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

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grams)andtheaverageAfricanfarmer(500grams)showhowdifferentourdietisintheWest.
Humanbeingshavebeenusedtoahighroughagedietformillionsofyears.Onlyinthepast100yearsorsohasthehighlyrefineddietthatwearenowusedtobeen
introducedtocertaincommunities—thoseofWesternEurope,NorthAmerica,AustralasiaandthewhitepopulationofSouthernAfrica.Weshouldnotbesurprised
tolearnthatinsuchashorttimeourlargeintestineshavenotbeenabletoadapttothechange.Theconsequenceistheconstipationthatissuchacommoncomplaintin
civilizedcommunities.Thereisalsogoodevidencetoshowthatdiverticulardisease,inwhichsmall,blownoutpouchesdevelopinthewallofthecolon(theendofthe
largeintestine),isassociatedwiththisdietandthatthesymptomsduetobothconstipationanddiverticulardiseasecanbecontrolled,inthemajorityofcases,simply
byintroducingadequateamountsofdietaryfibreintothediet.DrDenisBurkitthasproducedanexcellentbook,Don'tForgetFibreinYourDiet(calledEatRight
toStayHealthyandEnjoyLifeMoreintheUnitedStates),whichwecancertainlyrecommendyoutoreadonthissubject.
Whilecompletelyagreeingthatmanyofthebowelproblemswehavetodealwithinourpracticeareduetopeculiardietaryhabits,wewouldliketoseemore
evidencetoconnecttheWesternrefineddietwiththeoccurrenceofvaricoseveins.Nevertheless,therearemanypeoplewhoattachconsiderableweighttosuch
reasoning,andcertainlyweshouldnotdiscountanythingthatmayincreaseourknowledgeaboutvaricoseveinsand,throughit,ourabilitytoapplymethodsof
treatmentandprevention.Thoseexpertswhothinkthatourlow
fibredietshaveadirectbearingonthehighpercentageofvaricoseveinsintheWestarguealongthese
lines:animalswhowalkonallfourshavealargeintestinethathangsdownagainsttheabdominalwall(aglanceatthebulgingbellyofahorse,dogorcatwillconfirm
this).Inman,inhisuprightposition,thelowerpartofthelargebowelsinksdownintothepelvis.Ifthebowelisloadedwithconstipatedstoolitcompressesthelarge
(iliac)veinsinthepelvis,whichinturndraintheveinsoftheleg.Tomakemattersworse,thestrainingneededtoevacuateyourbowelwhenyouhaveconstipationwill
produceanincreaseinthepressureontheveinsintheabdominalcavity,andthistoowillbetransmittedtotheveinsoftheleg.Theincreasedpressurebuildupinthe
legveinsovertheyearswillleadtoadeteriorationofthevalvesandhencewillleadtovaricoseveins.DrBurkittandothershavepointedoutyetathirdpossibility.
Primitivemanemptieshisbowelinthesquattingposition.This
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positionpreventspressurebeingtransmitteddownthelegveins,butthisisnotthecaseinthecomfortablyseatedpositionadoptedbylavatorytrainedWesternraces.
Exercise
Anotherimportantandobviousdifferencebetweenourtwopopulationsisintheamountofwalkingandexerciseweundertake.HereintheWestwespendmuchof
ourtimestandingstillatthework
bench,sittingatourdesksorinfrontofourtelevision;AfricanorIndianpeople,ontheotherhand,spendmuchoftheirtimewalking
about.Now,whiletheyarewalkingabout,themusclepumpsoftheirlegsworkhardtoreturnbloodintheveinstotheheart.Whilewearesittingdownorstanding
stillwehaveastagnantcolumnofhighpressurebloodinourlegveins.This,enthusiastsargue,mustbeanimportantfactorinpointingtotheoriginofvaricoseveins.
