Podcast Episode 7: Signs and Symptoms of Venous Disease

Hello there, this is Professor Mark Whiteley of the Whiteley Clinics in Guildford, London Bristol and I'm delighted to be part of this fantastic idea of producing podcasts on behalf of the Lindsay Leg Clubs. I've been asked to give three podcasts and the first one of this is the sign and symptoms of venous disease. So why is it important to know about the signs and symptoms of venous disease when we know that most people have venous leg ulcers who attend with a leg ulcer and the importance is firstly to make sure it is venous and secondly if it is venous you should now know that most venous leg ulcers and indeed most venous disease of the lower limbs is curable. There have already been the first couple of suings where patients who have had long-term leg ulcers who have not been referred for investigation and not been offered a curable endovenous surgical technique have gone back and have successfully sued the nurses and doctors who were only bandaging them and compressing them and had not made that referral. So the first thing you must do if you're in this area and you are seeing patients with venous disease is you must be aware of the NICE guidelines that's the NICE clinical guidelines CG-168 which is the National Institute of Health and Clinical Excellence Clinical Guidelines 168 on varicose veins and although it is about varicose veins you will notice venous leg ulcers is also mentioned there and of course as we'll discuss half the people who have got these venous problems you cannot see have varicose veins on the surface but have venous hidden varicose veins. So most importantly you must know that if you are treating patients with potentially venous leg problems you must be aware of those guidelines and be aware that a venous duplex ultrasound scan is almost mandatory now if you suspect it in fact it is mandatory and a referral to someone who knows what they're doing a vascular or venous surgeon. So firstly if we look at the signs and symptoms of venous disease, let's think about who gets them. So who gets venous disease? In the past people have thought it is only the elderly. We now know that that's rubbish. We know that venous disease can affect all ages. Of course because it is a deterioration disease and people deteriorate as they get older is more common in the older people but we have already seen severe of varicose veins in a 12-year-old boy and a venous leg ulcer in a 19-year-old boy. Both of those were cured with endovenous surgery but both have been told previously that this couldn't be venous problems because they were too young. Never let age be a barrier to thinking about venous disease. Once people get past the tens and into their teens, it's quite possible that they can already have venous disease if it is strong in their family. When it comes to signs and symptoms, remember that almost all diagnoses are made just by symptoms and signs and investigations only follow the clinical suspicion. Firstly we're going to talk about symptoms because symptoms is traditionally the first thing we think of. Symptoms are what the patient tells you that they have or feel. Again please do look up the NICE Guidelines Clinical governance CG168 because they're listed there the sort of symptoms that the patients tell you about who have got venous disease and varicose veins. Remember as I said before 50% of people who have varicose veins that's about 15% to 20% of the population see that they've got varicose veins but another 50% that's another 15 to 20% of the population have venous reflux due to varicose veins but you see no bulging veins on the surface and those are the ones you might get into problems with if you haven't diagnosed that they might have varicose veins just because you can't see the varicose veins on the surface. So what symptoms can people with varicose veins or hidden varicose veins tell you that they've got? Well of course if you can see they've got varicose veins they'll say I can see lumpy veins but that's not the important symptoms. important symptoms are tired legs, aching legs, tender legs. People quite often say that the legs get more tired as the day goes through, as they go through the day. They can tell you their legs get a bit swollen. Any of those sort of symptoms that are improved when the patients lie down or put their legs up or get better once they've been in bed for a while and as they get worse during the day those are very very likely to be venous related and remember just when you have heard those think about getting a venous duplex ultrasound scan don't think well I can't see varicose veins so therefore I'm not going to do anything about it because of this problem of the hidden varicose veins so usually people with normal venous reflux don't complain of a lot of pain it's a throbbing aching heaviness tired legs you get those sorts of things told to you all of the time that are improved with support stockings, lying down, standing up or even walking because the walking makes the veins pump better. Those are the commonest symptoms that people will tell you about who have venous reflux. However, if patients have gone on to get further complications such as thrombosis or even leg ulceration, they can tell you that they get pain and usually with a superficial venous thrombosis, something that used to be called phlebitis but we now is a thrombosis, so we call it superficial venous thrombosis. People who have these hard red lumps will tell you that they have specific pain in certain areas and they can show you which lumpy veins are hard and they will tell you that those are painful. So the symptom is pain. Also people who have got deep vein thrombosis will also tell you that they've got a dull ache, usually it's sometimes in the calf, sometimes in the thigh and of course that's going to be associated with pain on stretching the muscle and walking. Often there's swelling but that's a sign so we can come back to that. One of the rarer causes of symptoms of venous disease is obstruction when people have had long-term occluded veins such as after many deep vein thromboses. It's rare after only one deep vein thrombosis but if you've had more than one or one that wasn't got rid of or you've got a strange problem such as a May 3rd syndrome which is blocking the vein you can then get what's called outflow obstruction. Patients tend to have long-term problems such as swelling of the legs and you can tell there's something going on and we'll talk about the signs of this in a bit but these patients can often tell you they get what's called venous claudication. So they've got excellent pulses, they'll have very good ankle brachial pressure indexes, so if you do a Doppler pressure at the ankle they'll be normal or good, but as they walk their legs feel they get tighter and more swollen and they feel very painful and that's called a venous claudication. So it's not your arterial claudication where there's not enough