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== Definition  ==
Thrombophlebitis is a [[Cardiovascular Disease|circulatory condition]] that occurs when a [[Blood Physiology|blood]] clot, which developed due to a venous inflammation, inhibits the [[Blood Physiology|blood]] flow. <ref name=":1">Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg (Cochrane  Review). Cochrane Database Syst Rev 2018;(2):CD004982.</ref> Most commonly, thrombophlebitis affects the superficial [[Cardiovascular System|veins]] of the extremities (arms and legs). Related conditions that may be used as a synonym are phlebitis, phlebothrombosis, and venous [[thrombosis]]. <ref name=":2">Thrombophlebitis. Farlex Partner Medical Dictionary, 2012. Available from: https://medical-dictionary.thefreedictionary.com/thrombophlebitis (last accessed: 26.09.2020).</ref> The word is compounded of the term "thrombus", which describes a blood clot that was formed inside a blood vessel, and "phlebitis", which is the medical term for the inflammation of a vein.
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===Types===
Multiple types of thrombophlebitis are known, sorted by highest to the lowest prevalence below.
* Superficial thrombophlebitis: occurs in the veins located under the skin
**Superficial thrombophlebitis on the lower extremity <ref name=":1" />
**Superficial thrombophlebitis on the upper extremity <ref name=":3">Di Nisio M, Peinemann F, Porreca E, Rutjes AWS. Treatment for superficial infusion thrombophlebitis of the upper extremity (Cochrane Review). Cochrane Database of Syst Rev 2015;(11):CD011015.</ref>
* Thrombophlebitis migrans: multiple inflammations in different areas<ref name=":2" />
A [[Deep Vein Thrombosis|deep vein thrombosis]], which mostly occurs without any inflammation process, will usually be referred to as a ''[https://www.youtube.com/watch?v=2vVqBjk-oqQ phlebothrombosis]''. <ref name=":4">Phlebothrombosis. Farlex Partner Medical Dicitionary, 2012. Available from: https://medical-dictionary.thefreedictionary.com/phlebothrombosis (last accessed: 26.09.2020).</ref>


== 1. Definition ==
== Causes ==
The causes of superficial thrombophlebitis are different for the lower and upper extremities. For the lower extremity, the causes are often a combination of a suboptimal condition of the veins and disease predispositions, as well as the exposure to risk factors, all of which include: <ref name=":3" />
* [[Varicose Veins|Varicose veins]]
* Immobilisation (also pre- and post-surgery)
* Trauma or [[Surgery and General Anaesthetic|surgical interventions]] (especially including interventions which include the removal of [[Lymphatic System|lymph nodes]])
* [[Pregnancy Related Pelvic Pain|Pregnancy]], and maternal and birth-related conditions
* Cancerous malformations
* [[Obesity]]
* History of [[Deep Vein Thrombosis|thrombosis]]
* [[Autoimmune Disorders|Autoimmune diseases]]
* Use of hormonal therapies (e.g. the contraceptive pill or hormonal replacement therapy)
* [[Smoking Cessation and Brief Intervention|Smoking]] (also as a higher associated risk factor to arteriosclerosis)


Thrombophlebitis is a circulatory problem that develops when a blood cloth slows the circulation in a vein. “Phlebitis” means a vein with inflammation (can be the result of swelling or irritation caused by trauma).&nbsp;<ref name="Bryg">Bryg R, Understanding Thrombophlebitis -- the Basics, WebMD, 24 Oct 2010</ref>  
The cause of thrombophlebitis in the upper extremity is most commonly the insertion of venous catheters into peripheral veins. <ref name=":3" /> This complication is believed to originate from inflammation processes caused by the trauma of the insertion, the possible invasion of bacteria in the area of the catheter, and the effect of the inserted chemicals. <ref name=":3" />


== 2. Causes  ==
===Pathogenesis===
The pathway of the development of the disease can be split into two stages:<ref name=":2" />
# Inflammation process in the vessel (due to a slow in blood circulation, inflammation factors, and possibly the exposure to risk factors).
# Secondary development of a thrombus (the blood clods around the inflamed tissue of the vessel, fibrous material builds up and forms a thrombus).  


