Look at this patient's leg: he has had similar such lesions at different sites at intervals.
Time course, pain and tenderness of skin lesions.· Ask the patient about local trauma (including intravenous infusions).· Gastrointestinal malignancies (pancreatic or gastric cancer).· History of oral contraceptives.
Inflamed superficial leg veins.
Proceed as follows:
Tell the examiner that you would like to investigate for the underlying malignancy,usually carcinoma of the pancreas or stomach (Trousseau's sign) (N Engl J Med 1994;327:1163-4; NEnglJMed 1992; 327:1128-33).
This patient has migratory phlebitis (lesion) and I would like to investigate for anunderlying pancreatic or gastric malignancy (aetiology).
In which other condition is superficial phlebitis a prominent sign?
Is superficial thrombophlebitis associated with deep vein thrombosis?
It may beassociated with occult deep vein thrombosis in about 20% of cases, although pulmonaryemboli are rare.
Is phlebitis more frequently associated with plastic venous catheters or with steelintravenous needles?
It is more likely to be associated with plastic catheters, but this may be because acatheter remains in the vein for a longer period.
How is superficial phlebitis treated?
Local heat, elevation of the leg, and NSAIDs.
When phlebitis is very extensive or in proximity to the saphenofemoral junction,ligation and division of the saphenous vein at the saphenofemoral junction (aspulmonary embolism may result if the phlebitis of the saphenous vein extends into thedeep vein).
Septic thrombophlebitis, which is usually due to Staphylococcus aureus,requires excision of the involved vein up to its junction with an uninvolved vein in orderto control infection.
What other dermatoses complicate pancreatic disease?
'Bronze' pigmentation of haemochromatosis.
'Necrolytic migratory erythema' of glucagonoma syndrome.
Cutaneous haemorrhage of acute pancreatitis - 'bruising' of the left flank (GreyTurner's sign) or umbilicus (Cullen's sign).
What is relationship between venous thromboembolism and cancer?
Cancer risk isincreased in patients with venous thromboembolism. A recent study reported adichotomous pattern of risk with time (Lancet 1998; 351: 1077-80). These investigatorsfound that in the first year after admission for venous thrombo-embolism there was afour-fold increase over rates in the general population, par-ticularly for cancers of thebrain, liver, pancreas, ovary, and Hodgkin's disease and polycythaemia vera. This studyalso reported that thromboembolism was a marker of long-term risk of cancer: there wasa 30% increased overall incidence of malig-nancy over a 10-year period. Another studyreported that cancer diagnosed at thesame time as or within one year of an episode of venous thromhoemhoemblism isassociated with advanced stage and poor prognosis (N Engl J Med 2000; 343:1846-50). Yet another study reported that the risk of newly diagnosed cancer after a firstepisode of venous thromboembolism is elevated during at least the following two years.Subsequently, the risk seems to be lower among patients treated with oralanticoagulants for six months than those treated for six weeks (N Engl J Med 2000; 342:1953-8).Armand Trousseau (1801-1867), physician at the H6teI-Dieu in Paris, noted the sign ashis death warrant, confirming his suspicion of an underlying malignancy in 1865.(Trousseau A 1872 Phlegmasia albia dolens. In: Lectures on clinical medicine, deliveredat the HbteI-Dieu, Paris, pp. 281-295. London: New Wydenham Society).G. Grey Turner (1877-1951), Professor of Surgery, Hammersmith Hospital, London.T.S. Cullen (1868-1953), Canadian born, Professor of Gynaecology, Johns HopkinsHospital, Baltimore, USA.