Rosen & Barkin's 5-Minute Emergency Medicine Consult (760 page)

• Primary valve incompetence (most common)
  
• Deep vein thrombosis (DVT)
  
• Risk factors include advanced age, family history, smoking, sedentary lifestyle, obesity, lower extremity trauma, prior DVT, and pregnancy
  

DIAGNOSIS

• Asymptomatic phase:
  
  • Venous dilation ranging from venous flares to small varicosities
    
• Symptomatic phase:
  
  • Ankle and calf swelling
    
  • Varicose veins
    
  • Skin discoloration/hyperpigmentation
    
  • Ulcer formation
    
  • Lipodermatosclerosis
    
  • Dull ache/pain in the legs:
    
    • Worsened by prolonged standing
      
    • Resolves with leg elevation
      
  • Burning sensation
    
  • Pruritus
    
  • Night cramps
    

• Varicose veins
  
• Ankle- and calf-dependent edema
  
• Ulcers, most often situated over the malleoli or medial portion of calf:
  
  • Must have preserved peripheral pulses to ensure ulcers are due to venous insufficiency and not arterial insufficiency
    
• Red, purple discoloration of skin
  
• Telangiectasias
  
• Reticular veins
  
• Stasis dermatitis
  
• Brownish hyperpigmentation
  
• Sclerosis, induration, and atrophy of skin
  
• Bacterial infection:
  
  • Surrounding cellulitis
    
  • Rapidly growing ulcer
    
  • Purulent drainage from ulcer
    
  • Increased pain
    
  • Fever
    
  • Lymphangitis
    
• Other etiologies than venous insufficiency, proximal to the lower extremity, should be suspected in the following settings:
  
  • History of heart failure
    
  • History of liver disease
    
  • Leg edema and ulcers in a patient with ascites
    
  • Periorbital edema
    
  • Orthopnea
    
  • Positive hepatojugular reflex
    
  • Jugular venous distention
    

The physical exam is essential to the diagnosis.

• Lab tests add little to the physical exam unless other causes need to be excluded.
  
• Cardiac markers, brain natriuretic peptide, albumin, and tests of renal function can be sent if considering other causes of leg edema.
  

• Doppler auscultation (DopA):
  
  • Used to assess for arterial flow to the lower extremities in differentiating venous insufficiency from arterial insufficiency
    
  • Used to estimate blood flow, as well as the presence or absence of reflux in a given vein.
    
  • Indications are diameter >3 mm, signs/symptoms of chronic venous insufficiency, the presence of a painful vessel, or concern for arterial insufficieincy (no distal pulses, history of peripheral vascular disease, decreased ankle–brachial index)
    
• Duplex US (DUS):
  
  • Combines Doppler and gray-scale imaging and shows vascular anatomy, soft-tissue features, detection and quantification of reflux and the source of it
    
  • Can assess for DVT, valvular incompetence, and retrograde flow.
    
  • Can be used for diagnosis, as part of the treatment (duplex-guided sclerotherapy and endovenous ablation) and for postoperative evaluation.
    
• Photoplethysmography (PPG):
  
  • Assesses venous hemodynamics and venous refilling time with and without leg muscle contraction.
    
  • Used to measure vein outflow and inflow, as well as muscle pump adequacy.
    
• Venography:
  
  • Expensive and invasive
    
  • Despite still often being considered the gold standard, duplex ultrasonography has been found to be more sensitive and specific in predicting the clinical severity of venous insufficiency.
    

Ankle–brachial index:

• Should be measured if arterial insufficiency is suspected
  

• Venous valvular incompetence
  
• Deep venous thrombosis (DVT)
  
• Arterial insufficiency
  
• Lymphatic disorders or obstruction
  
• Soft-tissue infections (diabetic foot ulcers)
  
• Trauma (compartment syndrome, vascular or lymphatic disruption, inflammatory response)
  
• Ruptured Baker cyst
  
• Pyoderma gangrenosum
  
• Congestive heart failure
  
• Pulmonary hypertension
  
• Renal disease (nephrotic syndrome, renal failure resulting in hypervolemia)
  
• Liver disease (ascites)
  
• Vasculitis or autoimmune disorders (polyarteritis, hypothyroidism with myxedema, systemic lupus erythematosus)
  
• Pregnancy (both normal pregnancy and preeclampsia/eclampsia)
  
• Medications (NSAIDs, calcium channel blockers)
  

TREATMENT

• Leg elevation to above the level of the heart
  
• Control bleeding with direct pressure.
  