Oneargumentagainstthetheorythatmodernwaysoflifeareattherootofvaricoseveinsisthesimplefactthatthisproblemissomuchmorecommoninwomenthan
inmen.Yetbothmenandwomengetjustasconstipatedaseachotherandbothspendaboutthesameamountoftimestandingorsitting.So,ifthedietandexercise
factorsaretobeofoverwhelmingimportance,thenthereshouldbeverylittledifferenceinthenumberofvaricoseveincasesbetweenthesexes.
Evenifwecouldprovethatourmodernwayoflifehassomethingtodowiththecauseofvaricoseveins,whatcanwedoaboutpreventingthedevelopmentof
varicoseveinsinfuturegenerations?Itisdifficultenoughtoconvincepeoplethattheyshouldgiveupsmoking,evenwithalltheoverwhelmingevidenceofitsstrong
associationwithcancer,heartdiseaseandchronicbronchitis(thoughnot,incidentally,withvaricoseveins).Canpeopleeverbepersuadedtogiveuptherefinedsugar
(carbohydrate)andoverprocessedfoodsandreturntoamorenaturaldietofatleastadequatefibrecontent,ortogiveupthecarandthetelevisionandwalk10
miles(16kilometres)adayinorderpossiblytopreventthedevelopmentofvaricoseveins?Althoughitseemshighlyunlikely,itisagoaltowardswhicheveryone
wishingtoliveahealthier,happierlifecanaspireto,evenifwecan't,forthemoment,proveconclusivelythatitwillevenpreventtheoccurrenceofvaricoseveins.
Thereisnodoubt,however,thatonceyouhavevaricoseveins,dietandexerciseshouldplayanimportantroleintheirtreatment;andtherearerecommendationson
bothinChapters6and7.
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YourSex
Anydoctorwilltellyouthatheorsheseesthreeorfourtimesasmanywomenasmensufferingfromvaricoseveins.Oneobviousreasonforthisisthatwomenare
morelikelytoreportfortreatmentforcosmeticreasonsorbecauseofvaricoseveinsinducedbypregnancy.Fewwomenwouldremainunperturbedbytheirunsightly
blackandblueknottedveinswhenwearingadressorswimwear.Anotherreasonwhyfewermenreportthisconditiontotheirdoctoristhehairinessofmalelegs.Itis
notuncommonforamantohavehislegsshavedinhospitalforsomesurgicalprocedure—acartilageoperation,forexample—todiscover,forthefirsttime,thathe
hasaconsiderablecropofunsuspectedvaricoseveinshiddenbeneaththehair.
Evenso,thiscertainlydoesnotaccountthenumberofwomenwithvaricoseveinsfaroutnumbersthenumberofmen.Thisisconfirmedbypopulationsurveysandalso
bythefactthathaemorrhage,phlebitisandulceration,complicationsthatbringpracticallyallsuffererstohospital,aremuchmoreoftenseeninwomenthaninmen.It
maywellbethat,aswesaidearlier,thistendencyforwomentobemoresusceptibletovaricoseveinshassomethingtodowiththefemalesexhormones,
(oestrogens),actingonthemuscleinthewallsoftheveinsandrelaxingthem.WeshallbedealingwiththismorefullyinChapter4.
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Chapter4—
ThePill,PregnancyandVaricoseVeins
Herewediscusstwoimportantproblemswhichworrywomenwithvaricoseveins.Wealsoconsiderthetreatmentofvaricoseveinsduringpregnancy.
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TheContraceptivePill
Itisestimatedthatmorethan3millionwomeninBritainaretakingoneorotherofthehormonebasedcontraceptivepillsavailabletoday,andthatthishasbecomethe
mostpopularformofcontraceptionthroughouttheWesternworld.Asweshallseelateroninthechapter,thereisawellrecognisedrelationshipbetweenpregnancy
andvaricoseveins.Itseemssensible,therefore,tolookforanypossiblelinkbetweenthepillandvaricoseveins.Therearetwoquestionstobeanswered.First,does
thepillproducevaricoseveins?Second,arethereanydangersforawomanonthepillwhoisalreadysufferingfromvaricoseveins?
