Case Presentation onVaricose Veins & Venous UlcerModerator

Dr Jamaluddin Ahmed,Asst. Professor, Dept. of Surgery,Gauhati Medical College & Hospital

Presented by:

Students of 8th semesterRoll no. 29, 30, 31, 32, 33, 34, 35

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Case study

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Patient History

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Patient Particulars• Name: Uttam Kalita

• Age: 66 years

• Sex: Male

• Religion: Hinduism

• Address: Palashbari, P.O-& P.S-Palashbari, Dist-Kamrup Phone no.: +91-9435035598

• Occupation: Daily wage worker in a rice-mill

• Date of Admission: 9-03-2017

• Date of Examination: 16-03-2017

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Chief Complaint• On and off pain in the left leg for 30 years.

• Recurring ulcers in the left leg for 27 years.

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History of Present Illness• The patient complains of pain in the lower left leg for 30 years. The

pain was gradual in onset and progressive in nature. The pain was dragging in nature and it worsens when the patient stands for a long time and is relieved when he lies down. There is no radiation of the pain. The pain is more towards the end of the day. The patient is said to have taken medication for the pain, but it didn’t get relieved.

• The patient also presents with an ulcer in the left leg for 27 years which occurred spontaneously. It was gradual in onset and progressive in nature. At first it was small in size and gradually increased in size as time progressed. There is no history of trauma. There was pain around the ulcer and discharge from the ulcer. The discharge was sero-purulent in nature, scanty in amount, and non foul-smelling. There is darkening and thickening of the skin around the ulcer. There is no associated fever or any other significant findings.

• The patient also complains of another ulcer over the lateral aspect of the lower limb, which started 5 years ago and was gradual in onset, progressive in nature with associated pain around the ulcer and no discharge or bleeding.

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History of Present Illness (Contd.)• There is no associated swelling of the left leg. Patient also

complains of itching. There is no complaint of night-cramps.

• There is no history of constipation, chronic cough or swelling of the abdomen. Pain abdomen and fever are absent.

• Patient’s appetite is normal, bladder and bowel habits are regular and sleep in normal. There is no history of weight loss.

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Past History• There is no history of similar illnesses in the past. There is no

history of hypertension, diabetes or any other serious illnesses in the past.

• There is no history of previous surgeries in the past.

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Personal History• The patient takes average rice-based non-veg Assamese diet,

consisting of three major meals a day and two minor meals.

• He is a non-smoker, non-alcoholic but chews tobacco for the last 20 years.

• The patient is a daily wage worker in a rice-mill. His occupation requires him to stand for prolonged periods of time.

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Family History• There is no history of similar diseases in the family. All other

members are enjoying good health.

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Socio-economic History• The patient belongs to a low socio-economic group with an

income of Rs. 4000 per month.

• He lives in a pucca house, drinks unfiltered water from the tube-well and uses sanitary latrine.

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Medication History• The patient took medication for the pain in the leg which he

couldn’t specify. He also took medication for gastritis for more than 5 years.

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Immunisation History• BCG scar is absent.

• The patient could not recall taking any other vaccinations.

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Allergic History• Patient is not allergic to any known contactant, ingestant or

inhalant.

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lGeneral Examination

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• Appearance: Patient looks well• Decubitus: Of choice• Build: Average• Weight: 63kg• Height: 175cm• Nutrition: Fair• Hair and skin: Hair is normal in

colour and texture. Skin in the left lower leg is hyperpigmented and thickened.

• Dehydration: Absent

• Icterus: Absent• Pallor: Absent• Cyanosis: Absent• Teeth and gums: Stained• Tongue: Moist and smooth

papillae• Neck vein: Not engorged• Neck glands: Not palpable• Clubbing: Absent• Koilonychia: Absent• Oedema: Absent• Skeletal deformities: Absent

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Vitals• Respiratory rate: 18/min.

Regular in rhythm, and abdomino-thoracic type.

• Blood pressure: 110/70 mm Hg in right upper arm in supine position.

• Pulse: 84 beats/min. Regular in rhythm, normo-volumic, normal arterial wall condition with

normal character. No radio-radial and radio-femoral delay found. All other peripheral pulses are bilaterally and symmetrically palpable.

• Temperature: 98⁰F

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lLocal Examination

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Inspection• Patient is examined in standing position.

• Long, tortuous and dilated veins are seen extending from above the medial malleolus to above the knee.

• Localised swellings are seen on the antero-medial aspect of the left leg along the course of the long saphenous vein.

• Skin of the lower left leg is hyperpigmented and thickened.

• There is eczema over the medial malleolus.

• The toes are hyperpigmented.

• There is no impulse on coughing at the saphenous opening.

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Inspection (Contd.)Lower left leg (Medial Aspect) Lower left leg (Lateral Aspect)

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Inspection (Contd.)• There are two ulcers present on the

lower left leg. One is above the medial malleolus with scab over the ulcer, and another ulcer above the lateral malleolus.

• Size: Medial malleolus: 11x7cm (apprx) Lateral malleolus: 4x2cm (apprx)

• Shape: Medial malleolus: Irregular Lateral malleolus: Vertically oval

• Margins: Irregular, with a sloping edge (Both ulcers)

• Floors: Covered with scab.

• No discharge or bleeding present.

• Surrounding area: Hyperpigmented.

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Palpation• Tenderness: Not present

• Sloping edge is felt in both ulcers, with an irregular margin with no indurations in both ulcers.

• Base: Formed of muscle and bone.

