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SYNDROME OF EDEMA Surgical department of TMA for general practitioners edema is an increasing of the contents of a liquid in tissues. Thus volume in space which is not belonging to vessels. To establish edema it is possible by infringement skin fold between fingers. Thus is felt pastrylike tissue, and at taking off fingers on a skin are visible pits on a place of compression. edema can be general and local. Lower extremity anatomy Thigh veins Lower extremity veins Classification of edemas By aetiology distinguished 1. Nephrotic syndrome edemas: • glomerulonephritis, • kidney amiloidosis, • diabetic glomerulosclerosis, • preeclampsia, • rheumatoid polyarthritis, • serum sickness, • LEN, • lymphatic leukemia, • lymphogranulemathosis. Classification of edemas (continuation) 2. As a result of circulatory deficiency: • valvular defect, • cardiosclerosis, • decompensated cor pulmonare. 3. orthostatic hydrops. 4. pregnancy edemas. 5. edemas of joints: • deforming arthrosis, • infectious arthritis, • reactive arthritis. 6. venous pathology edemas: • deep veins acute thrombosis, •Chronic venous insufficiency. 7.lymphedemas. 8. mixed edemas. Differential diagnosis of lover limb edemas ChVI Venous LE trombos is Often unilater bilaterall al y Nephrot Cardiac Orthost edema ic atic edema edema primary Always – bilatera bilatera l l; seconda ry – often unilater al Always bilatera l Always bilatera l artral Pregnan cy edemas Often bilatera l bilatera l Obesity, no edema Decompensated cardiac edema Gonarthrosis on the right side Venous thrombosis Skin pigmentation on the chronic venous insufficiency Differential diagnosis of chronic venous and arterial insufficiency signs Chronic arterial insufficiency (late Chronic venous insufficiency phase) (late phase) pain intermittent claudication [Charcot's] syndrome, later pain at rest Absent or nagging pain on upright position Ps Weak or absent. Normal, but determining would be little bit difficult because of edema Skin colour pale skin, at hanging becomes dark red Normal, at upright position becomes cyanotic Temperature low normal continuation edema Absence or weak. Presence often substantal. Trophic changes Atrophic, nail deformations. Often on ankles, stagnant dermatitis, pigmentations sores Often on fingers. On ankles, often on medial surface gangrene High risk. absence Varicose dilation of lower extremity veins Varicose expansion of veins is disease, accompanying by increase of length and presence coiled subcutaneous veins, by saccular expansion of their lumen statistics Is observed at 17-25 % of the population Patients by vein expansion makes 2-3,3 % from general( number of the surgical patients The women are fall ill 3 times more often, than man а б Varicose disease Posttrombophlebitic syndrome acute thrombophlebitis of SUPERFICIAL veins This is an inflammation of a vein wall , accompanying by formation of a blood clot in its lumen pathogenesis 1) venous wall disturbancies; 2) circulatory deceleration 3) hypercoagulation signs Pain upon vein; Hyperemia and skin swelling; Tenderness ; Subfebrile temperature; Treatment: anticoagulants; Medicines improves rheology NSAID; Desensitizing medicines ; heparin containing ointments treatment bandaging; Measured walking; Operative interventions. phlebothrombosis phlebothrombosis - obstruction of a vein by a blood clot, without preceding inflammation of its wall. It is most common within the deep veins of the calf of the leg (deep vein thrombosis, DVT). The affected leg may become swollen and tender and the clot may become detached and give rise to pulmonary embolism. Prolonged immobility, heart failure, pregnancy, injury, and surgery predispose to thrombosis by encouraging sluggish blood flow. Thrombophlebitis Thrombophlebitis is phlebitis (vein inflammation) related to a thrombus (blood clot). When it occurs repeatedly in different locations, it is known as "Thrombophlebitis migrans" or "migrating thrombophlebitis". Signs and symptomes The following symptoms are often (but not always) associated with thrombophlebitis: pain in the part of the body affected skin redness or inflammation (not always present) swelling (edema) of the extremities (ankle and foot) Prevention Routine changing of intravenous (IV) lines helps to prevent phlebitis related to IV lines. See the specific disorders associated with thrombophlebitis for other preventive measures. treatment For more specific recommendations, see the particular condition. In general, treatment may include the following: analgesics (pain medications) anticoagulants e.g. warfarin or heparin to prevent new clot formation thrombolytics to dissolve an existing clot such as intravenous streptokinase. nonsteroidal anti-inflammatory medications (NSAIDS) such as ibuprofen to reduce pain