Varicose Veins and Lymphatics — MCQs
A mother brings her 5-year-old boy to see you as a General Physician. On examination, he has red eyes, dry, cracked lips and a rash on his hands and feet. He also has cervical lymphadenopathy. What is the most important investigation to rule out a serious complication of this condition?
Which of the following does not cause deep venous thrombosis (DVT)?
A 65M presents with worsening dyspnea and leg swelling. Physical examination reveals an elevated jugular venous pressure and bilateral lower extremity pitting edema. Most likely cause of his symptoms?
A patient presents with dull aching pain and tortuous veins in both lower limbs. Which test would be appropriate for evaluating saphenofemoral junction (SFJ) incompetence?
Identify the condition given in the image below?
Which of the following are seen in chronic lymphedema?
Sclerotherapy for varicose veins is contraindicated in the following condition:
Fluorescein dye study is done to detect:
Which type of blood vessel is most commonly affected in hypersensitivity vasculitis?
Surgery in varicose veins is NOT attempted in the presence of which of the following?
Varicose Veins and Lymphatics Indian Medical PG Practice Questions and MCQs
Question 1: A mother brings her 5-year-old boy to see you as a General Physician. On examination, he has red eyes, dry, cracked lips and a rash on his hands and feet. He also has cervical lymphadenopathy. What is the most important investigation to rule out a serious complication of this condition?
- A. Blood pressure
- B. ECG
- C. Echocardiography (Correct Answer)
- D. Blood tests for autoantibodies
Explanation: ***Echocardiography*** - The constellation of symptoms (red eyes, cracked lips, rash on hands and feet, cervical lymphadenopathy in a 5-year-old) is highly suggestive of **Kawasaki disease**. - **Coronary artery aneurysms** are the most serious complication of Kawasaki disease, making echocardiography crucial for early detection and management. *Blood pressure* - While important in any pediatric assessment, **blood pressure measurement** is not specific for diagnosing or monitoring the most critical complication of Kawasaki disease. - Hypertensive or hypotensive episodes are not classic features and do not directly assess **coronary artery involvement**. *ECG* - An **ECG** can detect arrhythmias or signs of myocardial ischemia, which might occur with **coronary artery pathology**. - However, it is less sensitive and specific than **echocardiography** for directly visualizing and quantifying **coronary artery aneurysms**. *Blood tests for autoantibodies* - Kawasaki disease is not an autoimmune condition primarily diagnosed by **autoantibodies**; it is a **vasculitis** of unknown etiology. - Blood tests for autoantibodies would not be the most important investigation to rule out its most serious complication.
Question 2: Which of the following does not cause deep venous thrombosis (DVT)?
- A. Lower limb trauma
- B. Subungual hematoma (Correct Answer)
- C. Hip & pelvic surgeries
- D. Cushing's syndrome
Explanation: ***Subungual hematoma*** - A **subungual hematoma** is a collection of blood under the fingernail or toenail, usually caused by trauma. - It is a localized injury that **does not affect systemic coagulation** or venous blood flow, thus not increasing DVT risk. *Lower limb trauma* - **Trauma to the lower limb**, especially involving fractures or significant soft tissue damage, can lead to **venous stasis** due to immobility and direct vessel injury [1]. - This immobility and vessel damage activate the **coagulation cascade**, significantly increasing the risk of DVT [1]. *Cushing's syndrome* - **Cushing's syndrome** is characterized by **hypercortisolism**, which leads to a **hypercoagulable state**. - **Elevated cortisol levels** increase circulating procoagulant factors and decrease fibrinolytic activity, predisposing patients to DVT. *Hip & pelvic surgeries* - **Major surgeries**, particularly those involving the **hip and pelvis**, frequently cause **endothelial injury**, blood stasis, and activate the coagulation system [1]. - Patients undergoing these procedures are at a **very high risk for DVT** due to prolonged immobility and surgical trauma [1].
