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Superficial Thrombophlebitis

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VIDEO TRANSCRIPT 

Hey whats going on guys and welcome to the next video in the series.  Today I want to do a case presentation of a 20 year old male that came in complaining of leg pain.  So, what were going to discuss to day is the diagnosis and treatment of superficial thrombophlebitis.  So, the first thing we need to know is what exactly is superficial thrombophlebitis?  Well, its kind of a misnomer because, sure you can have a thrombus, but more importantly its inflammation of the vein.  You do not need a thrombus to diagnose superficial thrombophlebitis.  In fact, a lot of times its simple inflammation of the vein.  It can or cannot have a DVT or a thrombus involved.

So, our patient, he’s a 20 year old male who came in complaining of leg pain.  His leg pain was so severe, that when I saw him, he was on crutches.  He was unable to bear any weight on his leg at all.  It almost looked as if he had some type of a fracture.  He also was complaining of some swelling.  The swelling was pitting, it was 2+, and it wasn’t diffuse, and it was localized to only about the ankle.  Once you passed the ankle there was no swelling.  He says that this has been occurring for the past week or so.  He denies any type of trauma.  He says he woke up with a little bit of pain and over the course of that day, it started to progress until the point that he was unable to put any type of weight on his left foot.  He thought it was something that would go away.  He thought it wasn’t anything insignificant.  He thought maybe he twisted his ankle, but he doesn’t remember twisting his ankle.  In any event it took him a week, he finally made it to a clinic, and this is the first time I’m seeing this patient for this chief complaint.

So, first off, what are some risk factors for superficial thrombophlebitis?  In fact, they are the same risk factors you would look for in DVT.  This is known as virchows triad.  So, the first thing we need to know is hyper coagulability.  So, what are some things that can increase hyper coagulability?  Those are things like cancer, smoking, obesity, hormone replacement; he had none of these.  Another thing is going to be stasis.  So, these are things like immobilization, long hours on a plane, on a train, post op, things like that; none of that.  The last thing is going to be endothelial injury.  This is going to be from trauma.  This can be from hypertension, because of the atherosclerosis.  Again, he has none of these risk factors.  So the fact, or the probability, of him having a DVT is pretty low at this point.

So, what did I see?  When I did the clinical exam, I noted erythema.  But, its not diffuse erythema; its not erythema like cellulitis.  Its erythema that follows the path of the vein, so you can clearly see the vein extending.  Edema, like I stated earlier, he had pitting edema.  It was about 2+, localized to only about the ankle, and it was the medial portion of the ankle.  So, it wasn’t diffuse, and it wasn’t something you would expect from cellulitis, which a lot of times is non pitting and its not something that you would see from a fracture.  This was very localized, pitting edema to the medial aspect of the ankle.  He had tenderness.  Again, this is not diffuse tenderness.  The tenderness followed the course of the vein, or the path of the vein I should say.  So, if you were to go 1-2 cm peripheral to the vein, he had no pain.  So, this essentially ruled out any osteomyelitis, if thats what you were thinking; cellulitis or fracture.  It was very localized and had specific areas of tenderness.  When you palpated that erythema, that tenderness, you can feel the inflammation of the vein, and its known as a palpable cord.  Now, palpable cord is one of those buzz words that you need to know for your exam, for your board exam.  Palpable cord, erythema = superficial thrombophlebitis.  So, just know palpable cord.  But, in reality, you can feel a palpable cord as well.

Alright, so, imaging.  Do we need imaging?  For what, right?  Whats the point of imaging?  The imaging of choice, if you were to do one, is going to be a duplex ultrasound and the only reason to do imaging is to rule out DVT.  This man has no risk factors for DVT and it doesn’t look like he has a DVT.  Clinically, things that would point you to the direction of DVT would be involvement of the saphenous vein and/or the erythema extending towards the thigh.  The erythema from this gentlemen extended up until the tibial tuberosity.  No risk factors and doesn’t look like DVT; why would you waste your time on ordering a duplex ultrasound?  Its not going to change the way we manage this patient.  And if its not going to change the way we manage this patient, whats the point in order it, right?  This hold true for a lot of things, not just for the superficial thrombophlebitis.  So, no ultrasound, no imaging, this is a clinical diagnosis.