and inflammation antibiotics (if infection is present) selection will usually depend with the causative agent. Support stockings and wraps to reduce discomfort The patient may be advised to do the following: Elevate the affected area to reduce swelling. Keep pressure off of the area to reduce pain and decrease the risk of further damage. Apply moist heat to reduce inflammation and pain. Surgical removal, stripping, or bypass of the vein is rarely needed but may be recommended in some situations. Chronic venous insufficiency Chronic venous insufficiency or CVI is a medical condition where the veins cannot pump enough oxygen-poor blood back to the heart. It is sometimes referred to as an "impaired musculovenous pump", this is due to damaged or "incompetent" valves as may occur after deep vein thrombosis (when the disease is called postthrombotic syndrome) or phlebitis. Paratroopers, utility pole linemen, and men with leg injuries can suffer from damaged leg vein valves and develop this condition. Ordinarily, women make up the largest demographic for this problem. What are the symptoms of chronic venous insufficiency? The seriousness of CVI, along with the complexities of treatment, increase as the disease progresses. That’s why it is very important to see your doctor if you have any of the symptoms of CVI. The problem will not go away if you wait, and the earlier it is diagnosed and treated, the better your chances of preventing serious complications. Symptoms include: Swelling in the lower legs and ankles, especially after extended periods of standing Aching or tiredness in the legs New varicose veins Leathery-looking skin on the legs Flaking or itching skin on the legs or feet Stasis ulcers (or venous stasis ulcers) If CVI is not treated, the pressure and swelling increase until the tiniest blood vessels in the legs (capillaries) burst. When this happens, the overlying skin takes on a reddish-brown color and is very sensitive to being broken if bumped or scratched. At the least, burst capillaries can cause local tissue inflammation and internal tissue damage. At worst, this leads to ulcers, open sores on the skin surface. These venous stasis ulcers can be difficult to heal and can become infected. When the infection is not controlled, it can spread to surrounding tissue, a condition known as cellulitis. CVI is often associated with varicose veins, which are twisted, enlarged veins close to the surface of the skin. They can occur almost anywhere, but most commonly occur in the legs. What are the risk factors for chronic venous insufficiency? If you have risk factors for CVI, you are more likely than other people to develop the disease. The most important risk factors are: Deep vein thrombosis (DVT) Varicose veins or a family history of varicose veins Obesity Pregnancy Inactivity Smoking Extended periods of standing or sitting Female sex Age over 50 As functional venous valves are required to provide for efficient blood return from the lower extremities, CVI often occurs in the veins of the legs. Itching (pruritis) is sometimes a symptom, along with hyperpigmentation of the legs. Symptoms of CVI include phlebetic lymphedema and chronic swelling of the legs and ankles. The skin may react with varicose eczema, local inflammation, discoloration, thickening, and an increased risk of ulcers and cellulitis. The condition has been known since ancient times and Hippocrates used bandaging to treat it. It is better described as chronic peripheral venous insufficiency Venous valve incompetence is treated conservatively with manual compression lymphatic massage therapy, skin lubrication, sequential compression pump, ankle pump, compression stockings, blood pressure medicine, frequent periods of rest elevating the legs above the heart level and using a 7-inch bed wedge during sleep. Surgical treatments include the old Linton procedures and the newer subfascial endoscopic perforator vein surgery. Some experimental valve repair or valve transposition procedures as well as some hemodynamic surgeries are being pursued. This whole field of medicine while ancient is still filled with complications e.g. Sometimes an artery can strangulate a vein or sometimes an arteriovenous fistula (an abnormal connection or Patients are often encouraged to walk while wearing the prescribed medical stockings and to sleep in a 6 degree Trendelenburg position.[] Obese or pregnant patients might be advised by their physicians to forgo the tilted bed. Surprisingly, leech therapy long ago abandoned by medicine, can actually be beneficial treatment.[] The leeches draw out the excess venous blood that has CO2 and metabolic wastes in a measured amount with little danger of dropping the blood volume.