Question 3: A 65M presents with worsening dyspnea and leg swelling. Physical examination reveals an elevated jugular venous pressure and bilateral lower extremity pitting edema. Most likely cause of his symptoms?
- A. Hypothyroidism
- B. Right-sided heart failure (Correct Answer)
- C. Chronic kidney disease
- D. Liver cirrhosis
Explanation: Right-sided heart failure - **Elevated jugular venous pressure (JVP)** and **bilateral lower extremity pitting edema** are classic signs of fluid overload due to the inability of the right ventricle to effectively pump blood [2], [4]. - **Dyspnea** can occur due to congestion in the lungs (if left-sided failure is also present) or due to increased effort of breathing with significant fluid retention [1], [3]. *Hypothyroidism* - While **hypothyroidism** can cause **non-pitting edema** (myxedema), it does not typically lead to elevated JVP. - The dyspnea in hypothyroidism is often related to respiratory muscle weakness or pleural effusions, not primarily venous congestion. *Chronic kidney disease* - **Chronic kidney disease** can cause **fluid overload** and **edema**, but it typically presents with **pitting edema** and elevated JVP. - However, the primary cause of the fluid retention in CKD is impaired renal excretion, not cardiac pump dysfunction, as in this case. *Liver cirrhosis* - **Liver cirrhosis** can lead to **ascites** and **peripheral edema** due to low albumin and portal hypertension. - Elevate JVP is not a typical feature of cirrhosis unless there is a co-existing cardiac condition.
Question 4: A patient presents with dull aching pain and tortuous veins in both lower limbs. Which test would be appropriate for evaluating saphenofemoral junction (SFJ) incompetence?
- A. Fegan's test
- B. Brodie Trendelenburg test (Correct Answer)
- C. Modified Perthes test
- D. Morrissey test
Explanation: ***Brodie Trendelenburg test*** - This test evaluates **venous valve competence** at the saphenofemoral junction (SFJ) by observing the rate of venous refilling after emptying the superficial veins in the supine position and then standing. - Quick refilling of veins upon standing, particularly after compression of the SFJ, suggests **SFJ incompetence**. *Fegan's test* - This test is used to locate **incompetent perforating veins** by palpating for defects in the fascia after emptying the veins and applying compression. - It does not directly assess the competence of the saphenofemoral junction. *Modified Perthes test* - The Perthes test assesses the **patency of deep veins** and the competence of perforating veins by observing the disappearance of superficial veins during exercise with a tourniquet applied. - It primarily differentiates between superficial and deep venous insufficiency, not specifically SFJ incompetence. *Morrissey test* - This test (also known as the percussion test) involves percussing an incompetent vein distally and palpating proximally to detect a transmitted thrill, indicating **venous incompetence**. - While it helps identify reflux, it is less specific for SFJ incompetence compared to the Brodie Trendelenburg test.
Question 5: Identify the condition given in the image below?
- A. Chronic lymphedema (Correct Answer)
- B. Cushing syndrome
- C. Osteoporosis
- D. None of the options
Explanation: ***Chronic lymphedema*** - The image shows a **swollen foot** with **thickened, dry, and hyperkeratotic skin**, and **deep skin folds**, particularly between the toes. This is characteristic of **chronic lymphedema** due to impaired lymphatic drainage. - The presence of the **Stemmer's sign** (inability to pinch and lift the skin at the base of the second toe) is a common finding in lymphedema, which can be inferred from the overall appearance of the toes. *Cushing syndrome* - Cushing syndrome is characterized by **central obesity**, **moon facies**, **buffalo hump**, and **thin, fragile skin** with **striae**, not typically severe localized edema and skin changes as seen in the image. - While fluid retention can occur, it does not manifest as the characteristic cutaneous changes of chronic lymphedema. *Osteoporosis* - Osteoporosis is a condition of **decreased bone density**, making bones fragile and prone to fractures. - It does not present with visible skin changes or edema as depicted in the image. *None of the options* - The image clearly shows severe manifestations identifiable as **chronic lymphedema**, therefore one of the provided options is correct.
