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Monday, 26 March 2012

DIAGNOSIS and MANAGEMENT OF VARICOSE LEG



DISCUSSION

Peripheral vascular disease is a term referring to the partial or complete blockage of major blood vessels outside the heart that supplies blood to other vital areas of the body, such as brain, kidneys, arms and legs. There are two types: Peripheral arterial disease and peripheral venous disorders.
In this opportunity we will discuss about the problems / peripheral venous disease. Peripheral venous disorders, refers to problems in the peripheral veins such as:
1. Thrombophlebitis - a disease that prevents blood clots (which is a thrombus) if formed, it will cause nearby 
     blood vessels to become inflamed (phlebitis).
2. Buerger's disease - (thromboangitis obliterans) is a peripheral vascular occlusive disease is probably due to 
   an autoimmune disorder of blood vessels, which results ultimately led panangitis stenosis and occlusion of 
   blood vessels.
3. Varicose - abnormally dilated vein picture, swollen, darker colored and winding .. Usually occurs in the 
    legs, and can cause swelling (edema), pain and dark color around the ankles.
4. Chronic venous insufficiency - An advanced stages of venous leg disease in which blood vessels causing 
     the blood to the incompetent hands and feet. Blood does not return to the heart properly, resulting in 
     swelling and ulcers on the feet.

Anatomy of veins
Vena
Veins are veins that drain blood from the systemic return to the heart (atrium dextra), except v.pulmonalis derived from the lung into the left atrium. All systemic veins will lead to the vena cava superior and inferior vena cava.

Venous bleeding head
Veins in the head as v.emisaria and v.fasialis v.jugularis will lead to some internal, some external to the v.jugularis. Eventually will lead to external v.jugularis v.subclavia, where v.subclavia will anastomose with the internal v.jugularis v.brachiocephalica form. There are two v.brachiocephalica, respectively dextra and left. Both will be fused as v.cava superior.

Upper extremity venous bleeding
Veins in the hand, like v.intercapitular, v.digiti palmar and dorsal v.metacarpal will lead to v.cephalica and v.basilica in the forearm. From distal to proximal, the veins will undergo branching and reuniting to form v.mediana cephalica, v.mediana basilica, v.mediana cubiti, v.mediana deep and v. before reaching the region of the median antebrachii cubiti. After cubiti region, the veins are re-forming and v.basilica v.cephalica. V.basilica will unite with v.brachialis (which is meeting v.radialis and v.ulnaris) form v.cephalica v.aksilaris which will also be one with it (v.aksilaris). V.aksilaris will continue to walk to the heart as v.jugularis v.subclavia then anastomoses with the internal and external (from the head) to form the next v.brachiocephalica to get into the atrium dextra as superior vena cava.

Figure 1: Bleeding of the upper limb veins

Lower extremity venous bleeding
The dorsal venous arch on the dorsum pedis will ride through v.saphena magna in the anterior medial lower leg. V.saphena magna will be geared at v.femoralis. While v.saphena parva derived from the posterior lower leg will lead to v.poplitea and ends at v.femoralis. Anterior and posterior V.tibialis v.tibialis v.poplitea also boils down to.
Of v.femoralis, will continue to v.iliaca v.iliaca communis externa and then head further v.cava inferior. In addition there is also v.glutea superior, inferior and v.pudenda v.glutea internal gluteus area, which empties into the internal v.iliaca

