Venous Disease and Thrombosis — MCQs
Which of the following is not a direct cause of varicose veins?
Which of the following statements about deep venous thrombosis (DVT) is incorrect?
Which of the following tests is positive in lateral sinus thrombophlebitis:
Surgery in varicose veins is NOT attempted in the presence of which of the following?
Patient with clinical signs of DVT had tachycardia and history of bladder cancer. According to modified Well's scoring, the probability of pulmonary embolism would be :
Trousseau's syndrome is classically seen with:
Virchow's triad includes all except:-
Which of the following statements about cavernous hemangioma is false?
ABPI increases artificially in
What change is seen in the vessels during the initial stage of Raynaud's phenomenon?
Venous Disease and Thrombosis Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is not a direct cause of varicose veins?
- A. Superficial venous thrombosis (Correct Answer)
- B. Deep venous thrombosis
- C. Pregnancy
- D. Arteriovenous fistula
Explanation: ***Superficial venous thrombosis*** - While *superficial venous thrombosis* is a condition affecting veins, it is typically a **complication** or a co-occurring event with varicose veins, rather than a direct cause of their initial formation. - Varicose veins are primarily caused by **venous insufficiency** due to faulty valves, leading to blood pooling and vessel distension. *Arteriovenous fistula* - An *arteriovenous fistula* creates an abnormal connection between an **artery and a vein**, leading to high pressure flow directly into the venous system. - This **increased venous pressure and flow** can overwhelm venous valves and dilate veins, directly causing varicose veins. *Deep venous thrombosis* - *Deep venous thrombosis* can damage venous valves in the deep venous system, leading to **post-thrombotic syndrome** which includes chronic venous insufficiency and the formation of varicose veins due to reflux. - The resulting **venous hypertension** and impaired flow in the deep system can cause superficial veins to dilate and become tortuous. *Pregnancy* - *Pregnancy* is a common cause of varicose veins due to several factors, including **increased circulating blood volume** and the physical pressure of the growing uterus on the inferior vena cava. - Hormonal changes during pregnancy, particularly increased **progesterone**, also contribute by relaxing venous walls, further predisposing to varicosity.
Question 2: Which of the following statements about deep venous thrombosis (DVT) is incorrect?
- A. Mostly bilateral (Correct Answer)
- B. Most common clinically presents as pain and tenderness in calf
- C. Some cases may directly present as pulmonary thromboembolism
- D. Clinical assessment highly reliable
Explanation: ***Mostly bilateral*** - DVT is typically **unilateral**, affecting one limb [2]. Bilateral DVT is less common, making this statement incorrect [2]. - The symptoms of **pain, swelling, and tenderness** are usually localized to one leg [1]. *Most common clinically presents as pain and tenderness in calf* - **Calf pain and tenderness** are common clinical presentations of DVT, especially in the lower extremities [1]. - Other common signs include **swelling, warmth, and redness** in the affected leg [1]. *Some cases may directly present as pulmonary thromboembolism* - A significant concern with DVT is that a **clot can dislodge** and travel to the lungs, causing a **pulmonary embolism (PE)**, which can be the initial presentation [1]. - PE is a potentially life-threatening complication and may present with **dyspnea, chest pain, and hemoptysis**. *Clinical assessment highly reliable* - **Clinical assessment alone is not highly reliable** for diagnosing DVT due to its variable and often non-specific presentation [2]. - A definitive diagnosis usually requires objective diagnostic tests such as **compression ultrasonography** or **D-dimer assay** [3].
Question 3: Which of the following tests is positive in lateral sinus thrombophlebitis:
- A. Griesinger sign (Correct Answer)
- B. Tobey Ayer test
- C. Queckenstedt test
- D. All of the options
Explanation: ***Griesinger sign*** - This sign is characterized by **edema** and **tenderness** over the **mastoid process** due to thrombophlebitis of the **mastoid emissary vein**, which drains into the lateral sinus. - Its presence indicates an obstruction of venous outflow, strongly suggesting **lateral sinus thrombophlebitis**. *Tobey Ayer test* - The Tobey Ayer test involves **compression of the jugular veins** and observing for changes in CSF pressure. - While it can be indicative of **intracranial pathology** or spinal block, it is not specific to lateral sinus thrombophlebitis. *Queckenstedt test* - The Queckenstedt test is similar to the Tobey Ayer test, assessing the rise and fall of **CSF pressure** in response to **jugular vein compression**. - It is primarily used to detect a **spinal subarachnoid block** and is not a direct or specific indicator of lateral sinus thrombophlebitis. *All of the options* - While other tests might be used in the general evaluation of a patient with suspected intracranial pathology, only the **Griesinger sign** is directly and specifically associated with **lateral sinus thrombophlebitis** due to its anatomical relationship with the mastoid emissary vein.
