Case study on Varicose Veins & Venous Ulcers

Case Presentation on
Varicose Veins &
Venous UlcerModerator
Dr Jamaluddin Ahmed,
Asst. Professor, Dept. of Surgery,
Gauhati Medical College & Hospital
Presented by:
Students of 8th semester
Roll no. 29, 30, 31, 32, 33, 34, 35

Case study
Dept.ofSurgery,GauhatiMedicalCollege&Hospital

Patient History

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

Chief Complaint
• On and off pain in the left leg for 30 years.
• Recurring ulcers in the left leg for 27 years.

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.

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.

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.

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.

Family History
• There is no history of similar diseases in the family. All other
members are enjoying good health.

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.

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.

Immunisation History
• BCG scar is absent.
• The patient could not recall taking any other vaccinations.

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

General Examination

• 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

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

Local Examination

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.

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

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.

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.

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 Vein
1. 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

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.

Systemic
Examination

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.

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.

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.

D. Gastrointestinal System
INSPECTION:
• 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

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

Provisional
Diagnosis
Our 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.

Differential Diagnosis
D/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.

Investigations

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

B. Varicose Vein Investigation
• Venous Doppler
• Duplex Scan
• Venography

C. Additional Tests
• Chest X-Ray
• Left lower leg X-Ray
• ECG
• Culture Sensitivity
• Biopsy of the ulcer edge

Final Diagnosis
Our 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.

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

Treatment for Venous Ulcer
• Bisgaard Method
 To reduce edema, increase venous drainage, so as to promote ulcer
healing.
 It consist of:
1. Elevation
2. Massage of the indurated area and whole calf
3. 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.

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

Case study on Varicose Veins & Venous Ulcers

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