Diseases of veins

Phlebotic cider is a symptom complex that develops with the development of venous disease.

Varicose expansion of venous vessels - all diseases of veins, characterized by an uneven increase in their lumen, distorted course of vessels with the development of nodules and protrusions of thin walls, their functional insufficiency and vicious blood flow.

In the process, surface, perforating and deep veins can be involved. This principle is based on the classification of varicose veins.

1. Varicose veins are only superficial;
2. Varicose expansion of superficial and perforating;
3. Varicose expansion of superficial, perforating and deep:
   • without chronic venous insufficiency;
   • with chronic venous insufficiency:
     • without the phenomena of decompensation;
     • with the phenomena of decompensation.

Diagnosis of varicose veins presents no difficulty, since enlarged and convoluted superficial venous vessels are visible to the eye, they increase with physical exertion, prolonged standing, decrease in the prone position and can generally: disappear with the limb raised. Disturbing the feeling of fatigue in the legs, by evening, there are swelling.

To identify signs of venous disease and chronic venous insufficiency, there are many methods that can be divided into 3 groups.

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Methods for determining venous disease and valvular insufficiency

Trianel-Trendelenburg Trial - lying on the back of the patient raises his leg upwards to empty the venous vessels. At the mouth, the superficial vein is pressed with a finger and the patient is asked to stand up. Sharply take away the finger and watch the filling of the vessels, maybe three pictures:

1. vessels are filled from the distal side more than 2 s - the valve system is preserved;
2. vessels are filled from the distal side less than 2 seconds - there is a failure of the valves of the collateral vessels;
3. filling of the vessels occurs from the top - there is a valve failure.

The test of McKeling and Heyerdahl - in the standing position, the "listening" fingers are placed on the varicose knots on the thigh of the neck of the leg, lightly striking the vessel in the oval fossa region - the transmission of a wave-like shock indicates a valvular insufficiency.

The Gakkenbruch test - in the standing position, put a hand to the place of the admission of the saphenous vein into the femoral vein, ask the patient to cough - if the valves are inadequate, the cough pulse is transmitted through the vessel.

Methods for the detection of varicose veins and valvular insufficiency

The Burrow-Sheinis test (three-clotted, five-clotted) can reveal valve failure not only of superficial venous vessels, but also perforated - in the supine position with the limb raised and emptied, three venous tourniquets are placed (on the upper, lower third of the thigh, ). The patient gets up. The rapid filling of the vessels prior to the removal of the tourniquet at any of these sites indicates a valvular insufficiency. With the gradual removal of the bundles, according to the retrograde current of the blood, the areas of the superficial venous vessel with valvular insufficiency are determined. The Thalmann test - in the position on the back with the raised leg, make the bandage of the limb with a rubber tube from top to bottom, leaving a distance between the tours of 5-6 cm. The patient rises, the appearance of varicose veins between the tourniquet tours indicates areas with perforated veins that have valve failure.

Methods for determining varicose veins and permeability of deep vessels

The Delbe-Perthes (marching) test allows to determine the permeability of the deep vein - in the standing position, a venous tourniquet is placed on the thigh and the patient walks for 5-10 minutes. If the deep veins are passable and the valves function normally, the superficial vein is empty. In the case of preservation of varicose veins, more precise research is needed, a five-clot test

• on the upper and lower third of the thigh, the upper, middle and lower third of the tibia are superimposed by the venous strands in the standing position, marching - if at least in one of the zones between the bundles there is a decrease in the surface vessels
• the deep vein is passable, and in areas where there is no recession, there is a deficiency in the valves of perforating veins. Mayo tests - in a prone position with a raised limb, a venous tourniquet is placed on the thigh, and then a bandage is bandaged with a rubber bandage to squeeze the surface vessels from the fingers to the groin. If after a long walk (at least half an hour) there is pain in the leg, swelling and blueing of the folds - a deep vein is impassable. Pratt's test - after measuring the shin circumference, the patient is laid on his back with a raised leg, which is bandaged with an elastic bandage to reliably compress the subcutaneous vein. Ask to actively walk for 10 minutes. If during this time there will be pains in the lower leg and the shin circumference after the removal of the tourniquet will increase, then the deep vein is impassable. To confirm and document the diagnosis, conduct phlebography.

Signs of decompensation of varicose veins, depending on the severity of disturbance of microcirculation and metabolic processes, are:

1. Dermatitis, which is a hyperpigmented area of dry and atrophic skin in the lower third of the shin, annular;
2. local trophic ulcer of the lower third of the shin;
3. an extensive, usually annular, trophic ulcer of the shin.

