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- Phlebitis refers to inflammation of a vein and it can be caused by any insult to the blood vessel wall, impaired venous flow, or coagulation abnormality.
- Pain, swelling, redness, and tenderness are some common symptoms of phlebitis.
- Thrombophlebitis refers to the formation of a blood clot associated with phlebitis.
- Thrombophlebitis can be superficial (skin level) or deep (in deeper veins).
- Superficial phlebitis generally carries a favorable prognosis and can be treated with inexpensive home remedies.
- Deep vein thrombosis (DVT) can have serious complications and requires immediate treatment with blood thinners.
- Simple measures can be taken to prevent phlebitis.
What is phlebitis and thrombophlebitis?
Phlebitis means inflammation of a vein. Thrombophlebitis refers to a blood clot causing the inflammation. Phlebitis can be superficial, in the skin, or deep, in the tissues beneath the skin.
Superficial phlebitis is phlebitis that is in a superficial vein under the surface of the skin. Deep vein thrombophlebitis refers to a blood clot causing phlebitis in the deeper veins. Deep vein thrombophlebitis is also referred to as deep venous thrombophlebitis, deep vein thrombosis (DVT).
The presence of superficial phlebitis does not necessary suggest an underlying DVT. Upper extremity (upper limbs) and lower extremities (lower limbs) superficial thrombosis or phlebitis are typically benign conditions and have a favorable prognosis. A blood clot (thrombus) in the saphenous vein may be an exception. This is the large, long vein on the inner side of the legs. Thrombophlebitis in the saphenous vein can sometimes be associated with underlying deep vein thrombophlebitis.
On the other hand, deep vein thrombosis of the upper and lower extremities can be a more serious problem that can lead to a blood clot traveling to the blood vessels of the lungs and resulting in pulmonary embolism. Pulmonary embolism can injure lung tissue is serious and occasionally fatal.
What causes phlebitis?
Phlebitis has many causes. Some of the common causes of phlebitis are:
- local trauma or injury to the vein
- prolonged inactivity, such as, long driving or plane rides
- insertion of intravenous catheters (IV) in hospitals, or IV induced phlebitis
- period after a surgery (post-operative period), especially orthopedic procedures
- prolonged immobility, as in hospitalized or bed-ridden patients
- varicose veins
- underlying cancers or clotting disorders
- disruption of normal venous system drainage because of removal of lymph nodes, for example, after mastectomy for breast cancer
- intravenous drug use
- patients with burns
What are the risk factors for phlebitis?
- One of the common risk factors for phlebitis is a trauma. For example, a trauma or an injury to the arm or leg can cause an injury the underlying vein resulting in inflammation or phlebitis.
- Prolonged immobility is another common risk factor for phlebitis. Blood that is stored in the veins of the lower extremities normally is pumped toward the heart by the contraction of the lower leg muscles. If the muscle contraction is limited due to prolonged (hours) immobility by sitting on a plane or a car, the blood in the veins can become stagnant and clot formation can result in thrombophlebitis.
- Hormone therapy (HT), birth control pills, and pregnancy all increase the risk for developing thrombophlebitis.
- Cigarette smoking is another risk factor for thrombophlebitis. Smoking in combination with birth control pills can substantially increase the risk of thromboembolism.
- Obesity is also a risk factor for thrombophlebitis.
- Certain cancers are known to increase the risk of clot formation (referred to as a hyper-coagulable state) by causing abnormalities in the normal clotting system (coagulation pathway). Some cancers with hypercoagulable state cause phlebitis or thrombophlebitis.
- Inherited (primary) or acquired (secondary) hypercoagulable states are associated with an increased risk of phlebitis and thrombosis. Some, but not all, of these states can be identified by appropriate laboratory testing.
- Recent surgery of any type can be associated with the conditions. The highest risk seems to come with major orthopedic procedures and procedures for cancers.
What are the symptoms of phlebitis?
Phlebitis, if mild, may or may not cause symptoms. Pain, tenderness, redness (erythema), and bulging of the vein are common symptoms of phlebitis. The redness and tenderness may follow the course of the vein under the skin.
Low grade fever may accompany superficial and deep phlebitis. High fever or drainage of pus from the site of thrombophlebitis may suggest an infection of the thrombophlebitis (referred to as septic thrombophlebitis).
Palpable cords along the course of the vein may be a sign of a superficial clot or superficial thrombophlebitis.
A deep venous thrombosis may present as redness and swelling of the involved limb with pain and tenderness. In the leg, this can cause difficulty walking.
How is phlebitis diagnosed?