• Leg elevation above the level of the heart
  
• Compression stockings
  
• Barrier creams (white petroleum jelly or Zinc oxide) with wound dressings applied to ulcers
  
• Anticoagulants if confirmed DVT
  
• Antibiotics if signs of infection, specifically cellulitis or infected ulcer
  
• Aspirin (improves ulcer healing rate)
  
• Topical steroids for stasis dermatitis, pruritis, dry skin
  
• Antihistamines for pruritus
  

• Aspirin: 325 mg once daily PO
  
• Augmentin: 875 mg BID PO
  
• Benadryl: 12.5–25 mg QID PO
  
• Cephalexin: 500 mg QID PO
  
• Dicloxacillin: 500 mg QID PO
  
• Coumadin: Dose per prothrombin time/INR
  
• Lovenox: 1 mg/kg SC BID
  

FOLLOW-UP

• Arterial insufficiency
  
• Evidence of cellulitis, lymphangitis, or osteomyelitis may require admission, specifically in a patient that is immunocompromised (on steroids, receiving chemotherapy or radiation therapy, history of diabetes)
  
• DVT in the following setting:
  
  • Thrombosis is extensive
    
  • There is concern for pulmonary embolism
    
  • The patient is at high risk for bleeding with anticoagulation
    
  • Outpatient management with low molecular weight heparin and/or close follow up is not appropriate or available
    
• Treatment of an underlying etiology of lower extremity swelling other than primary venous insufficiency or the patient’s other comorbid conditions warrant admission
  

• Lower extremity pulses are present
  
• No evidence of bleeding or compartment syndrome
  
• DVT has been ruled out with DUS or patient is low risk (See Well’s Criteria for DVT)
  
• No evidence of bacterial infection requiring admission
  
• Appropriate follow-up/referral arranged
  
• Patient has been given instructions for wound care, dressing changes, and the use of compression stockings
  

The patients should be referred to their primary care physician. They should be referred to a vascular surgeon if there is concern for peripheral vascular disease.

• Home health care or close follow-up with outpatient care provider for ulcer management
  
• Immediate surgical procedures are not required for varicose veins.
  
• Vein stripping, vein ligation, sclerotherapy and endovenous thermal ablation are options for cases refractory to medical management:
  
  • These do not improve healing of ulcers but reduces ulcer recurrence
    
  • All these methods cause irreversible changes to the venous system of the lower extremity which can result in recurrence of edema and can increase risk for DVT in the future.
    

• In patients with no palpable pulses, extremity pain, ulcerations, or risk factors for peripheral artery disease, ensure that arterial insufficiency is not the underlying cause before assuming venous insufficiency.
  
• Compression therapy is contraindicated in patients with peripheral vascular disease and venous insufficiency presenting with overlying cellulitis.
  

• Gloviczki PA, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum.
  J Vasc Surg
  . 2011;53:2S–48S.
  
• Gohel MS, Barwell JR, Taylor M, et al. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): Randomised controlled trial.
  BMJ.
  2007;335:83.
  
• Kundu S, Grassi CJ, Khilnani NM, et al. Multi-disciplinary quality improvement guidelines for the treatment of lower extremity superficial venous insufficiency with ambulatory phlebectomy from the Society of Interventional Radiological Society of Europe, American College of Phlebology and Canadian Interventional Radiology Association.
  J Vasc Interv Radiol
  . 2010;21:1–13.
  
• Longo DL, FauciAS, Kasper DL, et al., eds.
  Harrison’s Principles of Internal Medicine.
  18th ed. McGraw-Hill,2012: Chap 249.
  
• O’Meara S, Cullum N, Nelson EA, et al. Compression for venous leg ulcers.
  Cochrane Database Syst Rev.
  2012;11:CD000265.
  

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