Transcript 12-Presentation & management of a swollen leg.ppt

Presentation and management of
a Swollen Leg
By:
abdulkrim al-kharashi
naif alsikan
Differential Diagnosis of a swollen
leg
Vascular vs Non vascular
Vascular

Venous causes:

DVT

Varicose veins

Post-thrombotic syndrome

Klippel-Trenaunay syndrome

External venous compression:
Pelvic or abdominal tumors including gravid uterus and
Retroperitoneal fibrosis
Vascular
Arterial causes

Arteriovenous fistula

AV malformation
Aneurysm:
- Popliteal
- Femoral
- False aneurysm following (iatrogenic) trauma

Non vascular

Systemic diseases:

Cardiac (congestive heart failure)

renal (nephrotic)

liver failure

Thyrotoxicosis (myxedema)

Allergic disorder

Immobility and lower limb dependency
Non vascular

Local disease :

Arthritis

Bony or soft tissue tumors

Heamarthrosis

Calf muscle hematoma

bone dislocations or fractures
Others
Trauma
 Steroids
 Lymphedema

Chronic Venous Insufficiency
Anatomy

Lower Limb Veins :
Anatomy

Superficial system :


Great saphenous vein
Short saphenous vein

Deep system:

posterior tibial , anterior tibial veins, and peroneal veins

Communicating veins:

between 2 superficial veins or 2 deep veins.

Perforated veins :

between 1 superficial & 1 deep vein
Pathophysiology:

Normally, when the leg muscles contract,
they squeeze the deep veins of the legs,
aiding in circulation.

Chronic venous insufficiency (CVI) results
when the veins in the legs no longer
pump blood back to the heart effectively.
Pathophysiology:

Veins contain one-way valves that keep
the blood from flowing in the opposite
direction, toward the foot.

These valves can wear out over time,
leading to blood leaking backward and
pooling in the veins of the leg
Causes:

Primary causes:
Due to inherent structural weakness of the
veins themselves, most common cause,often
familial.
Secondary causes:
Obstruction to venous flow:
Pregnancy, fibroids, ovarian cysts, pelvic cancer,
abdominal lymphadenopathy


Valve destruction( Deep Vein Thrombosis)

High Flow and pressure (AV fistula )
Classes:
Varicose veins

Veins that have become enlarged and
tortuous
Signs and symptoms

Aching, heavy legs (often worse at night and after exercise).

Appearance of spider veins (telangiectasia) in the affected leg.

Ankle swelling.

A brownish-blue shiny skin discoloration near the affected veins.

Redness, dryness, and itchiness of areas of skin - termed stasis
dermatitis or venous eczema, because of waste products building up in
the leg.

Cramps may develop especially when making a sudden move as
standing up.

Minor injuries to the area may bleed more than normal and/or take a
long time to heal.

Restless legs syndrome appears to be a common overlapping clinical
syndrome in patients with varicose veins and other chronic venous
insufficiency
Complaction

Pain, heaviness, inability to walk or stand for long hours.

Dermatitis.

Venous ulcers.

Carcinoma or sarcoma in longstanding venous ulcers.

Severe bleeding from minor trauma.

superficial thrombophlebitis , but can extend into deep

Acute fat necrosis can occur ( Females > Males).
veins becoming a more serious problem
Approach to varicose veins
 History:

History of venous insufficiency

Presence or absence of predisposing factors

History of edema

History of any prior evaluation of or
treatment for venous disease
Approach to varicose veins
 History
of superficial or deep
thrombophlebitis
 History
of any other vascular disease
 Family
history of vascular disease of any
type

Physical examination:
1.Inspection: from distal to proximal and
from front to back.
 Surgical scars
 Pigmentations and
skin changes
 Ulcers ( mostly in the medial aspect)
inspection
Varicose veins
Telangiectases
Reticular veins
Lipodermatosclerosis
Palpation:

Distal and proximal arterial pulses
 Entire skin surface:
•
Greater saphenous vein :
Anteromedial surface
•
Posterior surface:
Short saphenous vein
investigation

Doppler bidirectional-flow studies

Doppler color-flow
Management

Conservative management

Non-surgical management

Surgical management

Elevating the legs.

The wearing of graduated compression stocking
with a pressure of 30–40 mmHg.
has been shown to:

Correct the swelling.

Improve nutritional exchange.

Improve the microcirculation.

Provide relief.
Non-Surgical Management:

Sclerotherapy: injection of a substance
into the vein; shows greater benefits than
surgery in the short term but surgery has
greater benefits in the longer term.

Complications :
 Blood
clots and ulceration.
 Anaphylactic
 Stinging
reactions are very rare.
or pain at the sites of injection
Sclerotherapy
Schlerotherapy:
it’s not a good Rx for varicose veins because it
can cause superficial thrombosis. It can be
used in small sized veins pathologies such as:
telengectasia, spiders veins. NOT for
varicose veins > 3mm


Sclerosing agents: Sodium Tetradecyl Sulfate
and Polidocanol .

You aspirate FIRST then inject the substance
Non-Surgical Management:

Endovenous laser And radiofrequency
ablation.
Appears to be more effective in the
short term.

Complications :
 minor

skin burns (0.4%)
temporary paraesthesia (2.1%).
Endovenous laser And radiofrequency
ablation.
Surgical management

Surgical ligation and stripping
High ligation of the long saphenous vein at the
saphenofemoral junction together with ligation of all
tributeries.

Complications of stripping:-

DVT(5.3%).

PE(0.06%).

