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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4087_Библиотеки_им_академика_М_И_Перельмана

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Page98
ComplicationsofVaricoseVeins
Inagreatmanycasesvaricoseveinsarenomorethananuisance.Theyareunattractiveandtheyoftenache.
Surgeonsfeelnohesitationinundertakingthetreatmentofvaricoseveinspurelytoimprovetheappearanceoftheirpatient'slegs.Atypicalpatientwouldbe,for
example,ayoungwomanwhoenjoysopenairlife,swimmingandsunbathing,andwhofindsthepresenceoftheswollenblueveinsonherlegsanembarrassment.
Youmaybeoneofthosemanysufferersfromvaricoseveinswhospendalotoftheirtimeontheirfeet—suchashousewives/husbands,shopassistants,postal
workersandaremarkablyhighnumberofnursesandsurgeons—andyoufindthatyourlegsacheandthatyouranklesbecomealittlepuffyattheendoftheday.
Theachingisduetothestretchingoftheveinwallasitisexpandedbybloodunderpressureinthestandingposition.Thepuffiness(oroedema,togiveititscorrect
medicalterm)isduetothehighpressurewithintheveinswhichincreasesthenormalmovementoffluidacrossthecapillarywallsintothesofttissuesofthefootand
anklesothatthetissuesbecome`waterlogged'.Youwillfindthatboththeachingandtheswellingwillberapidlyrelievedwhenyousitdownwithyourfeetraisedin
theair.
Thereare,however,anumberofcomplicationsofvaricoseveinsthat,whilerelativelyuncommon,areunpleasant,painfulandeven,occasionally,dangerous.These
are:
1.phlebitis.
2.haemorrhage.
3.pigmentation;and
4.ulceration.
Phlebitis
Thisisduetoaclotforminginthestagnantcolumnofbloodinthevaricosevein.Theclotcreatesanareaofinflammationarounditandinconsequencetheskinover
theclottedpartoftheveinbecomeshot,red,swollenandtender.
Phlebitisoccursonlyinratherlargeandchronicvaricoseveins,soyouhavenoneedtoworryifyouhavesmall,earlyvaricoseveins.
https://t.me/med1917

Page99
Phlebitisisaninflammationcausedbytheclottingofstagnantbloodinavaricosevein.
Indeed,itisnotquitesuchaseriousconditionaswasoncethought.Infact,thesurgeonwhotreatsvaricoseveinsbyinjection—whichwedescribedinChapter5—
isreallysettingouttoproduceacontrolledlocalizedphlebitisoftheveininordertosealitoff.
Patientssometimesfearnotonlythattheymaybesubjectedtoagooddealofpainwithphlebitisinasurfacevein,butalsothattheclotintheveinwillbecome
detachedandenterthebloodcirculationsystem.Thisdoesindeedhappenwhenclottingtakesplaceinthedeepveinsoftheleg,forexampleaftermajoroperationor
injury,butithappensonlyextremelyrarelywhenphlebitisaffectsthesurfaceveinsoftheleg.
HowdoyouknowifyouhavePhlebitis?
Diagnosisiseasy,anditcanbemadebyyourselfevenbeforecomingtothedoctor.Theareaofredness,painandtendernessalongtheveincanbeduetonoother
cause.
https://t.me/med1917

Page100
TreatmentofPhlebitis
Treatmentissimplicityitself.Youmerelyneedtorestyourlegintheraisedposition—youcandothiseitherfromanarmchair,or,preferably,inbed.You'llfindlight
crêpebandagesupportcomfortingandthepainmeanwhilecanberelievedbysuitablepainrelievingpillssuchasaspirinorparacetamol(acetaminophen).
Althoughantibioticsaresometimesprescribedforthiscondition,theyareseldomrequired.Theyareveryuseful,indeedtheymaybelifesaving,ifyouhaveadisease
orwoundinfectedwithmicrobes(bacteria),butarequiteuseless(sometimespositivelyharmfultopeoplewhoreactagainstthem)when,asinthecaseofphlebitis,
thereisnoquestionofbacterialinfection.Phlebitisisachemicalinflammationproducedbytheirritatingeffectofthebloodclotonthesurroundingtissues;asimilararea
ofinflammationoccursaroundabruise.Itisnotduetobacteria(wecallitasterileinflammatoryprocess).
Thereisalsoagoodsidetophlebitis.Justasasurgeonproducesalocalizedchemicalinflammationinavaricoseveintocureitbyinjectiontreatment,soquiteoften
afteranattackofphlebitisthevaricoseveinssettledownandbecomelessprominentthanbefore.Weagree
Crêpesupportbandagingforphlebitis
(FigurecourtesyofSmith&NephewLtd)
https://t.me/med1917

