Thrombophlebitis
This is an inflammatory disorder caused by a blood clot that blocks the veins, causing swelling on the particular part the blockage has occurred. This condition usually affects the limbs and slows the blood flow in that part of the vein. When it affects veins near the skin surface, it is referred to as superficial thrombophlebitis and can heal on its own. Deep vein thrombophlebitis affects veins located deep in the muscles or within veins located deep away from the skin surface. The issue with this condition is that it can be deadly as the blockage can happen in veins interlinked to the heart or other body organs, exposing the individuals to risks of other medical conditions. The CDC (2022) establishes that this condition affects approximately 900,000 people annually, causing 1 in 4 people to die suddenly due to such blood clots.
Pathophysiology
This condition develops due to platelet adhesion where they bind due to vessel wall injuries or abnormal blood flow, especially stasis and turbulence that cause endothelial injury. This means the platelets will respond accordingly through aggregation at the injury site or vascular abnormality. People with superficial thrombophlebitis are at risk of deep thrombophlebitis and pulmonary embolism by around 4-6 times more (Czysz & Higbee, 2023) than those who do not have it. Pulmonary embolism is the presence of a blood clot from the deep vein to the lungs interfering with respiration, increasing the risk of death. This condition is usually caused by physical inactivity, trauma, or surgery that interferes with the normal functioning of the blood flow in the veins.
Clinical Presentation
Patients with this condition are usually in pain, and the affected area is warm and tender due to the swelling. The particular area is often red and swollen. When the inflammation affects the deep vein, a significant part of the leg or body part may be swollen.
Physical Examination
The clinician will look for redness on the part of the skin affected. Further, the clinician may feel the spot for warm or a palpable cord because the compromised vein is inflamed, which can be felt especially in superficial thrombophlebitis. Further, feeling the swollen part is necessary to identify the warmth associated with this condition. The clinician must seek a history of injury, trauma, or even a surgical procedure. Further, the patient’s medical history is important because the CDC (2022) establishes that 3 in 10 people have recurrent episodes. Understanding this is important for the diagnosis and treatment process.
Diagnostic Testing
Since the condition involves the blood, blood tests are essential in determining the characteristic of the patient’s blood. For example, a D dimer looks for the blood’s increased clot-dissolving substance, usually elevated in such conditions. Czysz & Higbee (2023) establish that this test is not conclusive in identifying the condition creating the need for further testing. Compressive ultrasonography is the most reliable diagnostic test that evaluates the extent of the inflammation and identifies accompanying deep vein thrombophlebitis. Venography can also be used to evaluate the condition of the veins in the leg.
Pharmacological Management
The treatment of thrombophlebitis is important in reducing the risks of the condition advancing to pulmonary thrombosis, which can be life-threatening. Blood-thinning medications are most appropriate, especially heparin as an anticoagulant is recommended considering the various ways thrombophlebitis develops (Czysz & Higbee, 2023). Clot-dissolving medication is also essential, especially thrombolysis which dissolves the blood clots causing the condition. Some of these medications are injected directly into the vein to solve the problem. The condition resolves within days or weeks of treatment but leaves the possibility of recurrence after some time.
Non-pharmacological management
Jinna & Khoury (2019) establish that some thrombophlebitis is migratory shifting from one place to another, hence the need for treatment. Further, they argue that compression stockings are one of the non-medical ways of treating the condition though there is inadequate literature against or supporting this form of therapy. These stockings reduce swelling and the risks of developing deep vein thrombosis. This indicates that non-pharmacological treatment targets the symptoms, including incorporating alternative medicine to treat the pain. Superficial thrombophlebitis can be treated through practices like managing the pain and elevating the leg more, but advanced cases of this condition may need further interventions.
Need for Referral
General health practitioners are well-equipped to treat this condition. However, a vascular specialist may be consulted if the condition results from untreated or similar varicose veins. Further interventions may be necessary when the patient prefers removing the vein, especially when the condition is recurrent in one vein. A vascular specialist may be referred when the condition worsens, especially initiating treatment.
Education/Health Promotion
This condition is usually caused by inactivity. Thus, it is essential for patients to quit their sedentary life as part of health promotion. The condition can recur or migrate to other places, thus the need for patients to be educated on that and its associated risk factors (Jinna & Khoury, 2019). Further, the patient should be educated on the importance of close monitoring and contact with their care provider, especially for individuals aged 40 years and above, because of the risk of venous thromboembolic disease. Individuals under the blood thinners regimen should be educated on the risk of injury as with such medications, and blood clotting may be impossible or take longer, leading to blood loss.
Differential Diagnosis
For proper intervention through testing, this condition should be differentiated from other venous thromboembolic diseases, hematoma, vasculitis, or tendonitis, among others. Also, spot-related injuries can be a mistake for this condition.