Beforewecananswerthesequestions,wehadbetterspendafewmomentsfindingoutwhatthevariouspillsactuallydo.Thecluetohowhormonescanbeusedas
contraceptiveagentswasfoundwhenitwasrealisedthatduringpregnancythemotherdoesnotgetpregnantagain!Thisisbecausethehormonesproducedbythe
placenta,orafterbirth,duringpregnancy—oestrogensandprogesterone—preventfurthereggs(orova)beingreleasedbytheovaryuntilthepregnancyhasended.
When,about40yearsago,oestrogenswerebeingusedinthetreatmentofpainfulperiods,doctorsfoundthattheyalsopreventedthereleaseofeggsfromtheovary.
Tenyearslateritwasfoundthatvariouslaboratoryproducedprogesteronelikechemicalshadasimilareffectontheovary.In1956,thefirstbigtrialwascarriedout
inPuertoRicointheCaribbeanusingEnavid,aprogesteroneagent.Thiswassoonfollowedbythemoderncontraceptivepills,thegreatmajorityofwhicharemade
upofamixtureofoestrogenandaprogestagen—aprogesteronetypehormone.
SideEffects
About25yearsagoevidencestartedtoaccumulateshowingthattherewasaverysmallincreaseintheriskofthrombosis,orclottingofthebloodvessels,inwomen
takingthepill.Casesofcoronarythrombosis(heartattacks),cerebralthrombosis(strokes)andthrombosisofthedeepveinsofthelegwerereportedaswellas,in
veryrarecases,clottingwithinthearteriessupplyingbloodtotheintestine.Wemuststressherethattheriskofalltheseisactuallyverysmall.Forexample,in1974a
reportwaspublishedinBritainon23000womenwhoweretakingcontraceptivepillscomparedwithanother23000whowerenot.Theresultssuggestedthattherisk
ofclottingwassomethinglikesixtimes
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greaterinwomenonthepillcomparedwiththosewhowerenot.Butweemphasizethatthenumbersaresmall.Inanotherstudy,thestatisticsshowthatoutofevery
200000womentakingthepill,threemightbeexpectedtodieofsomeclottingillnesseachyearinthoseundertheageof35.Theriskwasrathergreater,justlessthan
eightper200000,inwomenovertheageof35.Toputthisdangerintoperspective,oneauthoritysaidthatwhenafatherbuysamotorboatheintroducesatenfold
greaterriskofsuddendeathinhisfamilythancouldbeassociatedwithhiswifetakingthepill!Againstthiswemustalsoplace,ofcourse,alltherisksanddangersthat
areassociatedwithunwantedpregnancieswhenwomenchoosenottotakethepillforcontraception.
Sincethesestatisticshavebecomeavailable,theamountofoestrogeninthetwohormonepillhasbeenreducedby50%,soitmaybethatthepossibledangersofthe
contraceptivepillhavebeenreducedtoanevenlowerlevelthanthefiguresgivenabove,thoughitwillprobablybesometimebeforeweknowthisforsure.Thereare
pillscontainingonlyprogestagen,butthereisstillaproblemofbalance—findingadosesmallenoughnottoproduceirregularperiodsandalsolargeenoughtomake
sureofcontraception.Statisticsfortheprogestagenonlypillsgivearateoftwotothreepregnanciesforevery100womanyears,comparedwithlessthan0.5with
thetwohormonepill.
Armedwiththisinformationaboutthechemicalmakeupofthepill,anditseffectontheblood,wecannowlookatitseffectonvaricoseveins.
ThePillandVaricoseVeins
First,althoughweknowthatoestrogenrelaxesveinsandispartlyresponsiblefortheexpansionofveinsinthelegthatoccursduringpregnancy,wecanfindnodefinite
evidencethatvaricoseveinshavebecomemorewidespreadsincetheintroductionofthecontraceptivepill.Thereisnoreason,therefore,whyyoushouldnottakethe
pillbecauseoffearthatvaricoseveinsmaydevelopasaresult.