Page101
thatit'snottheidealtreatmentbutatleastitisalittlecomforttothephlebitissufferertothinkthatthelegmaylookratherbetteraftertheattackthanitdidbefore.
Haemorrhage
Haemorrhage,orbleeding,isoneofthecomplicationsthatcomestothemindofthelayman,suffererandnonsuffereralike,whenseeingbadlyswollenveins.Infact,
thispotentiallydangerouscomplicationisunusual,andoccursonlyinparticularlylargeandparticularlyprominentveinsthatlieimmediatelybelowtheskinoftheankle
orthelowercalf.Sometimestheseenormousveinsseemtohaveonlyapaperthinlayerofskinbetweenthemandthesurfaceofyourleg.Ifyouinjureoneofthese
veinsitcantakeonlyatrivialmattersuchasaknockgettinginoroutofabusorcar,orevenjustscratchinganitchintheoverlyingskin
therecanbeaseriousgush
ofbloodfromtheopenedveinifyou'restandingup.Thisgushisduetothefactthat,aswehavealreadydiscussedatsomelength,pressureintheseveinsisveryhigh
whenyouarestandinganditrepresentsthepressureofthecolumnofbloodstretchingallthewaydownfromyourhearttoyourankle.
Do'sandDon'ts
Likethetreatmentforphlebitis,treatmentforhaemorrhagetooissimple:thehighpressurewithintheveinisrelievedbylyingdownandholdingyourlegintheair.This
ismosteasilydonebylyingonthefloornexttoawallandelevatingyourlegstorestagainstthewall.Afirmbandageshouldbeapplied(acleanhandkerchiefwill
servejustaswell)andtheemergencyisover(seephotographonpage91).Tryingtoimprovizeatourniquetaroundthelegisworsethanuselessbecause,ifthisisput
onbyanamateur,itactuallyincreasesthepressurewithintheveinandthebleedingbecomesstillfiercer.
Itisaswelltorememberthetaleofawomanwhohadinjuredhervaricoseveinandhadbeenbroughtintohospitalsittinginacab.Hersittingposition,ofcourse,did
nothingtopreventthehigh
pressurebleedingandshewasallbutdeadonarrival.Onlyapromptbloodtransfusioninthecasualtydepartmentsavedherlife.Ifonlythe
cabdriverhadlearnedalittlefirstaid,hewouldhavedoneheragreatservice(aswellaspreventingtheinsideofhiscabfrombeingruined)merelybybringingherinto
hospitalwithherlegliftedupontotheseatinfront!
https://t.me/med1917