Question 6: Which of the following are seen in chronic lymphedema?
- A. Stemmer's sign
- B. Square toes
- C. All of the options (Correct Answer)
- D. Hyperkeratosis
Explanation: ***All of the options*** - **Chronic lymphedema** leads to significant tissue changes due to persistent fluid accumulation and inflammation, resulting in all the described clinical signs. - The combination of **Stemmer's sign**, **square toes**, and **hyperkeratosis** are classic indicators of advanced lymphedema, marking specific stages of its progression. *Square toes* - **Square toes** are a distinctive feature of chronic lymphedema, occurring due to protein-rich fluid deposition and fibrosis in the dorsum of the foot, specifically the toes. - The fibrosis leads to tissue thickening and hardening, making the toes appear "squared off" rather than rounded. *Stemmer's sign* - **Stemmer's sign** is a hallmark physical finding in lymphedema, defined as the inability to pinch and lift a fold of skin at the base of the second toe or middle finger. - This inability indicates **fibrotic thickening** of the skin and subcutaneous tissue due to persistent lymphatic fluid buildup. *Hyperkeratosis* - **Hyperkeratosis** refers to the thickening of the stratum corneum (outermost layer of the epidermis) and is a common dermatological manifestation of **chronic lymphedema**. - It results from chronic inflammation, impaired lymphatic drainage, and subsequent protein deposition, leading to rough, warty skin texture.
Question 7: Sclerotherapy for varicose veins is contraindicated in the following condition:
- A. Deep vein Thrombosis (Correct Answer)
- B. Varicose ulcers
- C. Pigmentation Over limb
- D. Hemorrhoids
Explanation: ***Deep vein Thrombosis*** - **Sclerotherapy** involves injecting a solution that irritates and scars the vein, causing it to close. If **deep vein thrombosis (DVT)** is present, this procedure could dislodge a **thrombus**, leading to a potentially fatal **pulmonary embolism**. - Additionally, DVT indicates a compromised deep venous system, and treating superficial veins with sclerotherapy when the deep system is inadequate can lead to **worsened venous insufficiency** and complications. *Varicose ulcers* - **Varicose ulcers** are often a complication of **venous insufficiency**, and **sclerotherapy** can sometimes be used cautiously, in conjunction with compression therapy, to treat the underlying insufficient veins that contribute to ulcer formation. - While it's not a universal treatment for all ulcers, the presence of an ulcer itself is not an absolute **contraindication** if the underlying venous pathology can be safely addressed. *Pigmentation Over limb* - **Pigmentation over the limb** (often **hyperpigmentation**) is a common sign of **chronic venous insufficiency** and a cosmetic concern associated with **varicose veins**. - It is not a contraindication to **sclerotherapy**; in fact, successful treatment of the underlying varicose veins can sometimes lead to an improvement in or prevention of further pigmentation. *Hemorrhoids* - **Hemorrhoids** are essentially **varicose veins** of the **anorectal region**. While **sclerotherapy** can be used to treat hemorrhoids (a procedure called sclerotherapy for hemorrhoids), they are distinct from **lower limb varicose veins**. - The presence of hemorrhoids does not contraindicate **sclerotherapy** for leg varicose veins, as they are separate vascular systems and pathologies.