[] May-Thurner syndrome May-Thurner syndrome is a rare condition in which blood clots, called deep venous thrombosis (DVT), occur in the iliofemoral vein due to compression of the blood vessels in the leg. The specific problem is compression of the left common iliac vein by the overlying right common iliac artery.[] This leads to pooling or stasis of blood, predisposing the individual to the formation of blood clots. How is chronic venous insufficiency treated or managed? Like any disease, CVI is most treatable in its earliest stages. Vascular medicine or vascular surgery specialists typically recommend a combination of treatments for people with CVI. Some of the basic treatment strategies include: Avoid long periods of standing or sitting: If you must take a long trip and will be sitting for a long time, flex and extend your legs, feet, and ankles about 10 times every 30 minutes to keep the blood flowing in the leg veins. If you need to stand for long periods of time, take frequent breaks to sit down and elevate your feet. Exercise regularly. Walking is especially beneficial. Lose weight if you are overweight. Elevate your legs while sitting and lying down, with your legs elevated above the level of your heart. Wear compression stockings. Take antibiotics as needed to treat skin infections. Practice good skin hygiene. The goals of treatment are to reduce the pooling of blood and prevent leg ulcers. ChVI on the right side Primary lymphedema Varicose disease complicated by trophic disordes Varicose disease, skin pigmentation Acute indurative cellulitis on VD Skin white atrophy Circulatory trophic disorders А А. Arterial insufficiency. Б. Venous insufficiency. Б Trophic disorders on diabetis Arterial trophic ulcer Pyogen ulcer. Hypertonic trophic ulcer. Malignant ulcer on the shin. Nonsurgical Treatment Nonsurgical treatments include sclerotherapy and endovenous thermal ablation. Sclerotherapy involves the injection of a solution directly into spider veins or small varicose veins that causes them to collapse and disappear. Several sclerotherapy treatments are usually required to achieve the desired results. Sclerotherapy is simple, relatively inexpensive, and can be performed in the doctor’s office. Sclerotherapy can eliminate the pain and discomfort of these veins and helps prevent complications such as venous hemorrhage and ulceration. It is also frequently performed for cosmetic reasons. Endovenous thermal ablation is a newer technique that uses a laser or highfrequency radio waves to create intense local heat in the affected vein. The technology is different with each energy source, but both forms of local heat close up the targeted vessel. This treatment closes off the problem veins but leaves them in place so there is minimal bleeding and bruising. Compared with ligation and stripping, endovenous thermal ablation results in less pain and a faster return to normal activities, with similar cosmetic results. Can chronic venous insufficiency be prevented? To reduce your risk of developing CVI, follow these guidelines: Eat a healthy balanced diet. Quit smoking. Exercise regularly. Avoid wearing restrictive clothing such as tight girdles or belts. Lose weight if you are overweight. Avoid prolonged sitting or standing. Septic pelvic thrombophlebitis Septic pelvic thrombophlebitis and septic ovarian vein thrombophlebitis are seen principally as complications of puerperal infections and of septic abortions. It occurs approximately 1 in 3,000 vaginal deliveries and 1 in 2000 times Caesarean sections. Factors contributing to the pathogenesis of gonadal vein thrombophlebitis include stasis of blood, increased levels of procoagulants, and endothelial damage. Gonadal vein thrombophlebitis can also be seen after gynaecological surgery or pelvic inflammatory disease. Anaerobic bacteria are often involved, resulting in septic pelvic thrombophlebitis. Bacterial organisms spread within thrombosed veins. Intermittent septicaemia results in septic pulmonary emboli and metastatic abscesses. Clinically, the patient with septic pelvic thrombophlebitis most present with fever of unknown origin in the postpartum period. Once the diagnosis is suspected, the administration of heparin quickly reduces the fever. Traditionally, resolution of the fever within 24 hours of heparin administration confirms the diagnosis thrombophlebitis. Perineal varicose Laparoscopy. Varicose of left ovarian veins Pathologies associated with IVC Health problems attributed to the IVC are most often associated with it being compressed (ruptures are rare because it has a low intraluminal pressure). Typical sources of external pressure are an enlarged aorta (abdominal aortic aneurysm), the gravid uterus (aortocaval compression syndrome) and abdominal maligancies, such as colorectal cancer, renal cell carcinoma and ovarian cancer. Since the inferior vena cava is primarily a right-sided structure, unconscious pregnant females should be turned on to their left side (the recovery position), to relieve pressure on it and facilitate venous return. In rare cases, straining associated with defecation can lead to restricted blood flow through the IVC and result in syncope (fainting).3 Occlusion of the IVC is rare, but considered life-threatening and is an emergency. It is associated with deep vein thrombosis, IVC filters, liver transplantation and instrumentation (e.g. catheter in the femoral vein).4 1. 