Page102
VaricosePigmentation
Manypatientsfearthedevelopmentofthesenexttwocomplications—thediscolourationofareasoftheleg,knownaspigmentation,andtheopensoresof
ulceration.Therewasoncesomecauseforthesefears,becausetheyusedtobeextremelycommonbutnow,withimprovedhealthservicesandsurgicalfacilities,
theseveryadvancedformsofvaricoseveinsthatweusedtoseeofteninourhospitalclinicsarefortunatelybecomingmuchrarer.
Pigmentationhasallsortsofnamesincludingvaricosepigmentation,varicoseeczemagravitationalpigmentationandvaricosedermatitis.Justwhythisunsightlyskin
discolourationcomesaboutcaneasilybeexplained.Onceagain,itistheresultofhighpressurepresentwithinthevaricosevein.Thisistransmittedrightdowntothe
thinwalledcapillariesofthelowerlegandforcestheredbloodcells(corpuscles)throughthemintothesurroundingsofttissuesoftheskin.Theredcellsbreakdown
intoanironcontainingpigmentcalledhaemosiderin,anditisthissubstancethatgivesthebluishbrownpigmentationsocharacteristicofthiscondition.
Oncebadlypigmented,theskinwillnotreturntoitsnormalappearance,althoughanyfurtherpigmentationcanbepreventediftheunderlyingveinsaretreated.
Sometimestheappearanceofthelegcanbeimprovedifthedoctorcantreatthecomplicationinitsearlystage,andskincolouredcosmeticcreamsareavailable
whicheffectivelycamouflagethediscolouration.
Ulceration
Inanadvancedcaseofvaricoseveins,theskinofthelowerlegbecomespigmented,thinandpoorlynourished.Itispoorlynourishedbecausethehighpressureinthe
varicoseveinspreventsarterialbloodanditsnutrientsfrombeingpushedthroughthefinenetworkofcapillariestosupplytheskin(seepage103).Althoughtheexact
causeofvenousulcerationisunknown,twotheorieshavebeenadvancedtoexplainit.First,itcanbeshownthatacuffoffibrindevelopsaroundthesmallcapillaries
inthelowerleg,andthisisthoughttoreducethesupplyofessentialnutrientstotheskinwhichsubsequentlybreaksdown.Second,duetothesluggishflowofblood,
thewhitecellsintheperipheralbloodstarttomovetowardsthevesselwallandthentomovethroughintothetissueswheretheybecometrappedandreleasepotent
chemicalscalledcytokineswhichdamage
https://t.me/med1917

Page103
Varicosepigmentation—alsocalledvaricose
eczemaordermatitis—canbecamouflaged
withskincolouredcosmeticcreams.
Stagnantbloodinavaricoseveinforcestheredbloodcellsout
throughthedelicatecapilliariesandintotheskin,resultinginpigmentation.
https://t.me/med1917

