Thrombotic superficial phlebitis is a common clinical condition characterized by venous injury followed by thrombosis. It is widespread and causes a marked inflammatory reaction in the vein wall and the tissues surrounding the vein wall 2-3 hours after the formation of the thrombus. The pathology varies depending on the location of the lesion, hence the different names of the disease. In the extremities, thrombotic superficial phlebitis can occur in the great saphenous vein, small saphenous vein and its branches in the lower extremities; in the upper extremities, it is often located in the cephalic vein and noble vein. The thoracoabdominal wall often occurs in the superficial veins of the thoracic and abdominal walls. The so-called flow type refers to the unknown cause of the disease, which can be migratory, alternating from one place to another in the body.
Thrombophlebitis belongs to the category of “pulse paralysis” in Chinese medicine, which is caused by dampness and heat accumulation and stagnation of blood stasis in the veins.
I. Thrombotic superficial phlebitis of extremities
Thrombotic superficial phlebitis of the extremities is a common clinical disease, mostly occurs after infusion or trauma, the superficial veins are in the shape of cords, clinically there are no special symptoms except local mild pain.
1.Etiology and pathology.
(1) Etiology: thrombotic superficial phlebitis of the extremities can be caused by different reasons. Clinically, there are three categories.
① chemical stimulation caused by superficial phlebitis, intravenous infusion of various irritant solutions or hypertonic solutions, such as hypertonic glucose solution, various antibiotics, hydrocarbon agent, organic iodine solution, etc., can be injected in the superficial venous lining, resulting in chemical stimulation, leading to more extensive damage, rapid thrombosis, followed by a significant inflammatory response.
②Catheter for continuous infusion, often can make the vein wall suffer direct damage, leading to thrombosis and rapid inflammatory reaction, commonly in large burns, severe trauma and major surgery and other critical patients.
(3) In varicose veins of lower limbs, whether they belong to the great saphenous vein or the genus branch of the small saphenous vein, the varicose veins can suffer from hypoxic and inflammatory damage due to venous blood stasis, skin in the foot and boot area often due to nutritional changes, and bear chronic infection, leading to thrombotic superficial phlebitis.
(2) Pathology: Intravenous input of various antibiotics or hypertonic glucose solutions, etc., not only damages the intima and thrombosis occurs. The lesion starts with extensive thrombosis of the entire superficial vein, which rapidly leads to an inflammatory reaction of the entire superficial vein wall and even involves the perivenous tissue with exudate. Local manifestations are painful, swollen and indurated columns of cords, often accompanied by a systemic reaction, but mostly not severe. Usually after 7-12 days, as the inflammation subsides and the exudate is absorbed, painless sclerosing cords with brown pigmentation are left behind. In some cases, after a period of time, local circulation can be re-established; even after a considerable interval, the involved superficial veins are reopened and can be used as a route of infusion again.
A special severe type of lesion DD vessel wall suppuration due to catheter, called septic thrombophlebitis, occurs in large burns and in critically ill and immunocompromised patients. The direct causes are gram-negative bacteria, staphylococci, etc. The septic lesion is often located at the tip of the endovenous catheter.
Thrombotic superficial phlebitis does not involve deep veins and therefore does not cause venous reflux disorders in the limbs. The thrombosis in the superficial vein is mainly stimulated by the inflammation of the blood vessel, and most of them are closely adhered to the blood vessel wall, so that they will not fall off and become pulmonary embolism.
2.Clinical manifestations and signs
Superficial thrombophlebitis systemic reaction symptoms are relatively light, local symptoms are more obvious, the typical performance, often have a history of injury can be found in patients, the sudden appearance of local mesh and columnar red swollen strips, skin temperature increases, there is obvious pain and pressure pain. Pain may decrease or disappear within 2-4 weeks.
Catheter-induced septic superficial phlebitis is more symptomatic, often septic, with unexplained sepsis and even sepsis in severe patients, when the cause should be traced and the catheter for infusion should be examined.
On clinical examination, cords can be palpated in the epidermis, which are relatively soft at first, with a red surface, 0.5-1 cm wide due to the extent of inflammatory infiltration, but varying in length. After the inflammation subsides, the cords are hard and resemble tubes when palpated. When the superficial reticular veins are involved, the redness may be silver fork or bead-like, and more clearly when the skin is stretched. As the local inflammation gradually dissipates, the local skin pigmentation, which starts as brown and then becomes purple. Suppurative superficial phlebitis local pain, pressure pain, erythema and edema are heavier, and even purulent fluid can be squeezed out from the incision to.
3.Auxiliary examination.
Superficial phlebitis is usually not feverish, a few patients have low fever and mildly elevated leukocytes, for those who have doubts about the diagnosis, pathological examination should be performed. In septic superficial phlebitis, the elevated white blood cell count can reach more than 20*109/L.