Deep Vein Thrombosis (DVT)
This condition is characterized by a blood clot in one of the body’s deep veins, especially in the leg. This blood clot is the activation of the platelets from an injury within the veins, especially from an injury or surgery that injured the veins. These clots in the blood are risky because they can travel to the lungs blocking blood flow to the lungs, which can be fatal. According to the National Heart, Lung and Blood Institute (2022), age, family history, sedentary life, some medical conditions, and sex where women at their childbearing age are risk factors for this condition.
Pathophysiology
Waheed et al. (2022) establish the Virchow’a triad consisting of damage to the vessel walls of the affected vein, interference of blood flow, and hypercoagulability where coagulation occurs without bleeding as the main pathophysiological mechanisms to determine deep vein thrombosis. Thrombosis is the body’s response to prevent blood loss through clotting of the blood to seal off the damaged blood vessels; where in this case, it is the blood vessels that are damaged, and sealing them off interferes with the blood flow in the vessels. This means that the blood flow is compromised as the vessels have been sealed off hence the swelling of the particular leg.
Clinical Presentation
The patient will present a swollen and painful leg, or the body part affected. This is because this condition can affect any body part but is most present in the lower extremities (Kruger et al., 2019). The affected area could be red or discolored, warm, and tender upon touch.
Physical Examination
Waheed et al. (2021) establish that physical examination is highly inaccurate because of the possibility of misdiagnosis, but the clinician may feel the swollen part for warmth and tenderness. A family history of blood clots may indicate DVT; further analysis is needed to confirm the diagnosis.
Diagnostic Testing
D-dimers test is a blood test that identifies blood clots in the bloodstream. This should be supplemented by a doppler ultrasound scan that evaluates how blood flows in the veins. This helps doctors identify when a blood clot possibly causes a blockage in the flow. Venography is an x-ray test that contrasts the blood flow in the body with another liquid injected, especially a dye that can be detected by the x-ray. Blood clots are identified when the dye stops moving or is blocked.
Pharmacological Management
The aim of treating DVT is to prevent the development of pulmonary embolism as a complication, thus reducing the associated morbidity. Recommended medicines include Heparin and Warfarin as anticlotting agents to prevent further clotting. Blood thinners make the blood clots smaller reducing the risk of pulmonary embolism, which include direct oral anticoagulants. NHLBI (2022) proposes catheter-assisted blood clot removal, which involves breaking the catheter through the tube and medication.
Non-pharmacological Management
Compression stockings worn for at least 6 months could help solve the swelling and facilitate a reduced obstruction in the vein. Increasing physical activity is also necessary to ensure blood flow in the veins, and alternative medicine like acupuncture can help deal with the associated pain.
Need for Referral
Kruger et al. (2019) establish that active cancer is linked with d-dimer levels in the blood even without DVT. Therefore, suspected DVT in patients with underlying conditions should be referred to a veins specialist to eliminate cases of misdiagnosis and advice on drug-drug interaction for both conditions. Deep vein thrombosis can reoccur, requiring specialists to advise on how to avoid or reduce the intensity of occurrence. Pregnant women are at risk of DVT. Hence, the importance of a referral for the safety of the mother and child, considering the risks associated with pulmonary embolism as a complication of DVT.
Patient Education
Patients with DVT should be educated on the risk of developing another clot. In this case, adherence to their pharmacological treatment, especially the blood thinners, to avoid a recurrence. Further, they must be educated that though blood thinners help with preventing blood clots, anticoagulants should be adhered to because of the bleeding risk. This bleeding could be through a nosebleed or excessive menstrual discharge; thus, the patient should be careful to avoid injury and have their dosage adjusted. Kruger et al. (20219) establish that the patient should be educated on the importance of wearing an alert tag to notify healthcare providers of their condition in case of emergencies, as surgeries on an individual with anticoagulants can lead to death.
Differential Diagnosis.
This condition can easily be mistaken for cellulitis, congenital vascular abnormalities, superficial thrombophlebitis, and other venous-associated conditions.
Raynaud’s Phenomenon
This condition is characterized by reduced blood flow to some body parts, especially the fingers and the toes. It affects up to 3-5% of the general population, but prevalence is differentiated, especially by geographic location, because it is linked to the body’s response to cold and genes (Nawaz et al., 2022). The condition is classified as primary when it develops by itself and secondary Raynaud’s when it is associated with an underlying condition, especially autoimmune conditions like lupus.