Question 8: Fluorescein dye study is done to detect:
- A. Retinal vascular pathology (Correct Answer)
- B. Posterior segment of eye
- C. Assess retinal vascular conditions in babies
- D. Macular vascular pathology
Explanation: ***Retinal vascular pathology*** - **Fluorescein angiography** is a diagnostic procedure using a fluorescent dye to visualize and study blood flow in the **retinal blood vessels**. - It helps detect and characterize various retinal vascular conditions like **diabetic retinopathy**, **retinal vein occlusions**, and **macular edema**. *Assess retinal vascular conditions in babies* - While fluorescein angiography can be performed in babies, it's generally avoided due to the need for sedation and potential risks, making it less routine than for adult retinal conditions. - The primary purpose is broader than just babies; it's used across all age groups where retinal vascular pathology is suspected. *Macular vascular pathology* - **Macular vascular pathology** is a specific type of retinal vascular pathology, but the dye study assesses the entire retinal vasculature, not just the macula. - Focusing solely on the macula would be an incomplete description of the widespread utility of fluorescein angiography. *Posterior segment of eye* - The **posterior segment** includes structures beyond just the retina, such as the choroid and optic nerve. - While fluorescein angiography provides some information about choroidal circulation, its primary and most detailed application is for evaluating the **retinal vasculature**.
Question 9: Which type of blood vessel is most commonly affected in hypersensitivity vasculitis?
- A. Postcapillary venules (Correct Answer)
- B. Arterioles
- C. Veins
- D. Capillaries
Explanation: ***Postcapillary venules*** - Hypersensitivity vasculitis primarily affects **postcapillary venules**, leading to immune complex deposition and subsequent inflammation [1]. - This type of vasculitis results in **nonspecific inflammation**, commonly seen in conditions like **drug reactions** and **infections**. - The immune complex vasculitis typically involves **small vessels such as the vascular plexus of the skin**, which features neutrophilic infiltration [2]. *Veins* - While veins can be involved in various vascular diseases, they are not specifically characteristic of **hypersensitivity vasculitis**. - This type of vasculitis is more centered around **smaller vessels**, particularly venules, rather than the larger venous systems. *Capillaries* - Capillaries are involved in many vascular conditions, but hypersensitivity vasculitis particularly correlates with **venular structures**. - The immune response seen in hypersensitivity vasculitis is more pronounced in **postcapillary venules**, leading to specific symptoms. *Aerioles* - "Aerioles" may refer to arterioles, which are primarily associated with **hypertensive and ischemic events** rather than vasculitis. - Hypersensitivity vasculitis is primarily due to **post-capillary venule** inflammation rather than changes in arterioles. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 514-515. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 278-279.
Question 10: Surgery in varicose veins is NOT attempted in the presence of which of the following?
- A. Deep vein thrombosis (Correct Answer)
- B. Multiple incompetent perforators
- C. Varicose veins with leg ulcer
- D. None of the above
Explanation: ***Deep vein thrombosis*** - **Surgery in varicose veins is absolutely contraindicated in the presence of DVT** (both acute and chronic) - In **acute DVT**, the deep venous system is already compromised, and removing superficial veins could further impair venous return and worsen the thrombotic state - In **chronic DVT with post-thrombotic syndrome**, the deep veins may be occluded or heavily damaged, and the superficial varicosities often serve as **crucial collateral vessels** to maintain venous drainage—their removal would be detrimental - Surgery should only be considered after complete resolution of acute DVT and adequate anticoagulation *Multiple incompetent perforators* - **NOT a contraindication**—incompetent perforators are actually a common indication for surgical treatment - Incompetent perforators contribute to venous insufficiency and recurrent varicose veins - Can be addressed surgically with **subfascial endoscopic perforator surgery (SEPS)** or endovenous ablation techniques - Their presence often indicates need for more comprehensive treatment alongside superficial venous surgery *Varicose veins with leg ulcer* - **NOT a contraindication**—venous leg ulcers are actually an **indication for varicose vein surgery** - Leg ulcers result from chronic venous hypertension due to venous insufficiency - Surgical treatment (saphenous vein ablation, ligation and stripping, or sclerotherapy) reduces venous hypertension and improves venous drainage - Surgery promotes ulcer healing and prevents recurrence when combined with appropriate wound care *None of the above* - Incorrect because **Deep Vein Thrombosis (DVT) is a well-established contraindication** to varicose vein surgery
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