Leg Ulcers Secondary to Venous Insufficiency: Description, Causes and Risk Factors:
Leg ulcers are present in 1 - 2 % of the adult population. In the majority of cases, leg ulcers are due to chronic venous disease, either VV (varicose veins) or DVT (deep vein thrombosis). Venous leg ulcers are due to increased pressure in the venous circulation, either because of Superficial Vein reflux (Varicose Veins) or Deep Venous reflux (as a result of DVT).
Chronic venous insufficiency and leg ulcers affect approximately 1-2 people per 1000 of the general population, with approximately 10-20 people per 1000 ever affected. Ulcer healing rates can be poor with up to 50% of venous ulcers open and unhealed for 9 months. Ulcer recurrence rates are worrying with up to one third of treated patients on their fourth or more episode. In the UK leg ulcer treatment accounts for 1.3% of the total healthcare budget and up to 90% are treated in the community. In the United States venous ulcers have been estimated to cause the loss of 2 million working days and to incur treatment costs of approximately $3 billion per year.
The venous system is made up of superficial and deep veins:
Superficial veins are located between the skin and the muscles.
Deep veins are located between the muscles.
Superficial and deep vein systems are connected to each other by veins that have one-way valves. These valves normally ensure that blood flows from the superficial veins to the deep system. Failure of these valves causes blood to flow from the deep veins back out to the superficial ones - a major cause of varicose veins and most of venous leg ulcers occur because the valves connecting the superficial and deep veins are not functioning properly.
There are some factors which appear to predispose patients to chronic venous insufficiency they may include being overweight, physically inactive, and smoking. Age and a family history of venous disease cannot be altered but do increase your risk.
Old ulcers that may have damaged part of the venous system.
A fracture or other injuries.
A blood clot in the deep veins.
Work that requires a lot of sitting or standing.
Inflammation in the veins (phlebitis), especially in the deep veins.
Pregnancy - the more pregnancies, the higher the risk.
Symptoms may include:
The leg is swollen.
The skin surrounding a venous ulcer is dry, itchy and sometimes brownish in color.
Eczema may appear.
The ulcer has a weeping, raw appearance and is usually painless unless infected.
Venous leg ulcers are often located just above the ankle, typically on the inside of the leg.
An accurate history and physical examination with special reference to venous and arterial disease, diabetes and rheumatoid arthritis is performed in all patients.The examination will focus on the ulcer itself and on the arterial and venous systems in the leg. The site and size of the ulcer, the edge of the ulcer and the base of the ulcer are particularly important in deciding what sort of ulcer is present. The appearance of the edge of the ulcer can raise suspicions of a possible skin cancer, but it also can indicate whether the ulcer is beginning to heal or if it is deteriorating. Very specific changes, such as a violaceous border, can indicate the presence of rare conditions such as pyoderma gangrenosum. Exposed bone or tendon, the presence of dead tissue or alternatively healthy granulation tissue are all important. Discharge, especially if smelly, can indicate the presence of infection. Discharge may be secondary to swelling in the leg.
Obvious varicose veins will be recorded. The pulses will be felt throughout the leg and the arterial circulation further assessed through color and warmth of the limb.
A formal assessment of the arterial circulation using the hand held Doppler and measurement of the ankle-brachial index (ABI) is essential before instituting treatment.
Duplex scan of the venous system will clearly identify patterns of venous reflux which can be surgically corrected in appropriate patients.
Some ulcers are clearly caused by problems in the veins. This should be confirmed by clinical assessment and on special investigations. If this is the case then compression treatment should be commenced. It should only be applied after the arteries have been assessed by measuring the ankle-brachial index (ABI). This is because if compression is applied and the arteries are badly diseased, this can damage the ulcer and the leg, and make matters worse. It would also be very painful. Sometimes it is necessary to close the ulcer by means of plastic surgery. This involves taking skin from somewhere else on your body and placing it over the ulcer.
Activate your calf muscles regularly by walking and exercising.
Reduce the amount of fat in your food. Eat more fruit and vegetables.
If you are overweight, losing weight will help prevent ulcers.
Sit with your legs raised whenever you have the opportunity - above heart level if possible.
Avoid sitting with your legs crossed. This impairs blood circulation.
If your work requires a lot of standing or sitting, try to vary your stance as much as possible. Walk about from time to time, if you can.
If you have to stay seated for a long time, move your feet up and down occasionally.
Support stockings may be useful, but talk to your doctor or practice nurse first.
Inspect your feet and legs daily. Look for sores or changes in color.
Disclaimer: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.
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