Thrombophlebitis

Risk Factors

• Prolonged immobilisation (e.g. long-haul flights, bed rest)

• Recent surgery (especially orthopaedic procedures of the lower limb)

• Active cancer or malignancy

• Pregnancy or postpartum period

• Use of oral contraceptives or hormone replacement therapy

• Obesity

• Varicose veins

• Inherited thrombophilias (e.g. Factor V Leiden mutation)

Many of these risk factors overlap with those for DVT, often summarised by Virchow’s Triad (stasis, endothelial injury, hypercoagulability).

Clinical Presentation

Superficial thrombophlebitis

• Localised tenderness, pain, redness, and a palpable cord-like vein

• The affected vein is often visible or palpable just below the skin surface

• Swelling is usually localised along the inflamed vein rather than the entire limb

• Patients might notice local warmth over the area

Deep vein thrombosis

• Typically presents with diffuse swelling of the entire calf or leg

• Pain, possibly worse on dorsiflexion (Homan’s sign), though this sign is neither sensitive nor specific

• The overlying veins are often not visible as dilated, cord-like structures

• More pronounced risk of pulmonary embolism if untreated

Because superficial thrombophlebitis can progress to DVT in certain scenarios, careful assessment is required.

Investigations

A thorough history (including risk factors) and physical examination are essentialLook for signs suggestive of DVT (e.g. diffuse swelling) or superficial thrombophlebitis (a palpable cord, local redness, tenderness)

Clinical Assessment

Assess for extension beyond superficial veins or suspicion of concomitant DVTCheck for risk factors such as recent immobilisation, active malignancy, or previous venous thromboembolic events

Ultrasound (Doppler) Examination

Duplex ultrasound is the main investigation to confirm superficial thrombophlebitis and assess for extension into the deep venous systemEven if the clinical suspicion is high for superficial thrombophlebitis, a Doppler ultrasound is recommended to exclude concurrent DVT or extension toward the deep system

Management

Management aims to reduce inflammation, relieve pain, and prevent extension into deep veins

Conservative Measures

• Leg elevation

• Warm compresses

• Compression stockings (graduated compression helps reduce pain and swelling)

• Mobilisation rather than strict bed rest

Analgesia and Anti-Inflammatory Treatment

• NSAIDs (e.g. ibuprofen 400 mg three times daily) for pain and inflammation

• Consider contraindications (e.g. peptic ulcer disease, renal impairment, cardiovascular disease)

• Paracetamol alone is less effective for the inflammatory component

Anticoagulation

• Consider anticoagulation if the thrombus is extensive, close to the deep venous system, or the patient is high risk (e.g. previous VTE, active cancer, thrombophilia)

• Low molecular weight heparin (e.g. enoxaparin 40 mg subcut once daily) for up to 4 weeks is often used

• Alternative agents (such as DOACs or fondaparinux) may be considered in specific circumstances

• Follow current Therapeutic Guidelines for dosing and duration

Monitoring and Follow-Up

• Ensure symptomatic improvement (decreasing pain, erythema, swelling)

• Consider repeat ultrasound if symptoms worsen or do not improve

• Advise patients to seek urgent review if signs of DVT or PE develop

Complications

• Propagation of the clot into deeper veins (leading to secondary DVT)

• Pulmonary embolism if extension reaches the deep system

• Recurrent superficial thrombophlebitis, especially in patients with varicose veins or thrombophilias

• Chronic venous insufficiency if repeated episodes damage venous valves

Prevention

• Address modifiable risk factors (weight reduction, smoking cessation, regular mobilisation)

• Optimise management of varicose veins (consider surgical intervention if recurrent issues)

• Provide prophylaxis in high-risk situations (e.g. prophylactic LMWH during high-risk periods for patients with previous VTE or known thrombophilias)