Venous Disease including Chronic Ulcers Flashcards
What is chronic venous disease?
Venous return impaired > sustained venous hypertension
What is telangiectasia?
Small dilated vessels
How can fusion of the ankle cause calf muscle pump failure?
Can’t dorsiflex and plantarflex > calf muscle pump doesn’t work
Where are you more likely to have a deep vein thrombosis: in the superficial or deep system?
Deep system, especially below knee
What do the perforating veins in the legs do?
Join superficial and deep system
Functional valves prevent reflux from deep to superficial to deep
What is the white cell trapping hypothesis?
WBCs larger and less deformable than RBCs
When perfusion pressure reduced by venous hypertension, WBCs plug capillaries and RBCs build up behind
WBC activation
Endothelial adhesion by WBCs release proteolytic enzymes and oxygen free radicals > endothelial and tissue damage
What is the fibrin cuff hypothesis?
Increased venous pressure directly transmitted to capilllaries > capillary elongation and increased endothelial permeability
Larger molecules like fibrinogen become deposited into tissues > fibrin
Accumulation of fibrin acts as barrier to oxygen > tissue hypoxia > ulceration
What is CEAP classification?
Standardises severity of venous disease C - clinical classification E - aetiological classification A - anatomic classification P - pathophysiological classification
How do you differentiate between venous and arterial pain in the leg?
Venous - To relieve pain, have to elevate leg - Takes 20 min Arterial - If pain after exercise > rest - If pain at rest > dangling leg (use gravity) - Takes 5 min
What are varicose veins?
Elongated, tortuous, dilated veins
What are primary varicose veins?
Affecting superficial/perforating veins in absence of deep incompetence
What are secondary varicose veins?
Associated with deep venous incompetence from recanalisation of previous deep vein thrombosis
Venous obstruction
What can cause a venous obstruction, leading to secondary varicose veins?
Mechanical obstruction - Big gut - Big hernia - Pregnancy Vein thrombosis Orthopaedic injuries
What are the risk factors for chronic venous disease?
Genetics
Previous deep vein thrombosis
What is the clinical presentation of chronic venous disease?
Cosmetic Pain Swelling Thrombophlebitis Bleeding Skin changes Ulceration
What is thrombophlebitis?
Inflammation of vein wall with associated thrombosis
What cosmetic issues can patients present with?
Telangiectasia
Reticular veins
Varices
What sort of pain do patients complain of?
General leg ache/heaviness
Venous claudication
What sort of swelling can patients present with?
Early ankle pitting oedema
Later becomes indurated
What sort of skin changes can patients present with?
Varicose eczema
Pigmentation
Lipodermatosclerosis
Atrophie blanche
What does lipodermatosclerosis often look like?
Inverted champagne bottle
- Narrow ankle
- Bulging leg higher up
What should you do if you see a red leg?
Don’t assume red leg = cellulitis
Look for other signs of infection
What is atrophie blanche?
Confluence of white, depressed scars
What investigations are done in chronic venous disease?
Venous duplex
Descending venography
What is the conservative treatment of chronic venous disease?
Elevate legs - Not ideal in long-term management Avoid standing still - Not ideal in long-term managemt Dressings for ulceration Graduated compression stockings
Who are class 1 compression stockings good for?
People with early venous disease
Preventative; eg: after ankle fusion
Possibly for some elderly patients because many can’t put on tighter socks
What sort of treatment is going to fix the underlying problem in chronic venous disease?
Surgery
What is sclerotherapy?
Inject something to shut down vein
Done under ultrasound
Less invasive
What surgical treatments are available for chronic venous disease?
Sclerotherapy
Open surgery
Endovenous laser therapy
Radiofrequency ablation
95% of ulcers are of what type?
Ischaemic
Neuropathic
Stasis/venous
Can be mixed aetiology
What other causes of ulcers are there?
Infective - Syphilis - Mycobacterium - Osteomyelitis Neoplastic - Squamous cell carcinoma - Basal cell carcinoma - Melanoma - Metastatic - Kaposi's sarcoma Systemic disease - Pyoderma gangrenosum Traumatic - Thermal burns - Radiation - Bites
What is pyoderma gangrenosum?
Condition causing tissue to become necrotic, causing deep ulcers on, usually on legs
How do you identify ischaemic ulcers on history?
Painful - but not always; eg: if have severe neuropathy
History of claudication/rest pain
Cardiovascular risk factors
Previous peripheral vascular surgery
How do you identify ischaemic ulcers on exam?
Location
- Distal periphery
- Over dorsum of foot/pretibia
Punch-out edges = clearly demarcated edge, quite deep
Ulcer base = poorly developed grey granulation tissue
Surrounding skin pale/mottled with no signs of inflammation
Little bleeding when debrided
- Slow weeping bleed
What are the signs of chronic arterial insufficiency?
Atrophic nails/skin Venous guttering Slow capillary return Absent pulses Beurger's positive
What is Beurger’s sign?
Elevate leg Drop legs (both for comparison) Bright rubor of skin as blood returns to limb
How does red ischaemic skin feel in temperature?
Usually cooler > compare to area on contralateral limb
How do you identify neuropathic ulcers on history?
Painless
- May not feel pain directly
- If neuropathic person suddenly feels pain > most likely deep tissue infection
History of diabetes/other causes of neuropathy
Other than diabetes, what are the causes of neuropathy?
Alcohol Stroke Myesthenia gravis Illicit drug use Chemotherapy HIV Syphilis Multiple sclerosis Congenital Sometimes severe B12 deficiency
How do you identify neuropathic ulcers on exam?
Deep Location: pressure points/calluses - Plantar surface of metatarsophalangeal joints - Bunion/bunionette areas - Dorsum of interphalangeal joints - Base of 5th metatarsal - Callused posterior rim of heel pad Signs of neuropathy - Hypoaesthesia - Proprioception - 2-point discrimination - Vibratory perception Features of distorted foot architecture - Hyperextension of metatarsophalangeal joints - Hyperflexion of interphalangeal joints - Charcot's deformity
Why does distorted foot architecture lead to ulcers?
Because of motor neuropathy
Small muscles of foot become weaker
Larger muscles deform foot
Loss of muscle bulk > loss of padding in foot
How do you identify venous ulcers on history?
History of venous insufficiency? - Varicose veins - Superficial thrombophlebitis/deep vein thrombosis - Variceal bleeding Previous venous surgery
How do you identify venous ulcers on exam?
Larger and irregular edge Shallow Location: over gaiter area - Commonly medial malleolus Moist granulating base Surrounded by zone of inflammation and stasis dermatitis Associated signs of venous insufficiency
What is the gaiter area?
Lower part of leg, above ankle
What are the signs of venous insufficiency?
Varicose veins Pitting oedema Varicose eczema Pigmentation Lipodermatosclerosis Atrophie blanche
What investigations can be done for ulcers?
Blood tests Swab X-ray +/- bone scan +/- MRI Duplex CT angiography Digital subtraction angiography Punch biopsy
What blood tests can be performed for ulcers?
Full blood exam Urea and electrolytes CRP Glucose HbA1c Vasculitis screen ESR Thrombophilic screen
How do you get a good swab of an ulcer?
Clean wound
Get to red area
What is more accurate: a swab, or a punch biopsy?
Punch biopsy
What is the treatment for ulcers?
Bed rest Elevation/dependency IV antibiotics Dressings Debridement Treat underlying aetiology - Try and do this first otherwise management won't work