Varicose expansion can be accompanied by complications in the form of thrombophlebitis and phlebothrombosis, interstitial bleeding from the thin walls of blood vessels and erosive of ulcers, infection.

Phlebitis - acute or subacute inflammatory diseases of the veins until the formation of thrombus and the transition of the process to thrombophlebitis or phlebosclerosis. Localization distinguishes:

Endoflebitis - a disease of the veins, the main cause of which are injuries of the venous wall or a long finding of needles, catheters, the introduction of sclerosing drugs, usually result in sclerotherapy of the vein; Periphlebitis develops mainly during the transition of inflammation to the vein from surrounding tissues, more often from abscesses, mainly the process passes into phlebothrombosis; Panflebit has a different etymology, but more often it is the initial stage of development of thrombophlebitis.

The clinic of venous disease can be observed only in the initial stages of the process, mainly in the localization of the lower extremities: acute pain along the veins, the skin over them is hyperemic, the veins are palpated in the form of a dense and painful crook, with a perifile along the vein, a painful infiltration appears.

Mondor's syndrome - proceeds in the form of a subacute form of vein disease of the lateral surface of the chest, is manifested by the formation of one or several painful cord-like strands of veins, during which the burning sensation is determined, the skin over it is not changed. The disease lasts 3-4 weeks, after which all phenomena disappear, but skin pigmentation and hyperesthesia can remain.

Phlebitis of internal organs form certain symptom complexes: Chiari - diseases of the veins of the liver, ending with their obliteration and development of portal hypertension; metrotromboflebit - diseases of the veins of the uterus, more often after birth; pylephlebitis - thrombosis or thrombophlebitis of the portal vein, as a complication of appendicitis and cholecystitis, with the development of jaundice and liver failure.

Thrombophlebitis - venous diseases, characterized by inflammation of the veins and thrombosis of the vessel. Depending on what is primary, distinguish: thrombophlebitis, when the inflammation first develops, and then thrombosis and phlebothrombosis when the thrombosis is primary, and then inflammation joins. But basically this is important only at the initial stages of the development of venous disease, since in the future the process is the same.

The causes of thrombophlebitis are diverse: the state of the organism's reactivity, endocrine, autoimmune and neurotrophic disorders, vascular damage, slowing of blood flow and venous stasis, the effect of infection, etc. It often develops with varicose veins. The veins of the lower extremities and the small pelvis are most often affected, but thrombophlebitis of the veins of the upper limbs, brain, portal vein, etc. Can develop.

Thrombophlebitis is distinguished only by acute, the outcome of which is sclerosis of the vein and the development of chronic venous insufficiency (postthrombophlebitic syndrome), against which relapses of venous disease may occur. There is no concept of chronic thrombophlebitis. The duration of the acute period of the disease is up to 20 days, subacute - from, 21 to 30 days after the onset of venous disease.

Thrombophlebitis of superficial (subcutaneous) vessels in most cases develops against a background of varicose veins with usual localization on the foot, shin, hip or all, subcutaneous veins are affected. Suddenly, pain appears in the zone of the thrombosed vein, when the limb is examined, the skin over it is hyperemic, glossy, the infiltration is visible along the vein, the palpator vein is revealed as a painful, dense strand. There is no edema of the limb. The general condition varies little, and there is rarely a febrile condition.

Thrombophlebitis of the deep vessels of the shin begins with pain in the calf muscles, which are amplified and spread retrograde, a feeling of bursting appears. On examination, the skin is not altered or has a cyanotic color, to the 2nd-3rd day of the disease, enlarged subcutaneous veins are revealed: The slower edema of the lower leg is characteristic, which differs from the thrombophlebitis of the surface vessels. Palpation of the gastrocnemius muscle is sharply painful in depth, but the abdomen itself is not very painful. The temperature of the skin of the limb is increased. The general condition is disturbed, proceeds with a purulent-resorptive fever. The characteristic symptoms of venous disease are revealed: a symptom of Homans is the appearance or strengthening of pain in the gastrocnemius muscle with the rear folding of the foot; symptom of Moses - tenderness in squeezing the tibia in the anteroposterior direction and absence when squeezing from the sides (has a differential value with myositis); a positive test of Lovenberg - on the middle third of the shin, a cuff is placed from the tonometer, in the norm the soreness in the gastrocnemius muscle appears at a pressure of more than 180 mm Hg. St., with thrombophlebitis there is a sharp pain even at a pressure of 60-150 mm Hg. Art.