                                                Figure 2: lower extremity venous bleeding


Venous bleeding visceral organs
Veins coming out of the viscera organs, such as v.hepatica (organ of the stomach, pancreas, small intestine and colon), v.suprarenal, v.renalis (kidney), and v.testicular v.lumbar will lead to inferior v.cava .
Compared with the artery, vein walls are thinner and easier terdistensi. Approximately 70% of blood volume contained in the venous circuit with a relatively low pressure. Bevolume high venous circuit and serves as a low-pressure circuit kapasistensi, in contrast to the high-pressure arterial circuit and low volume. Venous circuit capacity and volume are important factors in cardiac output due to the volume of blood by the heart diejeksi dependent on venous return.
On lower extremity venous system is divided into 3 subsistence: (1) subsystem superficial veins, (2) subsystem and the deep veins (3) subsystem interface (interconnected). Superficial veins are located in the subcutaneous tissues and the limb receiving the flow of venous blood vessels are smaller in the skin, subcutaneous tissue and a leg. The system consists of superficial saphenous vein and saphenous vein parva. Saphenous vein is the longest vein in the body; walk from the malleolus at the ankle, up to the medial calf and thigh, empties into the femoral vein just below the groin. Junction point between the two veins, the saphenous junctions, the anatomy is an important benchmark. Saphenous vein draining blood from the antero-medial calf and thigh. Saphenous vein parva runs along the lateral side of the ankle through the calf to the knee, to get blood from the postero-lateral calf and popliteal venous blood flow. Point at which the saphenous vein and popliteal called safeno-popliteal junction. Among the saphenous vein and there are many parva anastomosis: anastomosis is a route that has the potential for collateral flow is important, in case of venous obstruction.
The deep venous system carrying most of the venous blood from the lower extremity and is located within the muscle compartment. Deep veins received venules-flow of small venules and intramuscular blood vessels. The deep venous system tends to run parallel with the lower limb arteries, and given the same name as the artery. As akibtanya, which are included in this vein is the venous system of the tibialis anterior and posterior, peroneus vein, popliteal vein, femoral vein, deep femoral vein, and calf blood vessels that are not named. Iliac vein is also included in the deep veins of the lower limb due to venous outflow from the vena cava limb to depend on the patency and integrity of these vessels. The left common iliac vein through the common iliac artery on course for the vena cava, so that the veins are potentially depressed artery. The number of crosses has led to a 2:1 ratio in the deep vein thrombosis of the left than the right.
Subsystem deep veins and superficial channels are connected by blood vessels called veins connecting. Veins connecting the connecting subsystem compiled under the extremity. Usually in the shunt flow from superficial veins to deep veins and then into the inferior vana cava.
Semilunaris valves are one-way spread throughout the lower extremity venous system. Venous valves are folds of the tunica intima consists of endothelial and collagen. These venous valves prevent backflow and to direct the flow from the lower limb proximal to the caval vein, and from the superficial system into the deep system through the liaison. The ability of valves to perform its function is very important because of extremity blood flow to the heart goes against gravity.
Physiology of venous flow against the force of gravity involves a variety of factors known as the venous pump. Venous pump consists of peripheral and central components. Peripheral venous pump depends on the compression venous channels during muscle contraction. Muscle contractions to push forward flow in the deep venous system: venous valves prevent retrograde flow or reflux of blood during muscle relaxation. In addition, the sinuses are small veins or venules berkatup not located in the soleus and gastrocnemius muscle function as a reservoir of blood and blood to empty into the deep veins during muscle contraction. Contribution of intramuscular channel is very important for venous return. The forces that drive the central venous return is reduced intrathoracic pressure during inspiration and decreased right atrial pressure and right after ventricular ejection of particles.

Histological Structure of Blood Vessels in general
Tunica intima. is the layer in direct contact with blood. This layer is formed mainly by endothelial cells.
Tunica media. Layer that sits between the tunica media and adventitia, also called the media layer. This layer is mainly formed by smooth muscle cells and tissue and elastic.
Tunica adventitia. Is the outermost layer is composed of connective tissue.

                                                      Figure 3. Histology of blood vessels

Venous system. Have thin walls and little muscle tissue. Inner layer (intima) is stronger than that formed in the arteries, while the media layer and adventisia seemed to merge into one and consists of mixed connective tissue with little elastic tissue. We must remember, that the veins were named the arterial system, except the vena cava and jugular vein.
The composition of the structure of the venous system, describing the blood flow of low pressure in it and a large volume, the larger veins from arteries and their partners have a thin wall. Layer media has a few layers of smooth muscle.

DIAGNOSTIC PROCEDURES
Clinical signs of venous disease can not be trusted so it is important to evaluate methods of invasive and non-invasive. The goal is to detect and evaluate venous obstruction or reflux through the valves are not functioning properly.
Physical examination
Venous valves are not functioning properly can be clinically evaluated by testing the venous filling time. Brodie-trandelenburg tests carried out by emptying the saphenous vein through the elevation of the limbs and reduce the flow through the artery occlusion. The valve is not functioning properly, visible veins rapid charging when occlusion is released, and possibly also in the standing position. Another technique is the manual compression test, namely the compression adjacent to the proximal veins and palpation of the adjacent distal retrograde venous filling to evaluate because of the reflux valve.