Ifyoualreadyhavevaricoseveins,however,particularlyifyouhavehadanattackofphlebitis,orclotting(seepage98)intheveins,yourdoctorisunlikelyto
prescribethecontraceptivepillcontainingoestrogen(moreespeciallyifyouareovertheageof35or40),becauseweknowthattheriskofthrombosisinthatage
rangebecomesgreater.Itwouldbebettertousesomeotherformofcontraception,oryour
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gynaecologistmightprescribeapillcontainingonlyprogestagen.Theveryslightriskinusingthepillisalsoprobablyfurtherreducedifyouhavehadyourvaricose
veinsclearedupcompletelyeitherbysurgeryorbyinjectiontreatment(seechapter6).
Thereisoneveryimportantpracticalpoint.Somewomenhavereportedthattheircalfmusclesacheandtheyassociatethiswithbeingonthepill.Naturallyboththey
andtheirdoctorswillbeanxiousaboutthepossibilityofthisbeingasignthattheirvaricoseveinsordeepveinsareclotting.Medicalexaminationcanspeedilydecide
whethertheachingcalfmusclesareduesimplytocrampsinthemuscleortovaricoseveins.Ifcrampsarediagnosed,changingthepilltooneofaloweroestrogen
contentsometimesrelievesthesymptomsbut,ifitdoesnot,itmaybenecessarytochangetosomeothermethodofcontraception.
Becauseofaslightincreaseintheriskofthrombosisinveinswhenyouareonthepill,manysurgeonsadvisetheirpatientstostopusingthisformofcontraceptionfor
4—6weeksbeforeanoperation—andthisincludes,ofcourse,havingsurgeryforyourvaricoseveins.Youcanstarttakingthepillagain2weeksaftersurgery.
However,thispolicymeansthatyouhavetotakesomeotherformofcontraceptionfor2—3months,andsomepatientshavefallenpregnantduringthisperiod.An
alternativesolutionistothinthebloodoutbyaninjectionofheparin(ananticoagulant)justbeforesurgery.Thismeansthatyoucancontinuetakingthepillanddonot
requireanyotherformofcontraception.Itisveryimportantthatyoutellyoursurgeonthatyouareonthepillifsurgeryistobeundertaken,andyoumustdiscussthe
variousoptionsofpreventingthrombosistoselectwhichonesuitsyoubest.
VaricoseVeinsinPregnancy
Oneoftheproblemsthatshowsearlyinmanypregnanciesistheappearanceofvaricoseveinsor,ifthewomanalreadyhasthem,thenshenoticesthattheyare
suddenlygettingmuchworse.
Theveinsshowupasoneormoreofthefollowing:
Straightforwardvaricositiesofthesurfaceveinsoftheleg.
Developmentofbrokenveins(spidernaevi)intheskinofthethighs.
Vulvalvaricosities.
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Therearetworeasonsforthedevelopmentofnewvaricoseveinsortheworseningofthosealreadyexistinginyourlegduringtheearlymonthsofpregnancy.First,
thereisthepresenceoftheenlarginguterus(womb),whichpressesonthepelvicveinsandobstructsthedrainageofbloodfromyourlegs.Theriseinpressurebehind
theobstructionwillbetransmitted,ofcourse,downwardsintothesurfaceveinsofyourlegs.Thesecondreasonistheriseinthelevelofsexhormonesinyourblood.
Thesehormonesrelaxthemuscletissueintheveinwallsandsoincreasethelikelihoodoftheirswelling.
HormonesandyourVeins
Thereseemslittledoubtthattheeffectofhormonesontheveinsisanimportantoneanditmaywellbethereasonwhyvaricoseveinsareseveraltimesmorecommon
inwomenthaninmen.Hormonesmayalso
Onecauseofvaricoseveinsduringpregnancyisthewombpressingonthe
pelvicveins,thustransmittingpressurebackdowntothelegveins.