• Depth: 6mm on the medial side 2mm on the lateral side

• The ulcer does not bleed on touch.

• The ulcer is not fixed to deeper structures.

• There is no raised temperatures and tenderness in the surrounding skin. Mobility is present and it is not fixed to the deeper structures. No loss of sensation or motor deficit is present.

• Dorsalis pedis artery is palpable.

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Palpation (Contd.)• VARICOSE VEIN EXAMINATION

Dilated and tortuous vein is seen on the medial aspect of the left leg. So the vein involved is long saphenous vein.

• Test for Varicose Vein1. Brodie Tredelenburg’s Test I

On releasing the tourniquet immediately after standing the veins didn’t fill from above. So, the test is negative.

2. Brodie Tredelenburg’s Test II The tourniquet was tied for 2-3 minutes. There was gradual filling of the superficial

veins. So, the test is positive. This shows the perforators are incompetent.

3. Three Tourniquet Test All the three below knee perforators are involved.

4. Modified Perthes Test Distention of superficial veins seen with no pain while walking with tourniquet in

place. The test is negative, suggesting no DVT.

5. Morrisey’s Test Cough impulse at saphenous opening is absent.

6. Fegan’s test The sites of the perforators are marked

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Palpation (Contd.)• Lymph Node Examination

The vertical chain of inguinal lymph nodes is enlarged in the left leg.

• Other limb examination: There is no varicosity or venous ulcer seen.

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lSystemic Examination

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A. Central Nervous System• Higher mental functions

Patient is conscious, alert and cooperative. Patient is oriented to time, place and person. His speech is normal and memory is intact.

• Cranial nerves are intact.

• Motor system is normal.

• Reflexes and jerks are normal.

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B. Respiratory System• Inspection:

Shape and size of chest is normal. Movement of chest is bilaterally symmetrical.

• Palpation: Trachea is in the midline. Chest expansion is normal. Vocal fremitus is bilaterally symmetrical and normal.

• Percussion: Lung field is uniformly resonant in all areas.

• Auscultation: Normal vesicular breath sounds are heard and no additional

sounds are heard. Vocal resonance is normal on both sides.

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C. Cardiovascular System• Inspection:

Precordium is normal. No bulging or visible pulsations are seen.

• Palpation: Apex breath is felt in the 5th intercostal space just medial to

the mid-clavicular line.

• Auscultation: 1st and 2nd heart sounds are heard normally. No additional heart sounds are heard.

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D. Gastrointestinal SystemINSPECTION:

• Shape of the abdomen is neither flat nor distended

• Umbilicus is on midline and inverted

• No visible scar or pulsation or peristalsis

• No engorged vein seen

• Hernia sites are normal

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D. Gastrointestinal System (Contd.)PAPATION:

• On superficial palpation, no local rise of temperature, no tenderness

• On deep palpation, all the quadrants are normal

• Liver is not palpable

• Spleen is not palpable

• Kidneys are bimanually palpable

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lProvisional DiagnosisOur patient, Uttam Kalita, a 66 year old male is provisionally diagnosed to be a case of venous ulcers due to varicose vein as a result of below-knee perforator incompetence in the left limb with a normal right limb.

Dept

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Differential DiagnosisD/D for Venous Ulcer

• Ischemic Ulcer

• Diabetic Ulcer

• Rheumatoid Ulcer

• Traumatic Ulcer

• Neuropathic Ulcer

• Neoplastic Ulcer

D/D for Varicose Vein

• AV Malformation

• Renal and Cardiac Disease

• Hepatic Causes

• Vasculitis

• Chronic infection like Tuberculosis, Syphilis, etc.

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Investigations

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A. Routine Blood Tests• ABO Grouping: B+

• Rh Typing: Positive

• Haemoglobin: 12.2 g/dl

• TLC: 9,564/mm3

• DLC Neutrophil: 82% Lymphocyte: 12.6% Monocyte: 4.2% Eosinophil: 1.2%

• Platelet: 1.29 lacs/mm3

• Random Blood Sugar: 77 mg/dl

• Serum creatinine: 0.87 mg/dl

• TSH: 1.09 µIU/l

• Hbs Ag: Negative

• HIV: Non reactive

• VDRL: Non reactive

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B. Varicose Vein Investigation• Venous Doppler

• Duplex Scan

• Venography

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C. Additional Tests• Chest X-Ray

• Left lower leg X-Ray

• ECG

• Culture Sensitivity

• Biopsy of the ulcer edge

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Final DiagnosisOur patient, Uttam Kalita, a 66 year old male is diagnosed to be a case of venous ulcers due to varicose vein as a result of below-knee perforator incompetence in the left limb with a normal right limb.

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ManagementVaricose veins is to be treated first followed by treatment for venous ulcers.

Dept

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Treatment for Venous Ulcer• Bisgaard Method

To reduce edema, increase venous drainage, so as to promote ulcer healing.

It consist of:1. Elevation2. Massage of the indurated area and whole calf3. Passive and active exercise.

• Care of the ulcer by regular cleaning with povidone iodine + H2O2

• Dressing with EUSOL

• Antibiotics depending on culture sensitivity.

• Skin graft after ulcer granulates.

Dept

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Specific Treatment for Varicose Vein• CONSERVATIVE TREATMENT

Elastic Crepe Bandage Elevation of limb Unna Boots Pneumatic Compression method

• DRUG THERAPY Calcium dobesylate 500mg BD Diosmine 450mg BD

• SURGICAL TREATMENT Sub fascial ligation of below-knee perforators

Thank You