Disease of veins and lymphatics

Question 1

What is varicose veins?

Answer 1

• Abnormally dilated tortuous (full of twists and turns) veins due to a 1. prolonged increase in the intraluminal pressure and/or 2. loss of the vessels wall support

Question 2

Which vein is usually involved in the varicose veins?

Answer 2

• Superficial veins of the leg as it resides in the subcutaneous tissue having no support, Deep veins are supported by the muscle and fascia

Question 3

What are the risk factors for varicose veins?

Answer 3

1) Females (repeated pregnancy, and hormones)

2) Family history

3) Prolonged standing (Barber, Dentist, Surgeon, etc.)

4) Obesity

5) History of phlebitis

Question 4

What is the etiology (cause) of varicose veins?

Answer 4

1) Primary

• Due to either genetic or developmental defects in the vein wall causing a diminished elasticity and valvular incompetence, it is more common and occurs in the great saphenous and/or lessor saphenous veins

2) Secondary

• There is other diseases like:

1) Deep venous thrombosis (the thrombosis will cause obstruction increasing the venous pressure, and thus all of the veins that lead to it will also be obstructed and since veins have a high compliance this is a high risk factor for varicose vein)

2) Tumors (Abdominal and pelvic tumors for examples will increase the pressure on the veins affecting the pressure on them)

3) Arterio-venous fistula (congenital or acquired like the ones we induce for dialysis)

Question 5

Describe the pathophysiology of varicose veins

Answer 5

1) Stagnation

2) Overstretching of the vein

3) Increase in the vein size while the valve stays the same

4) Secondary valvular incompetence

5) Backflow of blood

6) Further stretching of the vein from the blood

7) Varicosity (varicous veins)

Question 6

What are the complications of varicous veins?

Answer 6

1) Pigmentation (due to escape of RBC from BV and then they are destroyed)

2) Eczema: itching due to hemosiderin irritation

3) Bleeding

4) Ulcers

5) Edema

6) Poor healing wounds and infections

7) Thrombosis - slower circulation - thrombophlebitis

Question 7

What are the special sites where varicous veins can be found?

Answer 7

• It can appear in any are where there is a connection between the systemic and portal circulation as these areas with difference in pressure might be weak areas

1) Esophagus

2) Testis

3) Anus

Question 8

Describe esophageal varices

Answer 8

• Very critical emergency that might lead to death
• In patients suffering from cirrhosis of the liver which might lead to portal hypertension
• It is found in 90% of cirrhotic, in the west usually due to alcohol in the Arabs usually infections (like hepatic schistosomiasis)
• Sudden Hemorrhage is the most feared consequence as it can be fatal

Question 9

What is varicocele?

Answer 9

• Dilated veins in the scrotum
• It affects the veins of the pampiniform plexus beside the testis
• The dilated plexus will increase the temperature in the scrotum which might result in testicular atrophy
• The scrotum will feel like a bag of hot worms

Question 10

What is haemorrhoids?

Answer 10

• Occurs in the anorectal junction (dilation of the hemorrhoidal plexus of veins called hemorrhoids resulting in prolonged pelvic congestion, source of bleeding and site of thrombosis)
• Dilated anal perianal collateral vessels that connects the portal and caval venous system to relieve the elevated venous pressure within the hemorrhoid plexus

Question 11

What is Phlebotrombosis?

Answer 11

• It is the thrombosis of a vein without inflammation
• The commonest example is DVT of the saphenous vein
• Occurs mainly after delivery, surgery, CHF, or injury
• It slows the circulation, causing endothelial injury, and changes the blood flow, causing hypercoagulability
• Causes are the Virchow’s triad (1. Endothelial injury, 2. Abnormal blood flow, 3. hypercoagulability)

Question 12

What is thrombophlebitis?

Answer 12

• When an inflammation of the vein wall preceeded the formation of a thrombus
• The inflammation could be bacterial (septic), might become fragmented and then circulate in the blood as a septic emboli causing a abscess, or nonbacterial (non-septic) like induced by radiation of chemicals

Question 13

What is a deep vein thrombosis?

Answer 13

• A thrombosis that forms in the deep veins accounting for more than 90% of thrombophlebitis and phlebothrombosis cases
• The pathophysiology is DVT - Obstructs the deep saphenous vein - Increased venous pressure - increased BF to the veins around the ankle
• One of the major causes is prolonged immobilization
• The thrombus can detach to the lungs obstructing the pulmonary flow leading to pulmonary hypertension which might lead to death

Question 14

What are the risk factors for DVT?

Answer 14

• The main risk factor is the prolonged immobilization, which results in venous stasis
• Age >60
• Cigarette smoking

-ETC

Question 15

What are the clinical features of DVT?