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''BokelbergG&JImages,Inc./TheImageBank,©1999"
forthemothertobe,agoodlongwalkeverydayisoftremendousvalue,notonlyin
helpingtocontrolhervaricoseveins,butalsoforhergeneralhealthandwellbeing.
beresponsibleforacommonlyobservedphenomenoninwomenwithvaricoseveins—theytendtofindthattheirveinsareworseandmoreuncomfortablejust
beforeamenstrualperiod.
Becausethehormonaleffectoccursquiteearlyinpregnancy,thesuddendevelopmentofvaricoseveins—ortheirbecomingpainful—islookeduponasbeing
almostassignificantasamissedperiodinmakinganearlydiagnosisofpregnancy!
Afterthearrivalofyourbaby,thevaricoseveinsthatappearedduringpregnancymaydisappearcompletely,andevenestablishedvaricoseveinswillcertainlybecome
muchimproved.However,itisalsotruetosaythatthevaricoseveinsareverylikelytoreappearagainatthenextpregnancyandbecomemoremarkedinfurther
pregnancies.
Treatment
Agreatmanydoctors,especiallyinBritain,areverymuchagainstthetreatmentofvaricoseveinsduringpregnancy.Inthefirstplace,wecan
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almostguaranteethatyourlegswillimprove,evengobacktonormal,afteryourbabyisborn.Inthesecondplace,doctorsareverycautiousindeedaboutsubmitting
apregnantwomantoanysortoftherapywhenitinvolveseitheranoperationorinjectionswhichtheydonotconsiderabsolutelyessentialeithertothehealthofthe
motherorthewellbeingoftheexpectedchild.Itisvirtuallyimpossibleforaminoroperationoraninjectionofavaricoseveintoaffectyourbabyinanyway.
ProfessorGeorgeFeganofDublinhastoldus,inthecourseofmanyconversations,howhehaspersonallydealtwithlargenumbersofpregnantwomenbyinjection
treatmentwithcompletesafetytobothmotherandchild.Nevertheless,ifaftertreatmentforaveinthereshouldbeanyblemishatallinthebaby,thenitwouldtakea
verystrongmindedparentindeednottothinkthatperhapswantingtogetridofuglyoruncomfortableveinsmighthaveharmedthechild.Whenthathappens,even
thestrongestreassurancescannotentirelyhelp.
SupportStockingsandExercise
Thestandardtreatmentofvaricoseveinsinpregnancyisthereforetofitthemotherwithfulllength,properlyfittingelasticsupportstockings.Putthestockingsonfirst
thinginthemorning,ongettingup,andwearthemthroughouttheday,butleavethemoffatnight.Cosmeticallythemodernstockingshaveanacceptableappearanceif
ordinarynylonstockingsarewornoverthem.Exerciseisalsoanexcellenttreatment:agood,briskwalkhelpstopumpthebloodoutofthelegveinsand3miles(5
kilometres)adayisareasonabletarget.Avoidgartersorundergarmentsthataretootight,astheyonlyaggravatethecongestionofbloodinlegveins.SeeChapter8
formoredetailedadviceonexerciseandelasticstockings.
PutyourFeetup!
Youwillsoonlearnthegreatvalueofputtingyourlegsupduringthedaywheneverpossible,andalsosleepingeitherwithyourheelsraisedonpillowswhileinbedor
elsewiththefootofthebedraisedabout12inches(30centimetres)abovetheheadbymeansofastrongbox,bricksorsomeotherfirmsupport.
Oncepregnancyisover,bothyouandyourdoctorcanassesswhetherthevaricoseveins,nowmuchimproved,aregoingtoneedtreatment.Iftheyarenotsevere,
thereismuchtobesaidforputtingofftreatmentuntilyouhavegivenbirthtoyourlastchild,butiftheveinsarecausinganydiscomfort,thenanytimefromafew
weeksafter
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