Question 4: 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
Question 5: Patient with clinical signs of DVT had tachycardia and history of bladder cancer. According to modified Well's scoring, the probability of pulmonary embolism would be :
- A. Low
- B. High
- C. Intermediate (Correct Answer)
- D. Intermediate
Explanation: **Intermediate** - Clinical signs of **DVT (3 points)**, **tachycardia (heart rate > 100 bpm, 1.5 points)**, and a history of **cancer (1 point)** sum up to 5.5 points, which falls within the range for an intermediate probability (2-6 points) on the modified Well's score for PE. - The modified Well's criteria assigns specific points for risk factors and clinical findings, guiding the diagnostic approach for pulmonary embolism [1]. *Low* - A low probability for PE according to the modified Well's score is indicated by a total score of **less than 2 points** [1]. - The patient's presentation accumulates significantly more points than this threshold due to multiple contributing factors. *High* - A high probability for PE according to the modified Well's score is indicated by a total score of **greater than 6 points** [1]. - The patient's score of 5.5 points does not meet this threshold, placing them in the intermediate category.
Question 6: Trousseau's syndrome is classically seen with:
- A. Carcinoma of the stomach
- B. Multiple Endocrine Neoplasia type II
- C. Neuroendocrine tumors of the pancreas
- D. Pancreatic carcinoma (Correct Answer)
Explanation: ***Pancreatic carcinoma*** - **Trousseau's syndrome**, or migratory thrombophlebitis, is a paraneoplastic syndrome characterized by recurrent, migratory episodes of **venous thrombosis** in unusual sites. - It is often associated with adenocarcinomas, particularly those of the **pancreas**, lung, stomach, and prostate, due to the tumor's ability to activate clotting [1]. *Carcinoma of the stomach* - While stomach carcinoma can be associated with Trousseau's syndrome, it is **less common** than with pancreatic carcinoma. - Trousseau's syndrome in gastric cancer may also involve other paraneoplastic phenomena like **acanthosis nigricans**. *Multiple Endocrine Neoplasia type II* - This syndrome is associated with tumors such as **medullary thyroid carcinoma**, pheochromocytoma, and parathyroid adenomas. - It does not typically present with **Trousseau's syndrome** but instead has a distinct set of paraneoplastic manifestations related to hormone overexpression [1]. *Neuroendocrine tumors of the pancreas* - These tumors often manifest with symptoms related to hormone overproduction, such as **insulinomas** (hypoglycemia) or **gastrinomas** (Zollinger-Ellison syndrome) [2]. - While any malignancy can theoretically predispose to thrombosis, they are **not classically associated** with Trousseau's syndrome, which is more typical of exocrine pancreatic adenocarcinoma.
Question 7: Virchow's triad includes all except:-
- A. Stasis of blood flow
- B. Endothelial injury
- C. Platelet thrombus (Correct Answer)
- D. Hypercoagulability
Explanation: ***Platelet thrombus*** - Virchow's triad describes the three primary categories of factors that are thought to contribute to **thrombosis**, but it does not specifically include a formed **thrombus** itself. [1] - While **platelet thrombus** formation is an outcome of an imbalance in these factors, it is not one of the predisposing conditions identified by Virchow's triad. *Stasis of blood flow* - **Stasis** refers to a reduction in the rate of blood flow, which allows clotting factors to accumulate and endothelial cells to become hypoxic, increasing the risk of **thrombosis**. [1] - This is a well-established component of Virchow's triad, explaining why factors like immobility or venous insufficiency predispose to clot formation. *Endothelial injury* - **Endothelial injury** or dysfunction exposes the subendothelial collagen, leading to platelet adhesion and activation, and the initiation of the coagulation cascade. [1] - It is a critical component of Virchow's triad, often seen in conditions like **atherosclerosis** or trauma, which directly promotes thrombus formation. [2] *Hypercoagulability* - **Hypercoagulability**, or thrombophilia, refers to an increased propensity for coagulation due to genetic or acquired abnormalities in clotting factors. [1] - This imbalance in the coagulation system is a central part of Virchow's triad, leading to an exaggerated thrombotic response even in the absence of significant stasis or injury. [2] **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Hemodynamic Disorders, Thromboembolic Disease, and Shock, pp. 132-133. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 142-143.
Question 8: Which of the following statements about cavernous hemangioma is false?