SPECIAL DIAGNOSTIC
On examination with the ultrasonic Doppler method used ultrasonic waves (8-20 MHz) to record blood flow. This tool comes with the unit so I can wave at the same time show a qualitative change can be measured (quantitative assessment).
Doppler technique is used to determine blood flow velocity and blood flow patterns of superficial and deep venous systems. Venous flow can be distinguished from arterial flow due to venous outflow and berpulsasi not change during respiration, normal venous flow pattern is characterized by an increased flow of the lower limb during expiration and decreased during inspiration. In the venous obstruction, passive respiratory variation is not visible. The veins with a total lumen obstruction due tromus there is no signal. While the majority of venous thrombosis, a higher signal peak due to the increased flow velocity through the narrowed segment, in addition, thrombosis will reduce the flow of the wicked.
Doppler technique allows a qualitative assessment of the ability of the valves in deep veins, venous connection, and the vein is perforated. Superfisalis deep venous obstruction and can be detected, although Doppler ultrasound is more sensitive to proximal vein thrombosis than venous thrombosis of the calf. This technique is inexpensive and simple: it requires a high level of technical capability and experience necessary to ensure the accuracy of test results.
Plestimografi recorded on a segment of extremity volume changes due to disruption of blood circulation there. This method can be used for the arterial system and venous system.

Venografi
On venous disease (venografi, or flebografi) is a standard technique in comparison to all other techniques. Bolus of contrast material injected into the venous system to provide an opaque picture of the veins in the lower extremity and pelvis. Venografi descendens with injection of contrast material into the femoral vein is used to indicate the extension of retrograde flow in patients with chronic venous insufficiency, venous. Venografi considered a reliable technique to evaluate the location and the extent of venous disease. However, the loss is relatively more invasive test than non-invasive tests, including greater cost, inconvenience, and greater risks. The high correlation between the combination, measurement, non-invasive venous obstruction, including duplex scanning with color flow and pletismogafi venografi invasive techniques, causing non-invasive tests are increasingly being used, venografi can still be used in cases of non-invasive, no clear or vena cava in a planned surgery in cases of pulmonary embolism.

PERIPHERAL VENOUS DISEASE
Line must be drawn a clear distinction between thrombophlebitis and flebotrombosis based on the degree of inflammation that accompanies the thrombotic process. Thrombophlebitis is characterized by signs of acute inflammation. Flebotrombosis showed venous thrombosis without signs and symptoms of inflammation are unclear. Flebothrombosis is the term applied when thrombosis occurs in blood vessels deep in the absence of inflammatory reaction in the blood vessels. This is commonly referred to as deep venous thrombosis (deep vein thrombosis).
1. Thrombophlebitis: Inflammation is accompanied by a blockage in the venous system is called 
    thrombophlebitis, most often on the edge of the venous system. While the deep venous system usually 
    suffer from thrombosis.
2. Buerger's Disease: thromboangitis obliterans or Buerger's disease (TAO) is a chronic occlusive disease of 
    the arteries and veins are small and medium. Especially regarding peripheral vascular inferior and superior 
    extremities. Disease of the arteries and veins are to be segmental in the limbs and rarely on the tools.

Figure 4: Buerger's Disease

3. Chronic venous insufficiency (CVI) Chronic venous insufficiency occurs when the leg veins do not allow 
    blood to travel back to the heart. (Arteries carry blood from the heart, while veins carry blood to the 
    heart). Problems with valves in the veins can cause blood to flow in both directions, not just toward the 
    heart. Valve is not working properly can cause blood in the legs to the heart. If chronic venous insufficiency 
    is left untreated, will cause pain, swelling, and can lead to ulcers.
4. Varicose Veins (Varicose Veins)
    DEFINITION
     varices (varus = crooked) are enlarged veins (venous) winding characterized by a valve in it that does not  
     work lagi.varises is a disease known since humans lived in a standing position. Has been suggested that   
     there are varicose veins in one Egyptian mummy in 1580 BC. It is estimated that approximately 50% of 
     adult Europeans suffer from this disease. This figure may be lower in Asian populations. Exact figures for 
     Indonesia not yet exist.