Page104
thetissues.Atthisstageaminorinjury,sometimesmerelyscratchingtheirritatingskin,isallthatmaybenecessarytocausethedevelopmentofanulcer.Inahealthy
leganinjurysuchasthiswouldhealwithinadayortwo.Withtheskinstarvedofnourishmentandoftheblood'shealingproperties,thetinywoundbreaksdowninto
anulcer,whichmaytakemanyweeksofcarefultreatmenttoheal.Iftheulcerisneglecteditmayenlargeandbecomeapainful,burdensomemiserytoitsowner.
PreventionisbetterthanCure
Varicoseulcersarealwaysprecededbyatleastseveralyearsofslowlyworseningtroublewiththeleg,leadingtopigmentation,itchinessandoftenveryprominentand
unpleasantvaricoseveins.Ifyoucanletyourdoctorbegintreatmentatthispreulcerstagesothathecandealwiththeveins,thenulcerationwillbeprevented.The
stepshewilladvisewillbe:
1.Supportthelegwithelasticstockings.
2.Elevatetheleginbedatnight.
3.Exerciseregularly.
4.Loseweightifoverweight.
5.Takecarenottoscratchorinjurethethreatenedskinoftheleg.
Asinsomanysituations,thispreventionisfar,farbetterthanwhatmayturnouttobealong,tediousandpainfulcure.
SmallUlcers
Iftheskindoesbreakdownintoanulcerfollowingsomeslightdamagetoyourlegsuchasaknockorscratch,theearlieryoucangettoyourdoctorforefficient
treatmentthebetter.Indeed,asmallulcercanbecompletelyhealedwithinafewweeks.
Thelarge,nastylookingulcersthatweseeinourhospitalclinicsfromtimetotimealwaysresulteitherfromneglectofasmallulcer,orfromitsinappropriateor
inadequatetreatment.
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Alegulcerlikethiscanbepreventedbytaking
thesimplestepsoutlinedonpage104.Ifonedoesdevelop,
thetreatmentissimplebuteffective:keepthelegraised
andsupportedbyelasticbandaging(seeoverleaf).
TreatmentofVaricoseUlcers
Tocureanulcerwehavetodealwiththecausethepoorbloodsupplytotheskinoftheaffectedareaduetothehighpressureinthedrainingveinswhichmeans
emptyingthehighpressureveins.Thisisdonebytwocombinedmeasures:elevatingthelegandsupportingitwithelasticbandaging.
Elevation
Whenyouraiseyourlegitemptiestheveinsofbloodbymeansofgravity.Ifyoukeepyourheelaboveyourkneeandyourkneeaboveyour
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hipwhileinbed,youwillhaveachievedagreatdealalreadytowardshealingtheulcer.Youcanelevatethelegeitherbyusingpillowsunderthelegorbyplacing
blocksunderthefootofthebedtoraiseit12inches(30centimetres)intheair.
Ofcourse,keepingyourlegupfor8to10hoursatnightiseasyenough,andyoucanaddtothegoodworkbyputtingyourlegupwheneverpossiblewhensitting
downduringtheday.Itisafact,though,thatmostpeoplejustdon'trelishtheprospectofremaininginbedwiththeirlegelevatedforseveralweekscontinuously,even
thoughthisalonewillgettheulcertohealinthegreatmajorityofcases.
ElasticBandaging
Youareprobablyoneofthemanypeoplewithabusyhouseholdtorunoralivingtoearn,andsoyoumustbeabletowalkaboutduringtheday.Thismeansthatwe
mustuseoursecondmeansoftreatmentforvaricoseulcers,firmelasticbandaging(whichcompressesthesurfaceveinsmoretightlythanelasticstockings).This
squeezesthebloodoutoftheincompetentsurfaceveins,throughperforators,orlinkingveins,andintothedeepveinsoftheleg.Thenwhenyouwalk,theseveinswill
beemptiedactivelybacktowardstheheartthroughthepumpingactionofthemusclesofyourleg,thusgreatlyimprovingthetissuenourishingcirculationofblood
aroundtheulcer.
Therearetwotypesofelasticsupportbandageavailable.Oneisstrong,elasticatedwebbandagethatcanbewoundaroundthelegeachdayfromthetoestojust
belowtheknee.Itrequiresagreatdegreeofskilltoobtainafirmandconstantpressurealongtheleg.Althoughitisahighlyeffectivetypeofsupport,mostpatients(or
theirfamilies)lacktheexpertiseneededtocarryoutthiskindofbandagingsatisfactorily.
Themajorityofpatients,therefore,musthavetheirlegsupportedbytheelasticatedadhesivetapeknownmostcommonlyinBritainasElastoplast.Thiscanbeapplied
byanurseordoctorinanoutpatientclinicorinyourdoctor'ssurgery,andrenewedeverycoupleofweeks.OnlyanelasticbandageorElastoplastwilldo—crêpe
bandagesorsupportstockingssimplylacktheelasticstrengthrequiredforthejobofemptyingtheveinsandarequiteineffectiveinhelpinganulcertoheal.
Unfortunately,manypeopleare,orbecome,sensitivetoElastoplast,andthediscoloured,scalyskinaroundtheulcerseemsespeciallypronetosuchanallergy.
Obviously,asensitivityrashistheverylastthingyouwanttohaveinthiscondition.
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Havinganulcerbandaged(FigurescourtesyofSmith&NephewLtd)
Applyanabsorbentpaddingafterfirst
dressingthewoundwithprimarydressings.
Thiswillredistributethepressurearound
theankleandabsorbanyexudate
Toapplybandagingstartatthebaseof
thetoes,beginturningaroundthefoot,
passingthebandagefromhandtohand.
Applyfirmlybutwithoutcompression.
Keepaboutsixinchesofthebandage
stretchedthroughouttheapplication
Reinforcecoverageoftheheelbymaking
thefirstturnmoreabovethanbelowthe
heel,thenthesecondturnmorebelow
thanabove.
Nowcommencefullcompression.
Bandageattherequiredextensionusing
a50%overlapandspiraltechnique.Finish
belowthekneeandcutoffanyexcess
bandagethentapetosecure
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