Thrombophlebitis occurs mostly in the lower extremity.&nbsp;<ref name="Nabili"/> It can happen right under the skin (superficial thrombophlebitis) or deeper in the leg (deep venous thrombosis). <br>The forming of the blood cloth can have many causes&nbsp;: sitting down for a long time, being hospitalized for a surgery, disorders that make you more likely to develop blood cloths, trauma, … <ref name="Nabili"/><br>But it also can be caused by varicose veins, underlying cancer, disruption of normal venous system drainage because of the removal of lymph nodes, intravenous drug use and patients with burns <ref name="L"/>.<br>Also cigarette smoking combined with birth control pills is a risk factor.&nbsp;<ref name="L"/>
== Symptoms  ==
Symptoms associated with thrombophlebitis are the signs of inflammation (swelling of the body part, [[Pain Behaviours|pain]], skin redness, warmth), and tenderness of the area around the vein. <ref name=":1" /> Often, the leg appears warm to the touch of the hand and patients report increasing discomfort which can easily be mistaken for muscle pain. For physiotherapists, it is important to check for these symptoms both in inpatients and outpatients. Especially in clinics with low-mobility patients and intensive care units this condition is a common complication.


== 3. Symptoms ==
==Diagnosis  ==
Thrombophlebitis can be diagnosed based on a clinical examination. If the above-mentioned symptoms are visible/palpable, initial diagnostics can include the comparison of pulse palpation proximal and distal to the affected area. This test is positive if the pulse is barely or not at all detectable distal to the affected area. To ensure the diagnosis and to differentiate to a phlebothrombosis, an ultrasound (e.g. Doppler ultrasound) can be used. <ref name=":5">Schimmelpfennig J, Schwahn-Schreiber C, Marshall M. Aktuelle Standards der Diagnostik und Therapie der oberflächlichen Venenentzündung. Vasomed, 2013. Available from: https://www.der-niedergelassene-arzt.de/fileadmin/user_upload/zeitschriften/vasomed/Artikel_PDF/2013/3-2013/CME.pdf (last accessed: 26.09.2020). </ref> Blood testing indicate thrombophlebitis, but is not always conclusive, e.g. testing for the clot-dissolving substance called ''D dimer''  positive results can also indicate for other diseases. Another blood test is the international rationalised ratio (INR) which is used to determine the coagulation tendency of the blood, in other words: how long it takes the blood to form a clot. This indicator is usually used both as an initial diagnosis parameter, and as a monitoring test to check the prescribed medication levels.


Symptoms associated with thrombophlebitis are inflammation and swelling of the body part, pain, skin redness and warmth and tenderness of the vein. <ref name="Nabili"/><br>Low grade fever may also be a symptom of superficial and deep phlebitis, higher fever may suggest and infection of the thrombophlebitis. <ref name="Nabili"/>
==Complications==
Although thrombophlebitis has been considered a fairly benign disease, some research indicates that there is a correlation of a higher prevalence of deep vein thrombosis (phlebothrombosis) in patients with superficial thrombophlebitis. <ref name=":1" /> This condition can be tested for with the [[Homan's Sign Test]].  


== 4. Diagnosis  ==
Another related, very serious complication is ''pulmonary embolism''. This can be caused if the clot (or a part of it) detaches and migrates through the venous system into the lungs where it blocks a pulmonary artery. Thereby, the related lung tissue is in danger of necrosis.  


Thrombophlebitis can be diagnosed based on physical examination and how the affected area looks. It may be needed to have your pulse, blood pressure, temperature, skin condition checked. <ref name="Nabili">Nabili S, Phlebitis and Thrombophlebitis, Medcine.net.com, 5 Jan 2009</ref><br>You can also take a D-Dimer bloodtest (a normal D-Dimer makes the diagnosis of thrombophlebitis unlikely) or take an ultrasound of the area which can help in making the diagnosis of phlebitis or excluding it.&nbsp;<ref name="L"/>  
It is crucial to be on the look out for symptoms in patients with thrombophlebitis. The videos below give more insight into these two complications.
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== 5.Preventation ==
== Prevention ==
During long car or plane trips, patients should be advised to stretch their legs frequently and drink plenty of liquids. Walking and exercises that [[Cardiovascular Exercises For Elderly|increase blood circulation]] are effective measures to keep the blood flow steady. Wearing compress stockings are often used as a prevention method for patients who are at a higher risk of developing thrombosis. In case of hospitalisation or as a prophylactic measure previous to surgery, subcutaneous injections or oral medication of anticoagulants are most commonly prescribed. The currently recommended dosage is 2.5mg Fondaparinux as a subcutaneous injection once daily for 45 days. <ref name=":7">Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg (Cochrane Review). Cochrane Database of Syst Rev 2018;(2):CD004982.</ref>  Routine changing and cleaning of intravenous (IV) lines help to prevent thrombophlebitis of the upper extremity.