Wound complications including infection (2.2%).
Surgical ligation and stripping
Deep vein thrombosis
Deep vein thrombosis

Is the formation of a blood clot (thrombus) in a
deep vein. It is a form of thrombophlebitis.
Deep vein thrombosis
Risk factors :
immobility
hypercoagulability
trauma to vein
age
drugs
orthopedic surgeries
Decrease flow
rate of blood
Damage of
blood vessel
wall
Increase
tendency of
the blood to
clot
hypercoaguble state includes: antithrombin 3 deficiency, protein C
and S deficiency, factor V leiden deficiency
Signs and symptoms

Asymptomatic

Symptomatic:
Pain
 redness,
 warmth,
 tenderness and dilation of the surface veins
 swelling.
 PE symptoms

Massive DVT:

Phlegmasia alba dolens: the leg is pale
and cool with a diminished arterial pulse
due to spasm.

Phlegmasia cerulea dolens: The leg is
usually painful, cyanosed and
oedematous. Venous gangrene may
supervene.

They need surgical intervention usually at
the iliofemoral junction
Physicians and healthcare providers, must
regard DVT as a life-threatening condition
because more people die each year from
PE than motor vehicle accidents, breast
cancer or AIDS.
management

History

Physical examination

Measuring the circumference of the affected and the
contralateral limb at a fixed point(edema).

Palpating the venous tract, for tenderness.

Homans' test: Dorsiflexion of foot elicits pain in posterior
calf.
Pratt's sign: Squeezing of posterior calf elicits pain.

Wells scor for DVT probability
Criterion
Score If
Present
Lower limb trauma or surgery or immobilization in a plaster cast
+1
Bedridden for more than three days or surgery within the last
four weeks
+1
Tenderness along deep venous system
+1
Entire limb swollen
+1
Calf more than 3cm bigger circumference,10cm below tibial
tuberosity
+1
Pitting oedema
+1
Dilated collateral superficial veins (non-varicose)
+1
Malignancy (including treatment up to six months previously)
+1
History of DVT
+1
> 2 or higher :DVT is likely Consider
imaging the leg veins.
 <2 :DVT is unlikely. Consider blood test
such as d-dimer test to further rule out
deep vein thrombosis.

Work up
Blood
tests :
CBC , PT , APTT , fibrinogen , LFT , U and E
D-dimer testing
imaging

Plethysmography, (Used in research not clinical
practice)

Doppler US.( Gold standard BUT Operator
dependent, if the operator wasn’t good do
venography)

Compression US scanning of the leg combined with
duplex US .

Venography

MRI
Doppler findings of DVT:

Decrease blood flow in vein.

Non-compressible vein.

Heterogenicity.
Treatment and mediations
Anticoagulation
 Patients are initiated on a brief course (3 week) of
heparin treatment while they started on a 3-6 month
course of Warfarin.





Anticoagulants: heparin unfractionated bolus
100 unit /kg  monitoring by PTT, can be used in
pregnancy.
LMWH  can be given twice daily 1 mg/Kg
Warafarin monitoring by INR
Length of Rx w/ anticoagulant :
below common femoral vein  3 months
at Common femoral, PE, iliac vein  6 months

Thrombolytic Therapy
 Is generally reserved for extensive clot,
e.g. an iliofemoral thrombosis.
Inferior vena cava filter:Indication:

anticoagulant therapy is ineffective, unsafe, or
contraindicated.
2. to prevent PE.
1.
Contraindications:

Uncorrectable, severe coagulopathy.
 Extensive IVC thrombosis such that placement of a filter
above the thrombus is not possible.
 Bacteremia.
Cont.

Compression stockings (routinely
recommended)

Venous thrombectomy. In very rare cases
complications
1.
Pulmonary embolism
2. Post-phlebitic syndrome:
signs and symptoms, including:



Swelling of your legs (edema)
Leg pain
Skin discoloration
prevention

Patients for surgery, LMWH are routinely
administered to prevent thrombosis.

Prophylaxis for pregnant women who
have a history of thrombosis may be
limited to LMWH injections.

Early and regular walking

Intermittent pneumatic compression (IPC)
machines have proven protective in bedor chair-ridden patients at very high risk
or with contraindications to heparins.

wearing compression socks or
compression tights while travelling

In a long trip , Exercise your calf and
foot muscles regularly
lymphoedema

Regional swelling due to failure of
lymph drainage.
Causes:
Primary:
congenital, underdevelopment and decreased function
of lymphatic system.
-congenital in first year of life
 -precox if after one year
 -tarda if after 35 yrs of age

 Secondary:
 Cancer: breast, cervix, uterus, melanoma,
 Lymph node dissection.
 Surgery or trauma.
 Radiotherapy.
 Cancer Rx esp. breast cancer.
 Infection (filariasis, in tropical areas).
 Recurrent cellulites.

etc.
more common than 1ry happens after breast
surgery in the upper limb.
Sings & symptoms

Severe fatigue, pain.

A heavy swollen limb, reduced mobility.

Discoloration of the skin.

Eventually deformity (elephantiasis).

Diagnosis is clinical then
lymphoscintigraphy (nuclear study)

Duplex to check if there is varicose
veins
treatment
Treat the underlying cause . However,
medical treatment does’not always cure
the underlying condition or the cause is
wholly or partially lifestyle aspects.
Therefore various measures of the edema
are useful.
-Non-operative
-operative
 This
is a complete set of edema
treatment.
 The techniques used are:
1. Manual
2.
3.
4.
lymphatic drainage,
compression bandaging
therapeutic exercise
skin care.
complications
 Infections:
cellulitis, lymphangitis,
lymphadenitis, and in severe cases,
skin ulcers.
 Lymphangiosarcoma
(rare)