4.Identify and treat.
The initial stage of thrombotic superficial phlebitis is heavy with dampness and heat, and the heat is even {red, burning, swelling and pain; the dampness is heavy with puffiness and heaviness of the limbs, and its final transformation into stagnant veins and veins, leaving hard nodules or hard cords clinically. Specific typing and treatment are as follows.
Dampness and heat accumulation evidence: mostly for the acute phase type, treatment should be to clear heat and dampness, activate blood circulation and remove blood stasis; internal use of four miao yong’an soup or Yin Chen red bean soup plus reduction: jinyinhua, yuan shen, angelica, red peony, cow’s knee, yellow cypress, scutellaria, gardenia, forsythia, atractylodes, anti-heat, comfrey, raw licorice, safflower, mouton, etc.
Qi stagnation and blood stasis evidence: chronic inflammation period, for the stasis phase, treatment should be to activate blood stasis, pass the ligaments and disperse the knots, internal use of Dan Shen Tong Wei Tang, blood circulation and blood circulation drink plus reduction: Dan Shen, Red Peony, Angelica sinensis, Chicken Blood Vine, Mulberry, Chuan Niu Knee, Chuan Xiong, Huang Qi, Yu Jin, etc.
During the clinical treatment, we should also add and subtract according to the symptoms. For chronic nodules, add Radix Angelicae Sinensis, Radix Saponariae Sinensis, Boswelliae Sinensis, Myrrh, Trigonella, Curcuma longae, Seaweed, Xia Gu Cao Cao, Wang Bu Liu Xing, Di Long, Chrysanthemum vine, Lobelia vine, Orange nucleus, Mountain cichlid mushroom, etc. If the disease is in the upper limbs, add mulberry branch and turmeric; if the disease is in the lower limbs, add yellow cypress and hyssop.
Chinese medicine external treatment prescriptions.
① Fresh amaranth, pounded and applied externally to the affected area, twice a day;
②Apply golden ointment externally;
③Fumigation method: 60 grams of Amaranthus, 30 grams of Sumac, 30 grams of Safflower, 10 grams of Gentiana, 15 grams of Wilingxian, 10 grams of Sichuan pepper, 10 grams of Red peony, 10 grams of Thornbush, 10 grams of Fangfeng, and 30 grams of Park nit. After mixing the above herbs, soak them in cool water for 1 hour first, adding water standard should be soaked through about 5 cm of the dry herb plane. After soaking, bring it to a boil with high heat. After boiling, then switch to a slow simmer for 1 hour over medium-low heat. During the simmering process, the herbs should be stirred continuously to make a full decoction. Pour the simmering liquid into a warming bottle with the help of a funnel and strainer. Add cool water to the dregs and boil the liquid for the second and third time according to the previous method. The decoction time can be shortened to half an hour after the second and third boiling. Pour the liquid from these three decoctions together into a warming bottle and set aside. Pour the resulting liquid into the bathing basin, and after the temperature is suitable, bathe the affected limbs in the liquid for 30 minutes twice a day to clear heat and detoxify, activate blood and dampness, and eliminate venous inflammation.
5.Western medicine treatment.
(1) General treatment: thrombotic superficial phlebitis generally needs special treatment, under the condition of wrapping elastic bandage or wearing elastic stockings, the upper limb can move and the lower limb can walk without bed rest. If the lesion is more serious, the local performance is more obvious, can be bed rest for several days. According to the specific situation, the upper extremity can be lined with pillow, and the lower extremity can be elevated 30 degrees, while using analgesics and local hot compresses, the symptoms tend to subside rapidly, leaving only a little pigmentation in the local area. Except for septic superficial phlebitis, antibiotics are generally not needed.
(2) Surgical treatment: In rare patients, if the above measures are ineffective and the thrombosis tends to invade the deep veins, surgery should be performed in time to ligate the involved veins in high position and remove or strip them. The advantages are.
(1) It prevents deep vein involvement;
(2) it can quickly eliminate upright pain after releasing the reverse pressure in the saphenous vein that lacks a valve; (3) it can simplify other adjuvant treatments and accelerate the course of treatment. If the lesion occurs in the original varicose saphenous vein, after a considerable period of time, when the lesion enters a quiescent phase, stripping therapy can be administered again. In septic superficial phlebitis, it is better to remove the whole involved saphenous vein or your vein or cephalic vein, and the incision should be open and loosely filled with dressing, and after the symptoms are reduced and the local inflammation subsides, the second stage suture is made.
(3) Other treatment: if there is a heavy inflammation, then antibacterial and anti-inflammatory treatment; residual nodal strips are unclear and sometimes painful, and after the symptoms are obviously improved by herbal treatment, surgical removal can be considered.