Pathophysiology
This condition is mainly caused by reduced blood flow, blood vessel constriction, inflammatory and immune responses, and neurological responses (Musa & Qurie et al., 2022). The most common cause is reduced blood flow to the fingers and toes due to restricted blood vessels as a thermoregulating mechanism to sustain body temperatures and prevent further loss of body heat. Aside from temperatures, some underlying diseases may compromise the functionality of the endothelial vessels leading to vasoconstriction thus, reduced blood flow.
Clinical Presentation
The patient may report temporary numbness to the affected part lasting from a few minutes to hours. The fingers, toes, lips, ears, or nose which are commonly affected may appear pale or discolored and cold until the blood returns. The patient may present skin ulcers or gangrene, which are painful sores at the tip of the fingers or toes due to extended periods of lack of oxygen in these parts of the oxygen.
Physical Examination
The National Institute of Arthritis and Musculoskeletal and Skin Diseases (2022) establishes that no specific examination or test is used to diagnose the condition. During a physical exam, the clinician will look for the associated symptoms. They may use a nail fold capillary microscopy magnifier to look at the fingernails for any changes in the blood vessels. This can only distinguish the two types of conditions. The clinician may also seek information on the individual’s history of cold sensitivity or a family history of the same or autoimmune conditions.
Diagnostic Testing
Blood tests are essential to eliminate the possibility of other conditions with the same symptoms or can cause such conditions, for example, a full blood count. This checks for infections or diseases like cancer or leukemia. Nawaz et al. (2022) mention the contrast-enhanced magnetic resonance angiography that reveals the narrowing characteristics of the blood vessels.
Pharmacological Management
The goal of treating this condition is to avoid the associated complications linked to tissue damage when the tissues of that part lack oxygenated blood for a while. This condition is treated by dihydropyridine calcium channel blockers which reduce the incidences of vasodilation of the blood vessels. The dosage of this medication is essential as vasodilation is a vital body response mechanism.
Non-pharmacological Management
This is the most recommended approach to this condition because, in most cases, the condition resolves itself. In this case, the treatment involves reducing the frequency of Raynaud’s attacks, which are instances where these body parts lack blood. Non-pharmacological management involves keeping the body warm, especially the most vulnerable parts like the toes and fingers. Smoking also interferes with blood flow to the fingers, creating the importance of quitting smoking as a response mechanism.
Need for Referral
With the right diagnosis, this condition is easily managed by the general practitioner. However, in cases of sympathectomy, a medical procedure involved in treating abnormally sweating palms, a referral to a vascular surgeon may be necessary. A rheumatologist should be consulted in the event of secondary Raynaud’s phenomenon to help address the underlying condition effectively.
Education/Health Promotion
The patients or individuals at risk need to understand the importance of some lifestyle changes to manage conditions. This includes staying warm, especially during cold conditions, or quitting smoking. The patient may be educated on the importance of taking the right dosages of all drugs, especially those that may cause vasoconstriction. The patient should be taught to look out for gangrene and seek medication attention immediately because it indicates the associated tissues dying.
Differential Diagnosis
This condition may easily be mistaken for acute idiopathic blue fingers, especially with the discoloration of the fingers. Other conditions include peripheral neuropathy, excessive cold sensitivity, or external blood vessel compression.
References
CDC (2022). Impact of Blood Clots on the United States. https://www.cdc.gov/ncbddd/dvt/infographic-impact.html
Czysz, A., & Higbee, S. L. (2023). Superficial thrombophlebitis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556017/
Jinna, S., & Khoury, J. (2019). Migratory thrombophlebitis. https://europepmc.org/books/nbk547702
Kruger, P. C., Eikelboom, J. W., Douketis, J. D., & Hankey, G. J. (2019). Deep vein thrombosis: update on diagnosis and management. Medical Journal of Australia, 210(11), 516-524. https://www.mja.com.au/system/files/issues/210_11/mja250201.pdf
Musa R, & Qurie A. (2022). Raynaud Disease. StatPearls Publishing: https://www.ncbi.nlm.nih.gov/books/NBK499833/
National Heart, Lung and Blood Institute (2022). What Is Venous Thromboembolism? https://www.nhlbi.nih.gov/health/venous-thromboembolism
Nawaz I, Nawaz Y, Nawaz E, Manan MR, Mahmood A (2022). Raynaud’s Phenomenon: Reviewing the Pathophysiology and Management Strategies. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8884459/
The National Institute of Arthritis and Musculoskeletal and Skin Diseases (2022). Raynaud’s phenomenon. https://www.nhsinform.scot/illnesses-and-conditions/heart-and-blood-vessels/conditions/raynauds-phenomenon#about-raynaud-s-phenomenon
Waheed SM, Kudaravalli P, & Hotwagner DT. (2022) Deep Vein Thrombosis. StatPearls Publishing https://www.ncbi.nlm.nih.gov/books/NBK507708/
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