2nd July 2023

Blood and Lymphatic Vessel Disorders

Venous ulcers 

Venous ulceration can occur from venous insufficiency and hypertension in the lower limbs. Chronic venous hypertension alters capillary and lymphatic microcirculation, which can subsequently result in capillary leak, fibrin deposition, erythrocyte and leukocyte sequestration, thrombocytosis, and inflammation. In severe and more chronic cases, this can lead to tissue hypoxia and subsequent ulcer formation.

Identification and Symptoms

Diagnosis of chronic venous insufficiency is through the presence of symptoms, examination and venous doppler ultrasound of lower limbs. The main symptoms include leg pain, fatigue, and heaviness. Skin changes include venous eczema and discolouration, dilated superficial veins, and ultimately ulceration in severe cases. Venous ulcers tend to affect the medial aspect of the lower limb and have a poorly defined edge.

Venous insufficiency affecting the lower limbs with characteristic skin manifestations, including venous eczema, lipodermatosclerosis, and orange-brown macular pigmentation from haemosiderin deposition. 

Image Source: Wikimedia Commons (2018). Chronicvenousinsufficiency, Licensed under a creative commons licence. Available for free at: https://commons.wikimedia.org/wiki/File:Chronicvenousinsufficiency.jpg (Accessed on: 14 March 2023).

Treatment

Treatment can be divided into various categories and aims. These include improvement of symptoms, reduction of overall leg oedema, and healing of ulcers.

General measures recommended to patients include leg elevation, regular exercise, avoidance of prolonged standing and appropriate skin care. If ulceration occurs, treatments include compression therapy, ulcer debridement and possible antibiotic therapy depending on appearance and symptoms of ulcers.

Lymphoedema 

Defined as an ‘abnormal accumulation of interstitial fluid and fibroadipose tissues resulting from injury, infection, or congenital abnormalities of the lymphatic system’. When the lymphatic load exceeds the overall transport capacity of the lymphatic system, this results in the build-up of fluid in the interstitial tissues.

It is classified as either primary or secondary.

Primary causes are those without a precipitating cause and are congenital or inherited. It tends to present in children but can also present later in adulthood. This is referred to as Milroy disease.

Secondary lymphoedema occurs due to other conditions or treatments. The most common cause is cancer and cancer treatment, including radiotherapy and surgical excision of lymph nodes. Other causes include infection, inflammatory disorders, obesity, and chronic causes of lymphatic overload (venous insufficiency, trauma, and burns).

Identification and Diagnosis

The diagnosis can be made from a careful history and examination. Physical examination should include vascular, skin, and soft tissue examination with focus on the lymph nodes. Most cases are unilateral, often from precipitating events such as lymph node excision from cancer or radiotherapy. The circumference of the limbs should also be measured. Additional imaging is usually not required. However, in cases where imaging is required, CT and MR have been used but with variable results.

Management

The first line treatment is decongestive lymphatic therapy. This utilises multiple techniques to help control symptoms. The four main components are compression bandages, skin care, exercises to improve lymph drainage and specialised massage techniques to stimulate the flow of fluid in the lymphatic system.