So, what did we do for this man?  The first thing I told him to do was, when you get home I want you to elevate your leg.  Your going to elevate it at least waist level, but ideally, your going to elevate it to where its over your heart; so that means lay down and lift your leg up.  Next thing you want to do is give this man a compression stocking.  The compression stocking is going to increase the pressure, to relieve the edema, and relieve some of the pain; very important.  Another thing to note, is that patients cannot tolerate compression stockings very well.  You need to let them know its going to be uncomfortable, but he needs to bare with it.  This is short term, this is not life long; he needs to kind of just bear with it and if he needs a break he can take it off, but try and do that the last amount of time possible.  The next thing is going to be warm compresses.  You can also use cold compresses.  I don’t know what works best and I don’t even think its that important.  I think the elevation and the compression stocking are more important.  And even more important than that are going to be NSAIDs.  I used naproxen 500mg twice a day.  You can use any NSAID, no one NSAID is better than any other.  At first, this might seem a little counter intuitive, right?  Your going to think, well, this man might have a DVT, why are we going to give him something that can cause a DVT?  Well, he doesn’t have a DVT, he has inflammation of the vein.  Which, naproxen is going to be used for anti inflammation and its going to be used for pain as well.  So, using the compression stockings, and naproxen, I think are the two things that are going to benefit him the most.  So, I gave him 500 mg twice daily, and I said I want to see him back in one day.  Because I want to see if this is going to be progressing, or if its going to be at least stable.

If its progressing, we need to change our management a little bit and we might have to go down the path of DVT.  So, I saw him three days later, and he was actually improving, somewhat.  Not a lot, but he did notice less pain, he noticed less edema, and when I did the exam, he actually went down to 1+ edema.  He had 2-3+, and now he was down to 1+.  He had less pain, and he was actually able to put some type of weight on his foot.  Still not able to walk completely, definitely can’t run.  He was still on crutches, but he felt better.  He denied fever, chills, and there was no chest pain and there was no shortness of breath.  These are questions you need to ask because of pulmonary embolism.  The chance, or the risk, of having pulmonary embolism with this is very low, but the risk is there and it takes two seconds to ask the questions and three seconds to document it in the chart.  Just ask the questions are you short of breath, do you have any chest pain, any cough?  No? Good.  He said he was feeling better, so I said Ill see you back in two more weeks.

So, he has a follow up in two weeks.  I haven’t seen him yet.  I saw him yesterday, this is a patient that I just saw.  But, I said, if there is any type of worsening pain, any edema, anything else that you don’t like, come back sooner and well reevaluate.  I don’t think that he is going to worsen.  I think that he will keep improving, and for that reason I said keep the compression stockings, keep the elevation, keep the naproxen.  If for whatever reason he was to worsen, then at that point you need to worry about DVT.  And at that point you would send him for an ultrasound.  At that point you would probably anti coagulate, and you can use either heparin or lovenox (which is a low molecular weight heparin).  Lovenox is just so much easier to use.  You don’t need to worry about PT PTT.  Theres no type of studies; you don’t need a CBC, you don’t really need anything at all for lovenox.  Its very safe.  Of course, in this gentlemen, its just not needed.  I think he’s going to do just well, were going to see him back in two weeks.  If you have any questions about this at all, this was a very quick review for superficial thrombophlebitis.  This is a clinical diagnosis.  This is going to present with erythema, edema, and a palpable cord.  Your going to see the erythema following that superficial vein.  Alright guys, this was it.  If you have any questions, please don’t hesitate to ask, and Ill try and get back to everybody.  So, until the next video, I hope you guys have a good day, and I will see you guys.