The most severe form of venous disease is thrombophlebitis of the major vessels of the pelvis and femoral vein to the site of its division into superficial and deep - ileofemoral thrombophlebitis. During this disease, the veins are divided into 2 stages: compensation (prodromal) and decompensation (pronounced clinical manifestations). The stage of compensation develops with a preserved venous blood flow in the limb, or with a small wall clot, or with a developed collateral venous network. Clinical manifestations of venous disease are poorly expressed: a characteristic pain syndrome develops, blunt aching pains in the lumbosacral region, lower abdominal parts and lower limb on the side of the lesion. The general condition suffers a little. The duration of this stage is from 1 to 28 days and depends on the state of the collateral network, the process at this stage may end. When decompensated venous disease, severe hemodynamic disturbances occur in the limb. The pain is sharply increased, localized in the groin, thigh and calf muscles. Edema is pronounced, extends to the entire limb, perineum, anterior wall of the abdomen (differs from anaerobic slower development, lack of crepitation). The skin is cyanotic-violet, cold, or it can be milky white with a sharply disturbed lymphatic drainage. The picture of psoitis develops: tenderness in the iliac region with maximum hip flexion, flexion contracture in the hip joint. If the blood flow is not restored within 1-2 days, venous gangrene may develop, the sign of its onset is an increase in the limb volume by 2-3 times, absence of pulsation of arterial vessels on the foot due to compression, the development of intoxication syndrome, up to septic shock.

Pidget-Shretter syndrome - subclavian vein thrombosis, associated with trauma and squeezing it in the costal-clavicular space. Paget-Shreter syndrome should be distinguished from thrombophlebitis of subclavian vein of another genesis: catheterization, ascending thrombosis of the upper limb, germination and compression of the tumor, etc.

These veins diseases develop more often in young men with a developed musculature, more often has a right-sided localization. Pathogenetically, diseases are associated with physical stress on the shoulder girdle, sharp and one-stage, when there is a direct trauma to the inner shell with the development of spasm and thrombosis, or with multiple monotonous movements associated with work or stress. The disease begins acutely. The earliest symptom of venous disease is the appearance of pronounced edema throughout the upper; of the limb, which reaches its maximum by the end of the first day, but the intensity of its growth is not the same as with gas gangrene: the entire arm is sharply thickened with tissue, the depression is not formed by pressing the finger, since swelling is not determined by plasma swelling in the tissue, but by overflowing of venous and lymphatic vessels. Cyanosis of the extremity is most pronounced in the distal parts of the upper limb, the veins are significantly expanded and strained, the collateral network is revealed. In the first hours after thrombosis, the pain is sharp, sometimes burning, and then it subside and intensify with physical activity and movements. The duration of the acute period is 3 weeks, after which all events subsided, but the exacerbations are clearly associated with physical activity. Diagnosis of venous disease is confirmed by phlebography.

Given the threat of acute thrombophlebitis due to thrombus rupture and development of thromboembolism of arterial trunks, especially often pulmonary arteries, all patients, even for the first 2 weeks, should be hospitalized in a surgical hospital.

Post-thrombophlebitic syndrome - develops in patients who have experienced thrombophlebitis of deep vessels, but with unrecovered blood flow in the veins and insufficient collateral circulation. A picture of chronic venous insufficiency develops, mostly due to the failure of the valves of perforated vessels and the development of reflux from the deep vessels into the subcutaneous, with the formation of secondary varicose veins. Dysfunction of the musculoskeletal pump is accompanied by venous and lymphostasis, an increase in venous pressure, which leads to the discovery of arterio-venous shunts, the desolation of capillaries, tissue ischemia with atrophic changes in them.

The clinical picture of venous disease depends on the state of blood flow compensation. Disturbing pains, feeling of fatigue, heaviness in the lower leg, edema of the foot and lower leg, worse by evening, varicose veins of the subcutaneous veins. In the stage of decompensation of venous disease, brown pigmentation appears and skin induration located in the lower third of the shin, first along the medial surface, then more and more acquires an annular shape that engages the entire surface of the shin: the skin is thinned, immobile, not folded, devoid of hair. After a small injury, combs formed ulcer, at first a small size on the medial surface of the tibia, amenable to conservative treatment. As venous insufficiency grows, the trophic ulcer becomes chronic, broadens, acquiring an annular shape; difficult to give conservative treatment, after healing quickly recurs, often nagnaivaetsya, gives erosive bleeding. Tactics: treatment of long-term venous disease, conservative, outpatient, general surgeon or angio-surgeon.