Onset is usually slow, but may be fast in a few cases.
Lower limb trauma is an important triggering factor. Patients usually tell a history of varicose veins, and some may have a past history of deep venous thrombosis DVT. The question on whether they have had lower limb edema after surgery or pregnancy should be asked, since those may be associated to a previous non-diagnosed DVT episode. Other situations related to subclinical DVT should be questioned, such as prolonged bed rest and lower limb fracture treated with cast. Pain is the most frequent symptom and it varies in intensity, not being influenced by ulcer size, since small lesions may be very painful, while large ones may be almost painless.
When present, pain usually worsens towards the end of the day, with orthostatic position, and improves with limb elevation. Ankle edema is frequently present, especially at the end of the day. The venous ulcer is usually an irregular wound, shallow in the beginning but it may become deeper, with well defined borders and often with a yellow exudate.
Symptoms of Venous Insufficiency Ulcers
Rarely the ulcer bed will have necrotic tissue or tendon exposure. Ulcers may be single or multiple, of variable sizes and in different sites, but are usually at the distal portion of the lower limbs leg , most commonly in the region of the medial malleolus Figure 1. On such cases, other etiologies for chronic ulcers should be ruled out before the diagnosis of venous etiology. The skin surrounding the ulcer may be of purpuric color and hyperpigmented ochre dermatitis , due to red blood cell leakage into the dermis and hemosiderin deposit in macrophages.
There may be eczema around the ulcer, with erythema, scaling, pruritus and, occasionally, exudate Figure 2. There is no formal proof that the same pathophysiologic changes for development of venous ulcer and of chronic venous insufficiency be the cause of the eczema, known as stasis eczema. Lipodermatosclerosis also occurs, with induration and fibrosis of different intensities which, when present for many years, may comprise the whole distal third of the lower limb, that assumes the shape of an inverted champagne bottle.
Often, during such periods, lipodermatosclerosis may be confounded with erysipelas or cellulitis. Absence of the typical changes of lipodermatosclerosis must raise the hypothesis of nonvenous ulcer, although some cases of venous ulcer may not present with lipodermatosclerosis.
White atrophy may also be found in other vascular or systemic diseases, such as livedoid vasculitis.
Some patients have a plaque of intradermal dilated venules, usually at the ankle, on the submalleolar region. This is known as corona phlebectatica, and results from persistent venous hypertension, leading to dilation and elongation of capillaries and venules Figure 4.
Varicose veins may be found on the physical exam by the presence of venous dilations of different sizes. There may be varicose trunks in the territory of the venae saphena magna and parva, and the presence of leaking perfurans veins in the calf and thigh. A venous ulcer at the lateral malleolus may be associated to insufficiency of the vena saphena parva.
All lower limb pulses should be palpated, specially the pedis arterial and posterior tibial pulses, although this may be difficult to detect due to the presence of lipodermatosclerosis or ulcer at the site. The ratio is calculated using the highest value of systolic blood pressure at the ankle divided by the systolic blood pressure of the brachial artery Figure 5. An AAI lower than 0. An AAI bellow 0.
In some cases it is very hard to determine which factor is the most important in the ulcer pathogenesis. Once the clinical diagnosis of venous ulcer is established, some exams should be ordered for a more precise diagnosis of the anatomic and functional changes of the venous system. The anatomic identification of the venous disease is extremely important for planning treatment of these patients, since it may be localized in the superficial or deep venous system or in the perforating veins, or in more than one system. A functional assessment should also be carried out, identifying whether the venous disease is due to reflux, obstruction or both.
Non-invasive exams should be used, such as Doppler ultrasound, plethysmography and duplex scan.
Venous leg ulcers: Pathophysiology and Classification
An algorithm for the diagnostic management of patients with chronic ulcer of lower limbs is suggested for didactic and practical reasons Chart 1. PFor an adequate therapeutic management, accurate clinical and laboratorial diagnoses are essential. Besides establishing the diagnosis of venous ulcer, it is important to recognize and treat chronic ulcer complications, mainly soft tissue infections, contact dermatitis, osteomyelitis and, more rarely, neoplastic transformation. Soft tissue infection happens when there is deep penetration and proliferation of bacteria in the tissues surrounding the ulcer, leading to erysipelas, cellulitis or bacterial lymphangitis.