2. 1 3. 2 3 Collaterals at v.cava thrombosis: V. thoracoepigastrica; V. circumflexa ileum superfacialis; V. cutanea abdominis. Thromboemboly consequences Inferior vena cava thrombosis is usually a side effect of IVC filters. If the thrombosis is left untreated the IVC may shrivel away and become atretic. This can make the problem even worse and prevent treatment. Inferior vena cava thrombosis can cause the IVC syndrome. vena cava thrombosis can cause the IVC syndrome. Inferior vena cava filter with thrombus that extends above, but mainly below. Notice clot burden in the IVC below the filter Inferior vena cava thrombosis consequences Thrombosis of the IVC is usually symptomatic. The IVC syndrome is not subtle. People suffer from swollen legs, heaviness and pain. A severe form of the postphlebitic syndrome can occur. A rare consequence of inferior vena cava thrombosis is cauda equina syndrome. The thrombus can extend from the IVC into the lumbar veins. This may cause elevated pressure on the spinal cord and paralysis. Patients with lumbar vein thrombosis can have difficulty walking and problems with bowel control. Treatment of inferior vena cava thrombosis The best treatment for inferior vena cava thrombosis is prevention. IVC filters are the main cause for this condition. Therefore IVC filters should only be used for proper indications. If an IVC filter is inserted it should be a retrievable one. The filter needs to come out as soon as possible. If the filter cannot be removed, anticoagulation should be given indefinitely. Inferior vena cava thrombosis can also be treated by endovascular techniques. Catheter directed techniques can remove the clot. This uses mechanical thrombectomy and pharmacological thrombolysis. Success rate is limited as there is often much clot to cross. Sometimes stents are placed in the IVC after the procedure. This is not a simple procedure and patients should be chosen carefully. On the other hand, if the procedure is successful, results can be astounding. Mondor's disease Mondor's disease (also known as "Mondor's syndrome of superficial thrombophlebitis"1) is a rare condition which involves thrombophlebitis of the superficial veins of the breast and anterior chest wall. It sometimes occurs in the arm or penis. Patients with this disease often have abrupt onset of superficial pain, with possible swelling and redness of a limited area of their anterior chest wall or breast. There is usually a lump present, which may be somewhat linear and tender. Because of the possibility of the lump being from another cause, patients are often referred for mammogram and/or breast Mondor's disease is self limiting and generally benign. A cause is often not identified, but when found include trauma, surgery, or inflammation such as infection. There have been occasional cases of associated malignancy. Management is with warm compresses and pain relievers, most commonly NSAIDS such as ibuprofen. Localisations of venous disturbancies at Mondorsdiseases Subclavian Vein Thrombosis Sir James Paget first described thrombosis of the subclavian veins in 1875. He coined the name gouty phlebitis to describe the spontaneous thrombosis of the veins draining the upper extremity. He observed that the syndrome was accompanied by pain and swelling of the affected extremity. However, he incorrectly attributed the syndrome to vasospasm. In 1884, von Schrötter postulated that this syndrome resulted from occlusive thrombosis of the subclavian and axillary veins. In recognition of the work of these pioneers, in 1949, Hughes coined the term Paget-von Schrötter syndrome. A related condition is thrombosis of the subclavian vein that is induced by the presence of indwelling catheters. The incidence of this condition has increased remarkably over the past two decades because of the extensive use of catheters in patients with cancer and other chronic medical conditions Presentation Not all patients with subclavian vein thrombosis are symptomatic. Those with symptoms may present with mildto-moderate nonpitting edema and mild cyanosis of the hands and fingers on the affected side. Dilatation of subcutaneous collateral veins may be present over the upper arm and chest. This later sign may be the only clue to ASDVT in otherwise asymptomatic patients with catheter-related