Routine changing of intravenous (IV) lines helps to prevent thrombophlebitis related to IVs.  
== Treatment  ==
Several measures can be taken to resolve thrombophlebitis, including: <ref name=":8">Mayo Clinic Staff. Thrombophlebitis. Mayo Clinic, 2020. Available from: https://www.mayoclinic.org/diseases-conditions/thrombophlebitis/diagnosis-treatment/drc-20354613 (last accessed: 27.09.2020).</ref>
* Anti-coagulants which are blood-thinning medications (such as Fondaparinux/Arixtra 2.5mg)  can shorten the recovery time and reoccurrence of thrombophlebitis, as well as help prevent complications of deep vein thrombosis. <ref name=":7" /> Other anti-coagulants which are used as a continuous oral treatment are Xarelto 10mg (rivaroxaban) and Coumadin/Jantoven 2-5mg (warfarin). <ref name=":8" />
* Thrombolysis (dissolution of the blood clot through clot-dissolving drugs) with Activase <ref name=":8" />
* Surgery to remove the entire clogged vein (in extreme cases) <ref name=":7" />
* External compression with fitted compress stockings; especially in combination with surgical interventions, stockings are associated with lower occurrence of venous thromboembolisms or the progression of superficial thrombophlebitis  <ref name=":7" />
* Anti-inflammatory medication (e.g. non-steroidal anti-inflammatory drugs) effects on the duration of the thrombophlebitis is controversial  <ref name=":7" />
* Varicose vein stripping (surgical intervention) <ref name=":8" />
* Topical treatments (e.g. with Heparin spray gel) to reduce local symptoms <ref name=":7" />
* Stenting procedures, a surgical intervention where a metal cage is inserted into the clotted vein to reopen the blockage, is most commonly used for deep vein thrombosis, but is also discussed as a treatment for thrombophlebitis.


If you are taking a long car or plane trip, walk or stretch your legs once in a while and drink plenty of liquids. Wearing support hose may help.  
Recovery can take from a few weeks to a couple of months. <ref name=":6">Vorvick L, Thrombophlebitis. Medline, 5 oct 2010.</ref><br>


If you are hospitalized, your health care provider may prescribe medicine to prevent deep venous thrombosis.<ref>http://www.nlm.nih.gov/medlineplus/ency/article/001108.htm trusted health information mediplus</ref>
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== 5. Treatment  ==
== Physical Therapy Treatment  ==
Physical Therapy concentrates especially on the prevention of thrombophlebitis (see prevention).


Treatment may depend on location, extent, symptoms and underlying medical condition, but in general it can be treated with&nbsp;:  
[https://physio-pedia.com/Physical_Activity_in_Acute_Care?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Acute treatment] depends on location, extent, symptoms, and underlying medical condition, but generally include:<ref name=":6" />
* Warm compresses
* Elevation of the limb
* Encouraging circulation (walking around) and limb-specific exercises that activate the [https://www.youtube.com/watch?v=hbt79HcvTVo skeletal-muscle pump].
{{#ev:youtube|x32kRLlxaBI}}


*warm compresses
== References  ==
*elevation of the limb
*encouraging circulation (walking around)
*external compression with fitted stockings
*anti-inflammatory medication&nbsp;
*if deep venous thrombosis is the case&nbsp;: anti-coagulation (blood thinner)
 
Recovery can take from a few weeks to a couple of months. <ref name="L">Vorvick L, THROMBOPHLEBITIS, Medline, 5 oct 2010</ref><br>
 
== 6. &nbsp;Physical therapy treatment  ==
 
The role a physical therapist can play in the DVT treatment, detection and prevention can make all the difference to patients.DVT can be undiagnosed for some time, there is a lot of potential for collateral damage, ranging from vascular malfunction to muscle atrophy. These are two areas where physical therapists can be an important part of a DVT patient's recovery.There are varying levels of massage that are useful for stimulating better vascular response in affected areas, specific exercises that can help to re-tone damaged muscles and even specialized compression techniques that help the body recover from the stresses of a deep vein thrombosis.<ref>http://physical-therapy.yoexpert.com/physical-therapy-general/what-is-the-role-of-physical-therapy-in-dvt-treatm-1578.html</ref>
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
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<rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1d1GIw6PmDzoQuD-aVQWX0J3JHz3zIe4xPlO_CL3Fq_U7QTstW!!</rss>
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== 6. References  ==


