb: practical recommendations for diagnosis and treatment. Acta Chir Belg. Apr 2005;105(2):145-7. [Medline].
Feied CF. Pulmonary chest pain, cor pulmonale and pulmonary embolism. In: Gibler, Aufderheide, eds. Emergency Cardiac Care. Vol 1. ed. Mosby-Year Book; 1994:243-303.
Feied CF. Pulmonary embolism. In: Rosen P, Barkin RM, eds. Emergency Medicine Principles and Practice. 4th ed. Mosby-Year Book; 1998:3.
Feied CF. Peripheral venous disease. In: Rosen P, Barkin RM, eds. Emergency Medicine Principles and Practice. 4th ed. Mosby-Year Book; 1998:3.
Schonauer V, Kyrle PA, Weltermann A, et al. Superficial thrombophlebitis and risk for recurrent venous thromboembolism. J Vasc Surg. Apr 2003;37(4):834-8. [Medline].
Unno N, Mitsuoka H, Uchiyama T, et al. Superficial thrombophlebitis of the lower limbs in patients with varicose veins. Surg Today. 2002;32(5):397-401. [Medline].
Further Reading
Keywords
superficial thrombophlebitis, superficial thrombophlebitis causes, superficial thrombophlebitis treatment, superficial venous thrombosis, superficial vein thrombophlebitis, blood clot, deep vein thrombosis, DVT, pulmonary embolism, phlebitis, deep vein thrombophlebitis, superficial phlebitis