    Dilation of vessels behind
    On lower extremity venous system is divided into 3 subsistence: (1) subsystem vein edge (2) subsystem  
    and the deep veins (3) subsystem interface (perforating).
    The main edge of the leg veins are the saphenous vein (VSM) and saphenous vein parva (VSP). VSM is a  
    v ein of the most frequently suffer from varicose veins.
    Saphenous vein is the longest vein in the body, running from the malleolus at the ankle, up to the medial calf   
    and thigh, empties into the femoral vein just below the selangkangan.mengalirkan blood from the leg and 
    medial to the medial side of leg skin.
    Saphenous vein is located between the tendo Achilles parva and lateral malleolus. In mid-calf facilitated  
    through the VSP, and then empties into v.poplitea few inches below the knee.
    Connecting vein (perforating) veins are veins that connect the edge to the deep veins, which is facilitated  
    through the direct way (direct communicating vein). When the valve is not functioning (failure) then the 
    blood flow will be reversed so that the edge of the Ultra venous pressure and varicose veins will be easily 
    formed. On each leg there were 90 vein connecting but a failure on varicose veins only a few direct link. 
   Anatomical location of these veins is usually fixed, which is located on the thigh subsartorial canal (Hunter's 
   canal) of the connecting veins 3-4. Another important link existing veins 3 and found on the medial side of 
   the lower leg, the first located four fingers above the medial malleolus and the next four fingers above the 
   first and the third is as high as 1-2 centimeters below the tibial tuberosity.
   The most important part in the venous system is the valve located at strategic places, which can support the  
   flow of blood returning to the heart and veins from the edge to the deep veins. The fewer the number of 
   valves and veins in the proximal direction as well as more than the vein edge. VSM had 8-15 valve and the 
   Cotton study, two valves are always found in the proximal 5 centimeters before emptying into v. femoral.
   Valve located on the first and the second branching safenofemoral 5 centimeters below it. Both of these  
   valves with valves dibagiab 2/3 proximal VSM is the most frequent valve failures in primary varicose veins 
   of the leg. Liaison in the leg vein valves, reversed its direction other than the connecting valve, so that the 
   flow of venous blood is in the vein edge. This is what causes the skin disorder is most common in the ankle 
   area of ​​the leg veins and chronic venous failure.



                                                                        Figure 5


Role in the development of varicose veins perforating
Estrangement levels of blood vessel walls is determined by the environment in which the vessel is located. In the area of ​​the subcutaneous tissues are tight and stiff, the walls of blood vessels have a very limited tensile strength. Instead vessels located in the loose tissue such as the knees and calves would have a greater tensile strength. As for the perforating veins regangnya levels depending on the muscle fibers facilitated and passed.
The ankle area is an area with a strong subcutaneous tissue, because here there is a relationship between the tissue underneath the skin tight. At this point the stretch and dilatation of the vein wall is very limited. Conversely, if on the VSM or VSP there is a valve that incompetent and are on the loose subcutaneous area, then it will happen here konvolasi vein easily.
When peripheral veins lasted a long time, it will cause the diameter of perforating veins are enlarged gradually to the irreversible stage. At this time the diameter of perforating veins have been so large, so that the valve is located on the saphenous vein with veins branching in not close anymore. This means that the perforating vein insufficiency have experienced, as well as peripheral venous pressure will rise (venous hypertension) and the resulting increase in the number of peripheral varicose veins.

Differences in primary varicose veins with secondary varicose veins
Obtained two forms of saphenous varicose veins are primary and secondary varicose veins. Primary varicose veins is the type most (85%), the cause is not known with certainty, presumably because of the weakness of the vein wall, causing dilation. Valve failure caused by pelebarab happened rather than vice versa. Psalia and Melhuish dlam their study found levels of collagen (hydroxyprolene) which causes the vein wall weakness.
Secondary varicose veins are caused by venous pressure elevation edge (venous hypertension) due to a disorder such as post-phlebitis syndrome, arterial venous fistula dll.artinya secondary varicose veins initiated by the failure or connecting veins. progressive failure stems from the lower vein continues upward.
In the first primary varicose weakness of the vein wall and vein widening. As a result, the valve can not happen befungsi and flow back (reflux) so that the pressure increases and venous lebar.bila this happens to veins connecting each leg muscle contractions will cause the edge of the high venous pressure. Edge of the high venous pressure transmitted to the skin capillaries. The result is a disruption to the capillary diffusion of the network. This has led to complaints and skin changes in patients with varicose veins and chronic venous failure.

SYMPTOMS
In addition to unsightly, varicose veins often cause foot pain and fatigue. But many people who do not feel pain, although the vein is dilated.
Lower leg and ankle may itch, especially if the limb in warm (after using the socks or stockings). Causing the patient to scratch the itch and cause skin redness or rash appear. It is often misconstrued as a dry skin. Symptoms that occur in the developing varicose veins is sometimes worse than the symptoms in the vein that has been fully stretched.

