Phlebitis / Thrombophlebitis

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Diagnosis | Management

Definition

Phlebitis refers to the inflammation or irritation of a vein. When this inflammation is associated with a blood clot within the vein, it is termed thrombophlebitis. The condition typically involves small, superficial veins, and while it can cause pain and discomfort, it usually resolves on its own within two to six weeks without serious complications. The primary goals of treatment are to relieve pain and reduce discomfort.

Aetiology

In many cases, the cause of phlebitis or thrombophlebitis is not immediately apparent, but inflammation may be triggered by:

• Minor Vein Injury: Even a slight trauma to a vein can lead to inflammation.
• Intravenous Catheters: Use of IV lines can sometimes irritate veins, leading to phlebitis.
• Blood Clotting Disorders: Conditions that predispose to abnormal clot formation can increase the risk of thrombophlebitis.
• Prolonged Immobilization: Lack of movement, such as during long periods of bed rest or travel, can lead to sluggish blood flow and clot formation.

Pathophysiology

The pathophysiology of phlebitis and thrombophlebitis involves several factors:

• Vein Inflammation: Inflammation can occur in response to injury, infection, or irritation, leading to swelling and redness of the affected vein.
• Clot Formation: In the case of thrombophlebitis, the inflamed vein becomes a site for thrombus (blood clot) formation. The clot may further irritate the vein, perpetuating the cycle of inflammation.
• Complications: While superficial thrombophlebitis is usually not dangerous, if the clot extends into deeper veins (deep vein thrombosis, DVT), it can pose serious risks, including pulmonary embolism.

Risk Factors

Several factors increase the risk of developing phlebitis or thrombophlebitis:

• Family History: A history of blood clotting disorders in the family.
• Prolonged Inactivity: Long periods of immobility, such as during long flights or bed rest.
• Recent Surgery: Especially surgeries involving the lower limbs or abdomen.
• Pregnancy: Increased pressure on veins and hormonal changes can predispose to clot formation.
• Smoking: Smoking damages blood vessels and increases the risk of clot formation.
• Cancer: Certain cancers can increase the risk of thrombophlebitis.
• Obesity: Excess body weight increases pressure on veins, contributing to venous stasis.
• Varicose Veins: Enlarged veins that are more prone to inflammation and clotting.
• Age Over 60: Older adults are at higher risk due to reduced vascular elasticity and increased likelihood of other risk factors.
• Use of Oral Contraceptives or Hormone Replacement Therapy: These medications can increase the risk of clot formation.

Signs and Symptoms

The clinical presentation of phlebitis and thrombophlebitis includes:

• Redness and Swelling: Around the area of the affected vein, often accompanied by warmth.
• Pain and Tenderness: The inflamed vein may be painful to touch, and the area may feel tender.
• Visible Vein: The affected vein may appear as a red, hard cord under the skin.
• If Infected: Signs of infection may include fever, increased redness, heat, and pus formation.

Investigations

Diagnostic investigations for phlebitis and thrombophlebitis include:

• D-dimer Test: To rule out deep vein thrombosis (DVT); a positive result indicates the need for further investigation.
• Ultrasound: The primary imaging modality to assess for clot presence, vein blockage, and to diagnose DVT.
• Imaging (MRI/CT): May be used in more complex cases or when complications are suspected.

Diagnosis

The diagnosis of phlebitis or thrombophlebitis is primarily clinical, supported by investigations:

• Physical Examination: Look for signs of redness, swelling, warmth, and tenderness along the course of a vein.
• History: Consider patient history, including recent immobilization, surgery, or use of medications that could increase clotting risk.

Management

The management of phlebitis and thrombophlebitis focuses on symptom relief and preventing complications:

1. Conservative Management

• Anti-inflammatory Drugs: Oral or topical NSAIDs like ibuprofen or naproxen can help reduce pain and inflammation.
• Heparinoid Cream: Can be prescribed to alleviate symptoms of superficial thrombophlebitis.
• Elevation: Keep the affected limb elevated to reduce swelling.
• Compression Stockings: These help improve blood flow and reduce the risk of further clot formation.
• Activity: Encourage mobilization and avoidance of prolonged bed rest to improve circulation.

2. Medical Management

• Antibiotics: If infection is present, prescribe appropriate antibiotics based on the suspected or confirmed pathogen.
• Anticoagulation Therapy: If deep vein thrombophlebitis is diagnosed, anticoagulants such as low molecular weight heparin or warfarin may be necessary to prevent clot propagation and embolization.

3. Referral

• Consider referring the patient to a vascular team or specialist if there is concern about deep vein thrombophlebitis, complications, or if conservative measures are ineffective.

References

1. National Institute for Health and Care Excellence (NICE) (2024) Guidelines for the Management of Phlebitis and Thrombophlebitis. Available at: https://www.nice.org.uk/guidance/ng228 (Accessed: 26 August 2024).
2. British Heart Foundation (2024) Understanding Phlebitis and Thrombophlebitis. Available at: https://www.bhf.org.uk (Accessed: 26 August 2024).
3. British National Formulary (BNF) (2024) Medications for Thrombophlebitis. Available at: https://bnf.nice.org.uk/ (Accessed: 26 August 2024).

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