Its clinical manifestations are erythema, edema, pain and local heat of the tissues surrounding the ulcer, and sometimes fever. It is usually difficult to determine whether the ulcer is really infected or only colonized. The increased number of bacteria in the surface of the ulcer means colonization, not necessarily infection.
Some studies have shown that a large amount of bacteria on chronic ulcers may also hinder healing,. Systematic use of swabs for bacteriologic exams is not indicated since they will identify only contaminating and colonizing bacteria. When there is associated infection and bacterial identification is necessary to guide the treatment, biopsies of the base of the ulcer should be performed as well as cultures of the biopsy specimens.
Contact dermatitis is usually manifested by eczema-like lesions around the ulcer. It may appear as acute eczema, with erythema, vesicles and blisters, and exudation, or as sub-acute and chronic eczema when there is an erythematous scaling lesion or lichenification, respectively.
In both situations the lesions are usually itchy and secondary to sensitization that patients develop along time, especially to topical antibiotics neomycin, sulfa, gentamycin, among others , lanolin and antiseptics povidineiodine. In such cases, the triggering cause should be avoided and topical steroids as well as antihistame drugs should be used and, in more severe cases, systemic steroids for a short time, 40 to 60 mg of prednisone, for instance.
Some patients may also present with dermatitis due to the irritation caused by the ulcer exudate. The exudate will macerate the skin around the ulcer and increase the local inflammatory process, favoring bacterial colonization which has additional pro inflammatory role, and is known as microbial eczema.
There may be osteomyelitis in long lasting venous ulcers, but its incidence is unknown.
When bone tissue is exposed and can be palpated at the base of the ulcer, osteomyelitis should be suspected. A radiograph is then indicated to check for bone destruction, increased soft tissue volume and periosteal reaction.
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In some cases a bone biopsy is indicated. There may be neoplastic transformation at the bed of chronic ulcers, such as squamous cell carcinomas and basal cell carcinomas Figure 7. Chronic ulcers of atypical appearance and lesions that do not respond to adequate clinical treatment should raise the possibility of neoplastic transformation.
Squamous cell carcinomas over venous ulcers, known as Marjolin ulcers, usually have raised borders, excessive exudate and necrotic tissue. Upon a diagnosis of malignant transformation, the treatment is either surgery or radiation therapy. After a correct diagnosis of venous ulcer and appropriate control of complications, the goal should be healing, and after that, avoiding recurrence. The major advance in understanding the pathophysiology of venous ulcers has led to the development of new modalities of clinical and surgical treatments.
The most important methods for ulcer healing are compression treatment, local treatment of the ulcer, systemic drugs and surgical treatment of the venous disease. Venous ulcers are caused by venous hypertension; thus some steps should be taken to decrease hypertension and its consequences in the macro and microcirculations. Compression treatment is mandatory for that, 28,29 since it acts on the macrocirculation, increasing deep venous return, decreasing pathologic reflux during deambulation and increasing stroke volume during the activation of the calf muscles.http://img.hipwee.com/19746.php
Venous Stasis Ulcer
The compression methods available are compression dressings, elastic stockings and pneumatic compression. All these are not indicated if the patient has severe peripheral arterial disease, non-palpable distal pulses or AAI lower than 0. Compression bandages are often used in the initial phase of treatment and may be elastic or inelastic Figure 8. The Unna boot is the most used inelastic dressing, a bandage impregnated with a zinc oxide paste, creating a semi solid cast for efficient external compression.
Both the traditional and modified Unna boot should be worn for seven days, but in the beginning of treatment, due to the presence of large amounts of exudate and edema, they may be replaced more often. Unfavorable features are change in pressure along time, need for well trained nurses and physicians, inadequacy for extremely exudative wounds. Elastic bandages stretch more and cause high pressure under muscular contraction as well as at rest. The latter has superficial rectangles that shape into squares when stretched to a proper tension.
Treatment by multilayer elastic compression is the modern and effective form for the treatment of venous ulcer.