Varicose Veins and Lymphatics

Varicose Veins - Twisted Troubles

• Dilated, tortuous, elongated superficial veins; primarily in legs.
• Etiology: ↑ Intra-abdominal pressure (pregnancy, obesity, chronic constipation), prolonged standing, DVT history, congenital valve weakness, female sex, family history.
• Pathophysiology: Superficial venous hypertension due to valvular incompetence (reflux) or venous obstruction. Perforator incompetence allows blood from deep to superficial veins, ↑ pressure.

• Clinical Features: Asymptomatic, cosmetic concerns, aching, throbbing, heaviness, itching, swelling, skin changes (pigmentation, eczema, lipodermatosclerosis), ulceration (venous ulcers, typically medial malleolus).

⭐ Most common site: Great Saphenous Vein (GSV) and its tributaries.

• Complications: Superficial thrombophlebitis, bleeding, chronic venous insufficiency, ulceration.
• 📌 Trendelenburg Test: Differentiates saphenofemoral junction (SFJ) incompetence from perforator incompetence (Perthes test for deep vein patency).

Varicose Veins Clinical & Complications - Signs & Soreness

• Symptoms:
  • Leg aching, heaviness, fatigue, burning, or throbbing; worse with prolonged standing, relieved by elevation.
  • Night cramps, itching (pruritus) over veins.
  • Ankle swelling (edema), especially in evening.
• Signs:
  • Dilated, tortuous, bluish superficial veins (GSV/SSV territories common).
  • Visible/palpable varicosities.
  • Pitting ankle edema.
  • Tenderness along affected veins.

• Complications (Chronic Venous Insufficiency - CVI):
  • Skin Changes:
    • Corona phlebectatica (ankle flare).
    • Hemosiderin pigmentation (brownish).
    • Stasis dermatitis/Venous eczema: itching, scaling, weeping.
    • Lipodermatosclerosis: induration, fibrosis, "inverted champagne bottle" leg.
    • Atrophie blanche: white, stellate scars.
  • Venous Ulcers: Medial malleolus commonest; shallow, irregular, painful.
  • Superficial thrombophlebitis: painful, tender, palpable cord.
  • Bleeding from varices (can be profuse).
  • Secondary lymphedema.

⭐ Lipodermatosclerosis signifies severe CVI, with chronic inflammation and fibrosis of skin and subcutaneous tissues.

Lymphatic Disorders - Drainage Dilemmas

• Lymphedema: Chronic tissue swelling from impaired lymphatic drainage.
  • Progression: Early pitting edema → late non-pitting (brawny) induration.
  • Skin changes: Thickening, hyperkeratosis, papillomatosis, peau d'orange; "buffalo hump" (foot dorsum).
  • Stemmer's sign +ve: Inability to tent skin at base of 2nd toe.
  • Complications: Recurrent cellulitis/lymphangitis, fungal infections, Stewart-Treves syndrome (lymphangiosarcoma in chronic cases, e.g., post-mastectomy).

⭐ Milroy disease is an autosomal dominant congenital lymphedema, typically affecting lower limbs, caused by mutations in the VEGFR3 (FLT4) gene.

• Lymphangitis: Inflammation of lymphatic channels. Red, painful subcutaneous streaks; fever. Often Strep. pyogenes.
• Chylous Effusions: Accumulation of chyle (lymphatic fluid rich in TGs) in body cavities (e.g., chylothorax) due to thoracic duct injury/obstruction.

High‑Yield Points - ⚡ Biggest Takeaways

• Varicose veins: dilated, tortuous superficial veins, typically in legs.
• Pathogenesis: venous valve incompetence → ↑ intraluminal pressure & stasis.
• Key risks: obesity, pregnancy, prolonged standing, family history.
• Complications: stasis dermatitis, ulceration, poor healing, superficial thrombophlebitis.
• Lymphedema: interstitial fluid accumulation from impaired lymphatic drainage.
• Types: Primary (e.g., Milroy disease - congenital); Secondary (e.g., filariasis, post-surgery, malignancy - acquired).
• Lymphangitis: acute inflammation of lymphatic channels, commonly streptococcal.