The diagnosis of superficial phlebitis can be made based on the physical examination by a physician. Warmth, tenderness, redness, and swelling along the course of the vein is highly suggestive of superficial phlebitis or thrombophlebitis. An ultrasound of the area can help in making the diagnosis of phlebitis or excluding it.
Deep vein thrombosis is more difficult to diagnose on the basis of clinical examination. The strongest clinical indicator is unilateral extremity swelling, which may be associated with pain, warmth, redness, discoloration or other findings. The most commonly used imaging test for diagnosis of deep vein thrombosis is ultrasound. It is less expensive than alternatives and highly reliable. In many settings, however, it is simply not available 24 hours per day.
D-dimer is a useful blood test that can suggest phlebitis. This is a chemical that is released by blood clots when they start to degrade. A normal D-dimer makes the diagnosis of thrombophlebitis unlikely. The limitation of this test is its lack of specificity, meaning that an elevated D-dime level can be seen in other conditions including recent surgery, fall, pregnancy, or an underlying cancer.
Conditions that mimic phlebitis include cellulitis (superficial skin infection), insect bites, or lymphangitis (swelling and inflammation of lymph nodes) and can be distinguished by obtaining a careful medical history and physical examination by a physician. Sometimes, a biopsy of the skin may be required to establish the definite diagnosis.
Quick GuideSpider & Varicose Veins: Causes, Before and After Treatment Images
How is phlebitis treated?
Treatment of phlebitis may depend on the location, extent, symptoms, and underlying medical conditions.
In general, superficial phlebitis of the upper and lower extremities can be treated by applying warm compresses, elevation of the involved extremity, encouraging ambulation (walking), and oral anti-inflammatory medications (ibuprofen [Motrin, Advil], diclofenac [Voltaren, Cataflam, Voltaren-XR], etc.). Topical anti-inflammatory medications may also be beneficial, such as diclofenac gel. External compression with fitted stockings is also a recommended for patients with superficial phlebitis of the lower extremities.
If an intravenous catheter is the cause, then it should be removed. If the phlebitis is infected, then antibiotics are used. In severe cases of infected thrombophlebitis, surgical exploration may be necessary.
Superficial thrombophlebitis (blood clots) is evaluated by an ultrasound to exclude deep venous thrombophlebitis, especially those involving the saphenous vein. If deep venous thrombophlebitis is suspected or diagnosed, or if its risk of developing is considerable, then anti-coagulation (thinning of blood) may be necessary. This is typically done by injection of low molecular weight heparin (enoxaparin [Lovenox]), or by injection of fondaparinux (Arixtra). It can be done by treatment with therapeutic dosages of unfractionated heparin (usually in the form of an intravenous drip), followed by oral anti-coagulation with warfarin (Coumadin) for about 3 to 6 months. Newer anticoagulants may replace Coumadin in certain circumstances.
Patients with extensive deep vein thrombosis (DVT) may be appropriately treated with catheter-directed thrombolysis in selected cases, but will still require maintenance anticoagulation for 3 to 6 months.
Selected patients with DVT may require placement of inferior vena cava filters to help prevent pulmonary embolus. In a subset of patients, it may be appropriate to remove the filter at a future date.
Recovery of symptoms from superficial phlebitis can last a few weeks. A thrombophlebitis may take weeks to months to recover.
What are the complications of phlebitis?
Complications of phlebitis may include local infection and abscess formation, clot formation, and progression to a deep venous thrombosis and pulmonary embolism. When pronounced deep venous thrombophlebitis has seriously damaged the leg veins, this can lead to post-phlebitic syndrome. Post-phlebitic syndrome is characterized by chronic swelling of the involved leg and can be associated with leg pain, discoloration, and ulcers.
Can phlebitis be prevented?
Simple measures can be taken to prevent phlebitis, although, sometimes it cannot be avoided.
Preventive measures of phlebitis include:
- early mobilization after surgery,
- leg exercises during a long car travel or airplane ride,
- good nursing hygiene and prompt removal of intravenous catheters, and
- smoking cessation.
Compression stockings are required in many patients after an episode of phlebitis, especially deep venous phlebitis. These, and other measures, reduce post-phlebitic swelling and the risk of recurrent phlebitis. In most hospitalized patients who have limited mobility or have had recent orthopedic surgery, a low dose of blood thinners (heparin, fondaparinux, enoxaparin [Lovenox] or other agents ) may be injected routinely in order to prevent blood clot formation by keeping the blood relatively thin. This preventive dose is generally lower than the doses used for treating existing blood clots. A widely used alternative is the use of intermittent compression garments on the extremities during periods of high risk.
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