226 - Varicose Veins

Question 1

What is a varicose vein?

Answer 1

Enlarged and twisted vein

Question 2

Which veins are varicose veins most common in?

Answer 2

90% Long saphenous vein (medial side)

Rest usually short saphenous vein

Question 3

What symptoms can you get with Varicose veins?

Answer 3

Mostly cosmetic
painful, achy, heavy when standing for long periods
Restless leg syndrome

Question 4

What complications can varicose veins cause? (7 things)

Answer 4

Chronic venous insufficiency -> oedema
Thrombophlebitis
Hamorsiderin staining
Varicose eczema
leg ulcers
Haemorrhage
Lipodermatosclerosis

Question 5

What is lipodermatosclerosis?

Answer 5

Skin hardness due to s/c fibrosis, inflammation and necrosis of s/c adipose tissue

• pain, brownish-red staining
• inverted champagne bottle leg

Question 6

What causes varicose veins?

Answer 6

Primary cause unknown
? age (veins loose elasticity)
? imobility / standing (no muscle pump)
? female - progesterone effect on vessel walls

Secondary - impaired flow from deep system

• DVT
• Abdominal mass

Question 7

Describe the process of varicose vein formation

Answer 7

Valvular incompetance, reflux, hypertension -> stress distally

or, cellular and ECM changes -> vein wall weakens - venous dilatation - valvular incompetance

Question 8

What are the 5 key treatment options for varicose veins?

Answer 8

Surgery - strip vein
Radiofrequency ablation
EVLT - Endovenous laser treatment
Foam sclerotherapy
Compression therapy

Question 9

What can be done if there are leg ulcers caused by arterial ischaemia?

Answer 9

Bypass surgery of artery

Question 10

What is chronic oedema?

Answer 10

Oedema lasting more than 3 months

Question 11

What are the 4 key types of chronic oedema?

Answer 11

Lymphovenous
Dependancy
Lipoedema
Lymphodema

Question 12

Describe lymphovenous oedema

Answer 12

A lymphatic overload
Venous system pathology causing increased capilary filtration
s/c tissues are soft and pitting
oedema reduces with elevation

Question 13

What tissue changes can be seen in lymphovenous oedema?

Answer 13

Haemosiderin staining
Ulceration
varicose eczema
Lipodermatosclerosis
Telangicetasia

Question 14

What is dependancy oedema?

Answer 14

A lymphatic overload
Gravitational
Occurs in dependant, immobile limbs
reduced venous return -> increased cap filtration
Often people with comorbidities

Question 15

What tissue changes are seen in dependancy oedema?

Answer 15

Translucent skin
Wet legs - lymph leaks
Shiny
soft + pitting

Question 16

What is lipodema?

Answer 16

A lymphatic overload
Symmetrical fatty deposits occur
? disterbed venous function
? normal lymph system
But lymph transport capacity is reduced -
> backlog

Question 17

What is lymphoedema?

Answer 17

Oedema with a normal lymph load

There is normal capillary filtration but reduced lymphatic drainage - so increased protein conc

Question 18

What are the primary causes of lymphoedema?

Answer 18

Congenital - aplasia, hypoplasia, valvular incompetance

Herediatory - milroy’s

Question 19

What are the secondary causes of lymphoedema?

Answer 19

Parasitic - filleriasis (blocks lymph ducts)
Obstruction of vessels
Trauma
Cancer - lymph clearance
Infection
Venous disease
Immobility

Question 20

What signs are seen in lymphoedema?

Answer 20

Tickened, non-pitting s/c tissue
Dry and flaky skin
Doesn't reduce with elevation
Limb misshapen
Aching and heaviness
Altered sensation on skin

Question 21

What are the management approaches for lymphoedema?

Answer 21

Skin care
Multi-layer bandaging
Exercises
Weight management

Question 22

When is lymphatic damage suspected in an oedematous limb?

Answer 22

When the swelling doesn’t resolve overnight or with elevation

Question 23

Which vessels make up the microcirculation of the body?

Answer 23

Arterioles, capillaries, vennules

Question 24

What are the functions of the microvessels?

Answer 24

Transport, convection, diffusion

Question 25

Who first produced the evidence that microvessels existed?

Answer 25

Harvery - discovered circulation | Malpighi - Saw microvressels first in frog lung capillaries

Question 26

What species/part was studied to discover the organisation of microvessels?

Answer 26

Rat cremaster muscles

Question 27

What is vasomotion of microvessels?

Answer 27

The intermittancy of flow. Terminal arterioles open and close Allows for fluid reabsorption

Question 28

What are the 3 structural types of capillaries and where are they found?

Answer 28

Continuous - flattened, wrap around junction, in skin, lung, muscle. Fenestrated - have windows in cells to increase filtration - choroid plexus, GI mucosa, glands Discontinuous - gaps (100nm) between cells - BM, spleen, liver

Question 29

What is the diffusional permeability relationship?

Answer 29

``` Js = -PS x Conc change A variation of flicks law P=permeability depends on what substance is crossing s= surface area Js = diffusion rate ```

Question 30

What are the differences in permeability of lipid soluble, water soluble and larger solutes, and what does this mean?

Answer 30

Lipid soluble (eg. O2) - high perm - as expected as lipid bilayer Water soluble (glucose, hormones) - high perm - higher than expected if just a lipid bilayer - there must be water filled channels - Small pore system? Larger solutes - reduced permeability - different sizes have different permeabilities - molecular sieving with limit of about 5nm. But some larger ones do get through - large pores too?

Question 31

Describe the mechanisms that enable different solutes to diffuse across a capillary wall

Answer 31

Lipophilic - transcellular diffusion Water soluble - Intracellular small pores + fenestrations LArge solutes - Endothelial gaps of inflammation, transendothelial channels (large pores), vesicular transport

Question 32

What is the glycocalx in a capillary?

Answer 32

How sieving works? | A carbohydrate polymer that excludes larger proteins - so they can't get close to the capillary wall to try get across.

Question 33

How do we explain small pores existing in capillary walls?

Answer 33

Clefts between cells Despite tight junctions occuring between cells, there are small clefts between that could form channels. They are slightly too big so the glycocalx acts as a sieve

Question 34

How does fluid cross vessel walls?

Answer 34

By convection across microvessel walls

Question 35

What principle is applied to fluid movement across vessel walls?

Answer 35

Starlings principles | Tissue fluid balance - most well perfused capillaries filter fluid along their length

Question 36

How much fluid is taken up by the lymphatic system a day?

Answer 36

8L / day

Question 37

What are the 2 mechanisms that cause oedema?

Answer 37

Reduced lymphatic drainage Increased cap filtration rate

Question 38

What 3 mechanisms can increase cap filtration rate?

Answer 38

Increased capillary pressure (heart failure in lungs) Reduced oncotic pressure (plasma proteins lost through kidneys - kidney or liver diesase) Increased hydrolic permeability (inflammation - larger gaps)

Question 39

What pressure changes are seen int he leg veins when we stand up?

Answer 39

Pressure increases from 10 mmHg to 90 mmHg

Question 40

When muscle pumps are working when standing what pressure is in the leg veins?

Answer 40

10 mmHg

Question 41

If the leg veins have incompetent valves, what is the pressure in them on standing even with muscle pump action

Answer 41

60 mmHg