Surgery: Long Cases in Short Sabin P, Shabeer M
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A CASE OF VARICOSE VEINS1.

“Ashokan, 38 years old male coming from Kannur, he is working in an aluminium fabrication company, presented with dilated veins over left lower limb for 4 years”.
 
 
 
History of Present Illness
He noticed dilated veins over left lower limb below the knee 4 years back. It was associated with pain; after standing and especially walking. The pain gets relieved on lying; the pain is dull in character, with no radiation. No history of night cramps.
Three years back he noted itchy skin lesions over the left leg, which later blackened. He also noticed extension of dilated veins to thigh at the same time. The blackish discoloration spread to other areas. There is no history of ulceration. There is no history of painful swelling of leg (suggestive of deep vein thrombosis). No history of bleeding, fever, trauma. No history of constipation, mass in the abdomen, micturition problems.
The patient consulted here 1 year back and was advised to put bandage. There was relief of symptoms after that, but now there is increased pain and swelling.
 
Past History
No past history of surgeries, orthopedic procedures, immobilizations, chest pain, breathlessness or hemoptysis. No history of diabetis mellitus, tuberculosis, hypertension.
 
Personal History
Patient in taking mixed diet, bowel and bladder habits 2unaltered, sleep not disturbed, he is a smoker since last 15 years, smokes 10 cigarettes per day. No other addictions.
[Females: Obstetric history, H/O OCP]
 
Family History
He is second among 4 siblings. His father died of heart disease; mother is alive and has diabetes. His siblings are alive and healthy. He has two daughters and they are healthy.
 
GENERAL EXAMINATION
Moderately built and nourished, no pallor, icterus cyanosis, clubbing, significant lymph node enlargement or pedal edema. No thyroid enlargement.
Pulse Rate is 70/min, regular in rhythm, normal in character and volume, vessel wall not thickened, no radio femoral delay, all the peripheral pulses are palpable equally on both sides, respiratory rate 16/minute, regular, abdominothoracic, blood pressure 130/80 mm of Hg in right upper limb in supine position. JVP not raised.
 
LOCAL EXAMINATION
 
 
Inspection
There are dilated veins, involving the medial aspect of the left limb extending from just below the medial malleolus, to the middle of the thigh.
There is bluish discoloration of the skin on the medial aspect of left leg in lower part. There is loss of hair and skin is shiny. There is no redness, congestion, ulceration, or scar. There is no brittleness of nails.3
There is no impulse on coughing at saphenous opening.
— [Morrisey Test] – saphena varix.
 
Palpation
There is no local rise of temperature or tenderness. There is no edema or skin thickening.
Trendelenberg test I
– +ve [Sapheno femoral incompetence]
Trendelenberg test II
– +ve [Perforator incompetence]
Tourniquet test
– +ve in all perforator sites
(Remove from below)
Modified Perthe's (Tourniquet at S.F.J. ⇒ ask to walk for 5 min ⇒ pain ⇒ D.V.T): –ve
Schwartz test (Tap at a prominent part of veins, feel impulse at S.F.J.): +ve
Morrissey test (Elevate the limb to 30°, feel impulse on cough at S.F.J) +ve
Fegans test (Feel the vein after emptying ⇒ depressions) +ve
Arterial pulses– all pulses are present.
 
Percussion
Schwartz's test
Auscultation: No hum, bruit
Examination of regional lymph nodes: No lymph node enlargement
No nerve lesions
Signs of vascular insufficiency present
Other limb – Normal4
 
Examination of Abdomen
No local raise of temperature, no tenderness, soft, no mass, lymph nodes, fluid thrill or shifting dullness.
 
PROVISIONAL DIAGNOSIS
Primary varicose veins left leg involving long saphenous system with Sapheno femoral and perforator incompetence with pigmentation and no evidence of deep vein thrombosis.
 
CONSERATIVE MANAGEMENT
  1. Elevation of leg and rest
  2. Elastic crepe bandage
 
Indications
Pregnancy, Pelvic tumor, Positive Perthe's test, AV fistula5
In UK – sodium tetra decyl. Tetracycline can also be used.
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Causes of varicose veins
  1. Primary
  2. Secondary
    • Pregnancy
    • Pelvic tumor
    • Acites
    • DVT
    • AV fistula
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  • Management of bleeding varicose vein
    1. Elevate the limb
    2. Pressure bandage
    3. If not controlled suture through the skin – Seaton's suture.