- A. Not associated with VHL disease
- B. Less infiltrative than capillary hemangioma
- C. Intravascular thrombosis and dystrophic calcification are seen commonly
- D. Undergo spontaneous regression (Correct Answer)
Explanation: ***Undergo spontaneous regression*** - This statement is **false** because **cavernous hemangiomas** typically do not undergo spontaneous regression. They are persistent lesions. - Spontaneous regression is more characteristic of **capillary hemangiomas** (also known as infantile hemangiomas), especially those occurring in early childhood. *Less infiltrative than capillary hemangioma* - This statement is **true**. Cavernous hemangiomas are generally **well-circumscribed** and less infiltrative than capillary hemangiomas, which can sometimes spread more diffusely. - Their distinct, large vascular channels make them easier to delineate from surrounding tissue. *Intravascular thrombosis and dystrophic calcification are seen commonly* - This statement is **true**. The slow blood flow and large, irregular vascular spaces within cavernous hemangiomas predispose them to **thrombosis**. - Subsequent organization of thrombi and **fibrin deposition** often leads to **dystrophic calcification**, which can be visualized radiographically. *Not associated with VHL disease* - This statement is **true**. **Cavernous hemangiomas** are generally **not associated with von Hippel-Lindau (VHL) disease**. - VHL disease is primarily linked to **hemangioblastomas**, particularly in the CNS and retina, which are distinct from common cavernous hemangiomas.
Question 9: ABPI increases artificially in
- A. Ischemic limb ulcers
- B. Intermittent claudication syndrome
- C. Deep vein thrombosis (DVT)
- D. Conditions causing arterial calcification (Correct Answer)
Explanation: ***Conditions causing arterial calcification*** - In cases of **arterial calcification**, particularly in conditions like **diabetes** and **chronic kidney disease**, the blood vessels become stiff and non-compressible. - This stiffness leads to falsely elevated ankle systolic pressures because the cuff cannot effectively compress the calcified arteries, resulting in an artificially high **Ankle-Brachial Pressure Index (ABPI)** reading [2]. *Ischemic limb ulcers* - **Ischemic limb ulcers** are a direct consequence of **peripheral artery disease (PAD)**, which is characterized by reduced blood flow to the extremities [2]. - In these conditions, the ABPI would be **decreased** (typically < 0.9), indicating impaired blood supply, not an increase [2]. *Intermittent claudication syndrome* - **Intermittent claudication** is a classic symptom of **peripheral artery disease (PAD)**, where pain occurs in the legs during exercise due to insufficient blood flow [1]. - This syndrome is associated with a **reduced ABPI**, as arterial narrowing limits oxygen delivery to the muscles during exertion [1]. *Deep vein thrombosis (DVT)* - **Deep vein thrombosis (DVT)** is a condition involving a blood clot in a deep vein, typically in the legs. - DVT does not directly cause an artificial increase in ABPI; it primarily affects venous return and can cause swelling and pain, but not elevated arterial pressure readings [2].
Question 10: What change is seen in the vessels during the initial stage of Raynaud's phenomenon?
- A. No pathological changes (functional vasospasm only) (Correct Answer)
- B. Thrombosis
- C. Fibrinoid necrosis
- D. Hyaline sclerosis
Explanation: ***No pathological changes (functional vasospasm only)*** - Raynaud's phenomenon, particularly **primary Raynaud's** (Raynaud's disease), is characterized by **functional vasospasm** of arterioles, especially in fingers and toes, in response to cold or stress [1]. - In its initial stages, there are no structural changes or pathological alterations within the vessel walls; the vasoconstriction is entirely **functional** [1]. *Thrombosis* - **Thrombosis** involves the formation of a blood clot within a vessel, obstructing blood flow. - While severe Raynaud's can, in rare cases, lead to digital ischemia and microthrombosis, it is **not the primary or initial change** seen in typical Raynaud's phenomenon. *Fibrinoid necrosis* - **Fibrinoid necrosis** is a type of vascular damage associated with severe autoimmune diseases or malignant hypertension, where fibrin and plasma proteins deposit in the vessel wall. - This is a **structural, irreversible change** and is not characteristic of the initial, functional vasospasm seen in Raynaud's phenomenon. *Hyaline sclerosis* - **Hyaline sclerosis** is a change in small arteries and arterioles, often seen in benign essential hypertension or as part of the aging process, where the vessel wall thickens and becomes hyaline (glassy) due to plasma protein leakage and fibrosis. - This represents a **chronic structural change** and is not the acute, intermittent, functional vasoconstriction defining the initial stage of Raynaud's. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 520-522.
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