General Surgery Rotation

General Surgery: Varicose veins

Patient will present with → a 77-year-old Hispanic female with a dull ache in her legs that is worsened with prolonged standing and relieved with rest and elevation of her legs. She has 14 grown children and a past medical history of obesity and hypertension. On physical exam, her bilateral lower legs are edematous with multiple dilated, tortuous superficial veins.

Varicose veins are dilated superficial veins in the lower extremities. Usually, no cause is obvious.

  • Approximately 15% of adults, particularly women who have been pregnant, develop varicosities.
  • Other risk factors include obesity, family history, prolonged sitting or standing, and history of phlebitis.
  • The main mechanisms are superficial venous insufficiency and valvular incompetence; inherited defects in vein walls or valves also play a role.

Clinical features

  • Dilated, tortuous veins develop superficially in the lower extremities, particularly in the distribution of the great saphenous vein. Smaller blue-green, flat reticular veins; telangiectasias; and spider veins are further evidence of venous dysfunction.
  • Varicosities may be asymptomatic or associated with aching and fatigue.
  • Chronic distal edema, abnormal pigmentation, fibrosis, atrophy, and skin ulceration may develop in severe or prolonged disease.

Diagnosis is clinical - visual inspection of the leg in dependent position usually confirms the presence of varicosities.

  • Duplex ultrasonography locates incompetent valves/ venous reflux before surgery. In most cases, reflux arises from the greater saphenous vein.

Graduated compression stockings provide external support.

  • Leg elevation and regular exercise provide symptomatic relief.
  • Small venous ulcers heal with leg elevation and compression bandages; larger ulcers may require compression boot dressing (Unna boot) or skin grafts.
  • Interventional techniques include endovenous radiofrequency or laser ablation, compression sclerotherapy, and sometimes surgical stripping of the saphenous tree.
osmosis Osmosis
Picmonic
Varicose Veins Assessment

Varicose veins are dilated subcutaneous veins that may be small and harmless or large and bulging. Varicose veins are caused by increased venous pressure and incompetent valves. They typically occur in the legs but may also occur in the esophagus, vulva, anorectal area, and spermatic cord (varicocele). Assessment findings include telangiectasias (spider veins), small reticular veins, and dilated and tortuous veins.

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Varicose Veins Interventions

Varicose veins are dilated subcutaneous veins that may be small and harmless or large and bulging. Other types of varicosities include reticular veins and spider veins (telangiectasias). Varicose veins are caused by increased venous pressure and incompetent vein valves. They typically occur in the legs but may also occur in esophagus, vulva, anorectal area, and spermatic cord (varicocele). Interventions include laser therapy, sclerotherapy, or surgical removal of the saphenous vein. To prevent worsening conditions, the patient should be taught to avoid prolonged standing, and to wear elastic compression stockings.

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Question 1
A 65 year-old white female presents with dilated tortuous veins on the medial aspect of her lower extremities. Which of the following would be the most common initial complaint?
A
Pain in the calf with ambulation
Hint:
Patients with deep venous thrombosis (DVT) may present with complaints of pain in the calf with ambulation. Secondary varicosities may result from DVT's.
B
Dull aching heaviness brought on by periods of standing
C
Brownish pigmentation above the ankle
Hint:
Stasis Dermatitis and edema are most suggestive of chronic venous insufficiency.
D
Edema in the lower extremities
Hint:
See C for explanation.
Question 1 Explanation: 
Dull aching heaviness or a feeling of fatigue brought on by periods of standing is the most common complaint of patients presenting initially with varicosities.
Question 2
A retired operating room nurse comes to the clinic complaining of a dull ache in her legs after prolonged standing. She notes her legs feel heavy and she has mild ankle edema when she spends the day shopping. The aching pain and the edema resolve spontaneously if the patient elevates her legs. She denies calf tenderness or dyspnea. Physical examination reveals + 1 ankle edema bilaterally. What is her most likely diagnosis?
A
deep venous thrombosis
Hint:
Deep venous thrombosis edema is usually unilateral, may be associated with calf tenderness or a palpable cord, and does not resolve on its own.
B
lymphedema
Hint:
Lymphedema is a condition also associated with calf heaviness and edema but the symptoms do not resolve spontaneously.
C
varicose veins
D
intermittent claudication
Hint:
Intermittent claudication is not associated with peripheral edema generally and while the pain is resolved with rest, walking exacerbates the pain.
Question 2 Explanation: 
Varicose veins develop when individuals spend a prolonged amount of time on their feet. Lymphedema is a condition also associated with calf heaviness and edema but the symptoms do not resolve spontaneously. Deep venous thrombosis edema is usually unilateral, may be associated with calf tenderness or a palpable cord, and does not resolve on its own. Intermittent claudication is not associated with peripheral edema generally and while the pain is resolved with rest, walking exacerbates the pain.
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General Surgery: Arterial/venous ulcer disease (ReelDx) (Prev Lesson)
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