venous thrombosis. In a few cases, in which the diagnosis was missed or delayed or the patient presented late, the thrombus may have extended to the superior vena cava. These patients show most features of the superior vena cava syndrome, including face and neck swelling, periorbital edema, blurred vision, and some degree of facial cyanosis. treatment The initial treatment of subclavian vein thrombosis is conservative management, which includes rest, elevation of the limb, and application of heat or warm compresses. In a few patients who have minimal symptoms and no anatomical defects, physical therapy is always the first goal of therapy. Structured physical therapy may help the patient lose weight and loosens the adhesions at the site of obstruction. Physical therapy may also improve range of motion, decrease swelling, and help decrease pain. The different natural histories of Paget-von Schrötter syndrome and catheter-induced subclavian vein thrombosis indicate different treatment protocols. Because large series of patients with this condition are lacking, the therapeutic approach to subclavian vein thrombosis is mainly anecdotal. heparin Unfractionated or low molecular weight heparin (LMWH) can maintain patency of the venous collaterals and reduce the chance of propagation of the thrombus. In all cases, heparin therapy is followed by warfarin therapy, with an international normalized ratio (INR) goal of 2-3. Heparin is usually the initial therapy, followed by warfarin. LMWH has been used for both inpatient and outpatient therapy. Most studies have shown that LMWH is just as effective as unfractionated heparin, but the former is associated with a significant decreased incidence of venous thromboembolism. Warfarin is continued for 6-9 months, and an INR of 2:3 is maintained. Patients who only receive inpatient heparin and are no longer on warfarin therapy are at risk of recurrence and long-term disability. Anticoagulation is required in all patients for a period of 6-9 months or longer, depending on the cause of the thoracic outlet syndrome. In some patients who also have hypercoagulable disorders, the treatment is lifelong. Superior vena cava syndrome Superior vena cava syndrome (SVCS), or superior vena cava obstruction (SVCO), is usually the result of the direct obstruction of the superior vena cava by malignancies such as compression of the vessel wall by right upper lobe tumors or thymoma and/or mediastinal lymphadenopathy. The most common malignancies that cause SVCS is bronchogenic carcinoma. Cerebral edema is rare, but if it occurs it may be fatal. 1 signs Shortness of breath is the most common symptom, followed by face or arm swelling. Following are frequent symptoms: Dyspnea Headache Facial edema Venous distention in the neck and distended veins in the upper chest and arms Upper limb edema Lightheadedness Cough Edema of the neck, called the collar of Stokes Superior vena cava syndrome usually presents more gradually with an increase in symptoms over time as malignancies increase in size or invasiveness. Cause Approximately 90% of cases are associated with a cancerous tumor that is compressing the superior vena cava, such as bronchogenic carcinoma including small cell and non-small cell lung carcinoma, Burkitt lymphoma, lymphoblastic lymphomas, pre-T-cell lineage acute lymphoblastic leukemia (rare), and other acute leukemias. Syphilis and tuberculosis have also been known to cause superior vena cava syndrome.3 SVCS can be caused by invasion or compression by a pathological process or by thrombosis in the vein itself, although this latter is less common (approximately 35% due to the use of intravascular devices). Diagnosis The main techniques of diagnosing SVCS are with chest X-rays (CXR), CT scans, transbronchial needle aspiration at bronchoscopy and mediastinoscopy. CXRs provide the ability to show mediastinal widening and may show the presenting primary cause of SVCS. CT scans should be contrast enhanced and be taken on the neck, chest, lower abdomen and pelvis. They may also show the underlying cause and the extent to which the disease has progressed. Treatment Several methods of treatment are available, mainly consisting of careful drug therapy and surgery. Glucocorticoids (such as prednisone or methylprednisolone) decrease the inflammatory response to tumor invasion and edema surrounding the tumor. In addition, diuretics (such as furosemide) are used to reduce venous return to the heart which relieves the increased pressure. Prognosis Symptoms are usually relieved with radiation therapy within one month of treatment. However, even with treatment, 90% of patients die within two and a half years. This relates to the cancerous causes of SVC that are 90% of the cases. The average age of onset of disease is 54 years of age Thanks for attention!