<references />  
<references />  


[[Category:Cardiopulmonary]]
[[Category:Cardiopulmonary]]
[[Category:Primary Contact]]
[[Category:Acute Care]]
[[Category:Cardiovascular Disease - Conditions]]

Latest revision as of 03:09, 19 July 2022

Original Editor ­ - Dieter Schuddinck

Top Contributors - Anna Fuhrmann, Dieter Schuddinck, Andeela Hafeez, Lucinda hampton, WikiSysop, Kim Jackson, Manisha Shrestha, 127.0.0.1, Laura Ritchie, Evan Thomas, Karen Wilson, Claire Knott and Leana Louw

Definition[edit | edit source]

Thrombophlebitis is a circulatory condition that occurs when a blood clot, which developed due to a venous inflammation, inhibits the blood flow. [1] Most commonly, thrombophlebitis affects the superficial veins of the extremities (arms and legs). Related conditions that may be used as a synonym are phlebitis, phlebothrombosis, and venous thrombosis. [2] The word is compounded of the term "thrombus", which describes a blood clot that was formed inside a blood vessel, and "phlebitis", which is the medical term for the inflammation of a vein.

Types[edit | edit source]

Multiple types of thrombophlebitis are known, sorted by highest to the lowest prevalence below.

  • Superficial thrombophlebitis: occurs in the veins located under the skin
    • Superficial thrombophlebitis on the lower extremity [1]
    • Superficial thrombophlebitis on the upper extremity [3]
  • Thrombophlebitis migrans: multiple inflammations in different areas[2]

A deep vein thrombosis, which mostly occurs without any inflammation process, will usually be referred to as a phlebothrombosis. [4]

Causes[edit | edit source]

The causes of superficial thrombophlebitis are different for the lower and upper extremities. For the lower extremity, the causes are often a combination of a suboptimal condition of the veins and disease predispositions, as well as the exposure to risk factors, all of which include: [3]

The cause of thrombophlebitis in the upper extremity is most commonly the insertion of venous catheters into peripheral veins. [3] This complication is believed to originate from inflammation processes caused by the trauma of the insertion, the possible invasion of bacteria in the area of the catheter, and the effect of the inserted chemicals. [3]

Pathogenesis[edit | edit source]

The pathway of the development of the disease can be split into two stages:[2]

  1. Inflammation process in the vessel (due to a slow in blood circulation, inflammation factors, and possibly the exposure to risk factors).
  2. Secondary development of a thrombus (the blood clods around the inflamed tissue of the vessel, fibrous material builds up and forms a thrombus).

Symptoms[edit | edit source]

Symptoms associated with thrombophlebitis are the signs of inflammation (swelling of the body part, pain, skin redness, warmth), and tenderness of the area around the vein. [1] Often, the leg appears warm to the touch of the hand and patients report increasing discomfort which can easily be mistaken for muscle pain. For physiotherapists, it is important to check for these symptoms both in inpatients and outpatients. Especially in clinics with low-mobility patients and intensive care units this condition is a common complication.

Diagnosis[edit | edit source]

Thrombophlebitis can be diagnosed based on a clinical examination. If the above-mentioned symptoms are visible/palpable, initial diagnostics can include the comparison of pulse palpation proximal and distal to the affected area. This test is positive if the pulse is barely or not at all detectable distal to the affected area. To ensure the diagnosis and to differentiate to a phlebothrombosis, an ultrasound (e.g. Doppler ultrasound) can be used. [5] Blood testing indicate thrombophlebitis, but is not always conclusive, e.g. testing for the clot-dissolving substance called D dimer positive results can also indicate for other diseases. Another blood test is the international rationalised ratio (INR) which is used to determine the coagulation tendency of the blood, in other words: how long it takes the blood to form a clot. This indicator is usually used both as an initial diagnosis parameter, and as a monitoring test to check the prescribed medication levels.

Complications[edit | edit source]

Although thrombophlebitis has been considered a fairly benign disease, some research indicates that there is a correlation of a higher prevalence of deep vein thrombosis (phlebothrombosis) in patients with superficial thrombophlebitis. [1] This condition can be tested for with the Homan's Sign Test.

Another related, very serious complication is pulmonary embolism. This can be caused if the clot (or a part of it) detaches and migrates through the venous system into the lungs where it blocks a pulmonary artery. Thereby, the related lung tissue is in danger of necrosis.

