Superficial Thrombophlebitis in Emergency Medicine Workup
- Author: Robert G Klever Jr, MD; Chief Editor: David FM Brown, MD more...
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.
Ultrasonography
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.
Venography
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.
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