COMPLICATIONS
Only a small proportion of patients who have complications, which are:
• Dermatitis, rash causing red, scaly and itchy or brown area, usually on the inside of the leg, above the ankle.
• scratching or minor injury can cause the formation of ulcers (ulcers) are painful and does not heal.
• Phlebitis, can occur spontaneously or after an injury, usually painful but not dangerous.
• Bleeding.
   If the skin over the varicose veins are very thin, mild injury (mainly due to scratching or shaving) can cause 
   bleeding. Bleeding can also be derived from the ulcers.

DIAGNOSIS
1. History:
 Easily tired
 Pain
 swelling / edema, which increases the afternoon and disappeared when the leg is raised or lost their own  
    morning
 calf muscle cramps at night
 Pregnancy, family, physical activity risk factors 
 Changes in skin color of the legs

2. Physical examination
 People standing: wide and winding veins. When it comes to the upper leg saphenous vein  Magna
 If the dilation of the veins which ditungkai saphenous vein  Parva
 edema, skin disorders and ulcers  Vena In

Brodie Trendelenburg test
1. Patients recline, leg veins is raised to mengkosongkan contents
2. Tourniquets pd pairs groin
3. Ask the patient standing and see the venous filling
4. In the valve competent (good): no charging occurs
5. Valve incompetence: filling 15-20 seconds
6. Removed tourniquets, Sapheno-femoral valve incompetence  charging very fast (several seconds)
7. Removed tourniquets, Sapheno-popliteal valve incompetence  slow filling lbh
8. When tourniquets placed pd popliteal, tourniquets removed   fast fill valve incompetence Sapheno-
    popliteal

• To determine the competence of the deep valves are used:
1. Tests of Perthes: Tourniquets installed pd groin, patients were asked to walk around. When the leg veins to 
    be more likely to smear, there is obstruction. When morbidly widened, meaning vv. Msh Komunikantes 
    deep well and the blood continued to rise through the deep system
2. Tests bandages: superficial leg veins under pressure dg elastic bandage. Patients walk for 10 minutes. If 
    there is obstruction of the deep pd system, the patient will feel pain.
X-rays or ultrasound is performed to assess the function of the deep veins.
This examination is usually only done if the changes in the skin showed abnormalities of venous function in patients with or if the ankle was swollen from edema (accumulates in the tissue under the skin). Varicose veins alone do not cause edema.

TREATMENT
Because varicose veins can not be cured, treatment is primarily intended to reduce symptoms, improve appearance and prevent complications. Lifting the leg to reduce the symptoms but can not prevent varicose veins. Varicose veins that occur during pregnancy usually will improve in the 2-3minggu After giving birth.

Elastic stockings compress the veins and prevent them from stretching and injury to the vein. Patients who do not want to undergo surgery or injection therapy or patients who have medical problems that can not undergo surgery or injection therapy, can use these elastic stockings.

Surgery
The goal of surgery is to remove as much as possible varicose veins. The most superficial veins of the saphenous vein, which runs from the ankle to the groin, where the vein joins the deep veins. Saphenous vein can be removed through a procedure called stripping. Superficial veins have a less important role than the vein, because it does not interfere with removal of superficial veins during the venous circulation in normal functioning.

Injection therapy
On injection therapy, vein is closed, so no blood can pass through. A solution is injected to irritate the vein and cause the formation of a clot (trombus).Basically this procedure causes a harmless surface phlebitis. Healing thrombus cause scarring that will clog the vein. But the thrombus may be dissolved and the varicose vein then reopens.

If the diameter of the vein is injected can be reduced through the suppression by special splinting techniques, then the size of the thrombus can be reduced so it is more likely to form scar tissue, as expected. Another advantage of splinting is that proper emphasis can relieve the pain, which usually accompanies the surface phlebitis.

Injection therapy of varicose veins is usually performed only if the re-occur after surgery or if the patient wants her legs look beautiful.

PREVENTION
There is no way to completely prevent varicose veins. But increase circulation and muscle may reduce the risk of varicose veins expand or grow. The same steps can be done to treat the discomfort of varicose veins in the home can help prevent varicose veins, including:
1. Exercising
2. Monitor weight
3. Eating foods high in fiber, low-salt diet
4. Avoid high-heeled shoes and tight socks
5. Lift your foot
6. Changing the position of sitting or standing on a regular basis




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