Chapter 58 Thrombophlebitis
INTRODUCTION
Description: Thrombophlebitis is an inflammatory condition of the veins with secondary thrombosis. This may occur in two forms: aseptic or suppurative (septic). The vessels may be either superficial or deep. Risk factors may be present, or the onset may be idiopathic. Risk varies with location and cause.
Prevalence: Two million cases per year in the United States, 10% of nosocomial infections, intravascular (venous or arterial) catheter-related—88 of 100,000.
ETIOLOGY AND PATHOGENESIS
Causes: Sepsis (Staphylococcus aureus [65% to 75%], multiple organisms [14%]), hypercoagulable states (congenital deficiencies, malignancy, pregnancy, high-dose oral contraceptives, Behçets syndrome, Buerger’s disease, factor V Leiden deficiency), venous stasis (varicose veins), injury to vessel wall. Septic thrombophlebitis may be caused by Candida albicans in unusual cases. (Virchow triad: intimal damage [trauma, infection, or inflammation], stasis, or changes in the blood constituents [changes in coagulability].)
Risk Factors: Trauma (general or vascular), prolonged immobility (hospitalization, prolonged air travel), advanced age, obesity, pregnancy or puerperium, recent surgery, intravascular catheters, steroid or high-dose estrogen therapy (high-dose oral contraceptives), high altitude, hemoglobinopathies, malignancy, nephrotic syndrome, homocystinuria, congenital abnormality.
DIAGNOSTIC APPROACH
Workup and Evaluation
Laboratory: Complete blood count, blood culture (positive in 80% to 90% of superficial cases), D-dimer assay, coagulation profiles (antithrombin III levels are suppressed during the acute event—evaluations for abnormal levels should await completion of therapy), activated partial thromboplastin time (APTT) and prothrombin time (PT) to monitor anticoagulant therapy. For patients with septic thrombosis—periodic white blood cell counts.
Imaging: Contrast venography is the “gold standard” for diagnosis. Doppler studies of vascular flow may be effective for some deep vessels. Chest radiography or spiral computed tomography if embolism is suspected.
Special Tests: Impedance plethysmography, I125-fibrinogen scans (not widely available and requires 41 hours), bone or gallium scans for associated periosteal sepsis, ventilation/perfusion scans of the lungs if an embolism is suspected. Duplex ultrasound evaluation is becoming the diagnostic study of choice to search for venous thrombosis.
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