blood getting into the leg, this is a venous claudication where enough blood is getting into the leg it just can't get out in time when you exercise. So that's a specific symptom that you really only get when people have got this thing called outflow obstruction. So most of the patients will be of the former sort of aching and throbbing sort of symptoms. Now when we come on to the signs, signs are much more specific. The signs of venous disease mainly are enumerated in the CEAP score, which is the scoring system that most people use. Although there are four different sections to it, most doctors and nurses only use the C, which is the clinical signs. So the C part of the scoring, C0 means perfect legs. C1 means thread veins or spider veins or if you're going to be medical telangiectasia. C2 means varicose veins. In other words you can see bulging veins when you stand up or sit which tend to disappear when you lie down because of gravity. Remembering again that for every person who you see a varicose vein and there's another person who has the same problem but nothing visible on the surface. C3 is swollen ankles and it can be with varicose veins or it might be with hidden varicose veins, so you might see just the swollen ankles, the ankles get swelling more in the daytime, but that doesn't have to be with varicose veins that are seen because of these hidden varicose veins. Do remember with swelling if it goes all the way down to the toes and the toes are very swollen as well that's almost always lymphedema, whereas if it's venous swelling then it almost always stops at the ankle. C4 starts off with early C4 which is venous eczema, so red itchy patches, sometimes around the ankle, sometimes over varicose veins, sometimes on the calf, rarely on the thigh, but I have seen it there. Anyone with eczema of the legs who doesn't have it elsewhere on the body, do think of venous disease, even again if they don't have visible varicose veins. C5 and 6, oh sorry, going back to C4, then of course the big one is the brown stains, the haemocydrin. If you see brown stains around the ankles and lower legs, basically in what's called the gaiter area which is under the calf but over the ankle bone or around the medial ankle bone any brown staining that starts off just as a mild brown staining but if it's left will get darker and darker and darker that's a major problem because that haemocydrin shows that you've got a leg ulcer coming especially when it starts going a little white in the middle that's called atrophy blanche. At the same time you can get what's called LDS, lipodermatosclerosis. And in lipodermatosclerosis, what happens, the inflammation that is causing all this problem due to your varicose veins or hidden varicose veins, is causing the skin to thicken and get harder. And whereas many people get the eczema or get the brown stains first, other people will go on to get a really tight hard skin around the lower leg. And if that gets reddened and hard and really comes sclerotic, so it really gets tight, it can end up making the calf muscle bulge more and we get what's called a champagne bottle leg where the calf looks like the the bottom of the champagne bottle going into the neck and the ankle looks like the neck of it. So lipid tomatosclerosis is a specific sort of usually venous disease which is slightly different in looks and signs but it still is a C4 and you are still heading for leg ulcers. C5 and C6 are obviously the wrong way around but the way we have to look at them is C5 is a healed leg ulcer and C6 is a venous leg ulcer. So you don't progress from C0 to C6 because you have to go to C6 to have an active leg ulcer before you go back to C5 to get a healed one. Obviously an active ulcer is an open sore, usually on the inside of the leg, usually between the calf and the ankle, but it can occur anywhere around to the lower leg. It's rare to get venous leg ulcers above the knee, it is possible, but it's almost always on the lower leg and usually on the inner aspect, although I have seen on the foot and also on the outer aspect. If a leg ulcer is over the heel or bony prominence, always remember it could just be pressure. And it is important to start thinking about whether pressure sores are being mistaken as a venous leg ulcer. Usually if patients are infirm and not walking, then things become much more difficult. But if patients are able to walk quite well, then it's usually a venous problem because pressure is less of a problem in an ambulatory patient. Other signs that are important to note, if you see varicose veins going up the side of the abdomen or across the pubic bone, that is almost always collateral veins which mean that there is a blockage in the iliac veins, the veins in the pelvis and blood is having to bypass around and that's often a sign that occurs with swollen legs, brown stains and also venous claudication. Those are the patients who have had some form of major problem, usually deep vein thrombosis in the past and usually multiple ones up in the islet veins. That's quite specific and uncommon, but it is still curable in many patients with the new stents. Other signs that often aren't talked about in the CEAP classification because they don't get noted there, but are clearly venous, is people who have varicose veins that bleed. bleeding varicose veins is a very important sign of venous disease. Sometimes you don't even see much of the varicose veins, it's a hidden varicose vein, but a sudden torrential bleed that squirts out usually from a tiny little area around the ankle. I've seen venous bleeds anywhere from the knee downwards but they are more common in the little bulging vein around the ankle. Very simple just to put your finger on them, lie down and put your leg in the air and that stops them straight away, whereas it wouldn't stop an artery bleed. So bleeding from varicose veins is quite impressive if you're standing or sitting. Also signs of venous disease, again, if you suddenly get red lumps on the surface of the leg, just underneath the skin, which are very, very painful, that's almost always superficial venous thrombosis or in the old days called thrombophlebitis or just phlebitis. That is a sign that you've got varicose veins or hidden varicose veins that have been left long enough to cause clots or thrombus and also if you have a deep vein thrombosis and it's acute then very often there will be swelling and tenderness of the legs, pain on stretching of the muscle. So I'm coming to the end of this section of this podcast. I'm going to be giving a couple of other podcasts, one on current treatment trends of venous disease and then we're going to talk a little bit more about the treatments that can help or hinder wound swelling. So I look forward to speaking to you again in my next couple of podcasts. If you do have any questions about what I've said in this podcast about the signs and symptoms of venous disease please do not hesitate to contact me. Thank you.