It is crucial to be on the look out for symptoms in patients with thrombophlebitis. The videos below give more insight into these two complications.

Prevention[edit | edit source]

During long car or plane trips, patients should be advised to stretch their legs frequently and drink plenty of liquids. Walking and exercises that increase blood circulation are effective measures to keep the blood flow steady. Wearing compress stockings are often used as a prevention method for patients who are at a higher risk of developing thrombosis. In case of hospitalisation or as a prophylactic measure previous to surgery, subcutaneous injections or oral medication of anticoagulants are most commonly prescribed. The currently recommended dosage is 2.5mg Fondaparinux as a subcutaneous injection once daily for 45 days. [6] Routine changing and cleaning of intravenous (IV) lines help to prevent thrombophlebitis of the upper extremity.

Treatment[edit | edit source]

Several measures can be taken to resolve thrombophlebitis, including: [7]

  • Anti-coagulants which are blood-thinning medications (such as Fondaparinux/Arixtra 2.5mg) can shorten the recovery time and reoccurrence of thrombophlebitis, as well as help prevent complications of deep vein thrombosis. [6] Other anti-coagulants which are used as a continuous oral treatment are Xarelto 10mg (rivaroxaban) and Coumadin/Jantoven 2-5mg (warfarin). [7]
  • Thrombolysis (dissolution of the blood clot through clot-dissolving drugs) with Activase [7]
  • Surgery to remove the entire clogged vein (in extreme cases) [6]
  • External compression with fitted compress stockings; especially in combination with surgical interventions, stockings are associated with lower occurrence of venous thromboembolisms or the progression of superficial thrombophlebitis [6]
  • Anti-inflammatory medication (e.g. non-steroidal anti-inflammatory drugs) effects on the duration of the thrombophlebitis is controversial [6]
  • Varicose vein stripping (surgical intervention) [7]
  • Topical treatments (e.g. with Heparin spray gel) to reduce local symptoms [6]
  • Stenting procedures, a surgical intervention where a metal cage is inserted into the clotted vein to reopen the blockage, is most commonly used for deep vein thrombosis, but is also discussed as a treatment for thrombophlebitis.

Recovery can take from a few weeks to a couple of months. [8]

Physical Therapy Treatment[edit | edit source]

Physical Therapy concentrates especially on the prevention of thrombophlebitis (see prevention).

Acute treatment depends on location, extent, symptoms, and underlying medical condition, but generally include:[8]

  • Warm compresses
  • Elevation of the limb
  • Encouraging circulation (walking around) and limb-specific exercises that activate the skeletal-muscle pump.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg (Cochrane Review). Cochrane Database Syst Rev 2018;(2):CD004982.
  2. ↑ 2.0 2.1 2.2 Thrombophlebitis. Farlex Partner Medical Dictionary, 2012. Available from: https://medical-dictionary.thefreedictionary.com/thrombophlebitis (last accessed: 26.09.2020).
  3. ↑ 3.0 3.1 3.2 3.3 Di Nisio M, Peinemann F, Porreca E, Rutjes AWS. Treatment for superficial infusion thrombophlebitis of the upper extremity (Cochrane Review). Cochrane Database of Syst Rev 2015;(11):CD011015.
  4. ↑ Phlebothrombosis. Farlex Partner Medical Dicitionary, 2012. Available from: https://medical-dictionary.thefreedictionary.com/phlebothrombosis (last accessed: 26.09.2020).
  5. ↑ Schimmelpfennig J, Schwahn-Schreiber C, Marshall M. Aktuelle Standards der Diagnostik und Therapie der oberflächlichen Venenentzündung. Vasomed, 2013. Available from: https://www.der-niedergelassene-arzt.de/fileadmin/user_upload/zeitschriften/vasomed/Artikel_PDF/2013/3-2013/CME.pdf (last accessed: 26.09.2020).
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg (Cochrane Review). Cochrane Database of Syst Rev 2018;(2):CD004982.
  7. ↑ 7.0 7.1 7.2 7.3 Mayo Clinic Staff. Thrombophlebitis. Mayo Clinic, 2020. Available from: https://www.mayoclinic.org/diseases-conditions/thrombophlebitis/diagnosis-treatment/drc-20354613 (last accessed: 27.09.2020).
  8. ↑ 8.0 8.1 Vorvick L, Thrombophlebitis. Medline, 5 oct 2010.
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