Answer 15

• Many DVT are asymptomatic, especially in bedridden patients
• Local manifestations include (distal edema, cyanosis, superficial vein dilation, heat, tenderness, redness, swelling and pain)

Question 16

What are the complications of the DVT?

Answer 16

1) Most important is pulmonary embolism which is a common and serious clinical complication of DVT resulting from the fragmentation/detachment of the venous thrombosis (95% of pulmonary embolism originates from DVT)

2) Chronic venous insufficiency (long-term DVT can degenerate the venous valve)

3) Post-phlebotic syndrome

• Long-term complications occurs due to a damage & scarring of the veins, characterized by swelling, discomfort and skin pigmentation

Question 17

What is the clinical investigation for DVT?

Answer 17

Homan Sign

• Pain is elicited by pressure over affected veins, squeezing the calf muscle with forced dorsiflexion of the foot

Question 18

What is the superior vena cava syndrome?

Answer 18

It is when a tumor/cancer compresses the superior vena cava like the bronchogenic, mediastinal, or lymphoma causing the dilatation & congestion of the veins of the head, neck, and arms

• The same condition might occur in the inferior vena cava but due to liver and renal tumors mainly

Question 19

What are the diseases of the lymphatics?

Answer 19

• Primary lymphatics disorder is much more common due to secondary involved inflammatory, infectious, or malignant processes

1) Lymphangitis

2) Primary lymphedema

3) Secondary/obstructive lymphedema

Question 20

What is lymphangitis?

Answer 20

• Acute inflammation caused by bacterial infection of the lymphatic vessels
• It appears as red, painful subcutaneous streaks, usually associated with tender enlargement of draining lymph nodes (if associated with the tender enlargement is is called lymphadenitis)

Question 21

What is lymphedema and what are its different types?

Answer 21

• Lymphedema is swelling caused by the accumulation of lymphatic fluid in the body’s soft tissue

1) Primary Lymph Edema

• Might be congenital (like simple congenital lymphedema or familial Milroy disease) which results from the agenesis/hypoplasia of the lymphatics

2) Secondary Lymph Edema

• Due to (obstruction/damage):

1) Tumors involving the lymphatic channels or the regional lymph nodes
2) Surgical procedures
3) post-radiation fibrosis
4) Infection
5) Post-inflammatory thrombosis and scarring

Question 22

What are the different tumors of the blood vessels?

Answer 22

Benign:

1) Hemangiomas
- Capillary Hemangioma
- Congenital Capillary Hemangioma
- Cavernous

Malignant:

2) Angiosarcoma

Question 23

What is hemangioma?

Answer 23

They are very common (7% of all infancy and childhood benign tumors) benign tumors made up of blood-filled vessels

• They are present since birth and regress spontaneously

Question 24

What is a capillary hemangioma?

Answer 24

A hemangioma that is mostly situated in the skin of the scalp, neck, face, lips, tongue, or buttock, can be small/large, and red-blue in color

Question 25

Describe the microscopic picture of capillary hemangioma

Answer 25

Collection of closely packed small thinned wall blood vessels around connective tissue stroma

Question 26

Describe the macroscopic picture of congenital capillary hemangioma

Answer 26

Large capillary hemangioma, with elevated lesion from the surface of the skin

Question 27

Describe the macroscopic picture of cavernous hemangioma

Answer 27

• Usually seen on the skin and mucous surface, but also seen in the liver, spleen, pancreas, brain, and bones
• It varies in size from small to large
• They are soft spongy blue-red bloody-exudate from the surface

Question 28

Describe the microscopic picture of cavernous hemangioma

Answer 28

• Large intercommunicating vascular channels (resembles a cavern) that are filled with blood
• Separated by a connective tissue stroma with infiltration of chronic inflammatory cells, surrounded by endothelium

Question 29

What is an angiosarcoma?

Answer 29

• Malignant endothelial tumor (Malignancy of blood vessels)
• Mostly seen in adults in the skin, soft tissue, breast, and liver
• They vary from differentiated tumors resembling a hemangioma to ones with anaplasia making them difficult to distinguish from carcinoma or melanoma
• Basically, malignant endothelial neoplasm varies from well-differentiated to anaplastic

Question 30

What is the rare hepatic angiosarcoma associated with?

Answer 30

Distinctive carcinogens:

• Arsenic
• Thorotrast (radioactive contrast medium usually used in radiology)
• Polyvinyl chloride (PVC, used in plastic)

Question 31

Describe the macroscopic photo of angiosarcoma

Answer 31

Irregularly boundary with areas of hemorrhage, necrosis, fibrosis