ARTERIAL AND VENOUS DISEASE

Aortic aneurysms

An aneurysm is a permanent localized dilatation of an artery. They may be asymptomatic or cause symptoms by pressure effects or vessel rupture, occasionally with fistula formation, or they may be a source of emboli. Aortic aneurysms (vessel diameter > 3 cm) are usually abdominal and most result from a degenerative process and present in elderly men. Some are the result of connective tissue disease.

Abdominal Abdominal aortic aneurysms can be asymptomatic (and found as a pulsating mass on abdominal examination or as calcification on a plain X-ray), cause symptoms due to pressure effects (epigastric or back pain) or rupture. The latter is a surgical emergency presenting with epigastric pain radiating to the back, and hypovolaemic shock. Diagnosis is by ultra-sonography or CT scan. Surgical replacement of the aneurysmal segment with a prosthetic graft is indicated for a symptomatic aneurysm or large asymptomatic aneurysms (> 5.5 cm). In patients that are poor surgical risks, endovascular repair with insertion of an aortic stent is being increasingly employed.

Thoracic Cystic medial necrosis and atherosclerosis are the usual causes of thoracic aneurysms. Cardiovascular syphilis is no longer a common cause. Thoracic aneurysms may be asymptomatic, cause pressure on local struc-tures (causing back pain, dysphagia and cough) or result in aortic regurgita-tion if the aortic root is involved.

Dissecting aortic aneurysm Aortic dissection results from a tear in the intima: blood under high pressure creates a false lumen in the diseased media. Typically there is an abrupt onset of severe, tearing central chest pain, radiating through to the back. Involvement of branch arteries may produce neurological signs, absent pulses and unequal blood pressure in the arms. The chest X-ray shows a widened mediastinum and the diagnosis is con-firmed by CT scanning and transoesophageal echocardiography or MRI. Management involves urgent control of blood pressure (p. 486) and surgical repair for proximal aortic dissection.

Raynaud’s disease and phenomenon

Raynaud's phenomenon consists of intermittent spasm in the arteries sup-plying the fingers and toes. It is usually precipitated by cold and relieved by heat. There is initial pallor (resulting from vasoconstriction) followed by cya-nosis and, finally, redness from hyperaemia. Raynaud's disease (no under-lying disorder) occurs most commonly in young women and must be differentiated from secondary causes of Raynaud's phenomenon, e.g. autoimmune rheumatic disease and p-blocker therapy. Treatment is by keeping the hands and feet warm, stopping smoking and stopping β-blockers. Medical treatment includes oral nifedipine and occasionally prostacyclin infu-sions. Lumbar sympathectomy may help lower limb symptoms.

Venous disease

Superticial thrombophlebitis This usually occurs in the leg. The vein is painful, tender and hard, with overlying redness. Treatment is with simple analgesia, e.g. NSAIDs. Anticoagulation is not necessary as embolism does not occur.

Deep venous thrombosis Thrombosis can occur in any vein, but those of the pelvis and leg are the most common sites. The risk factors for deep vein thrombosis (DVT) are listed on page 238.

Clinical features

DVT is often asymptomatic but the leg may be warm and swollen, with calf tenderness and superficial venous distension. The differential diagnosis includes ruptured Baker's cyst (p. 275), oedema from other causes and cellulitis.

Investigations

Measurement of serum D-dimer is the initial investigation in patients with a low clinical probability score (Table 10.17) and no further investigation is indicated if D-dimers are normal. In all other patients venous compression ultrasonography is indicated which is a reliable test for iliofemoral thrombo-sis. It is not reliable for calf vein thrombosis and repeat scanning 1 week later with interim heparin treatment is indicated if the initial scan is negative and there is high index of clinical suspicion.

Table 10.17 Wells score for the clinical probability of a deep venous thrombosis (DVT)

History

Score if present

Lower limb trauma or surgery or immobilization in a plaster cast

+1

Bedridden for more than 3 days or surgery within the last 4 weeks

+1

Malignancy (including treatment up to 6 months previously)

+1

Tenderness along deep venous system

+1

Clinical findings

Entire limb swollen

+1

Calf swelling more than 3cm compared to asymptomatic side, measured at 10 cm below tibial tuberosity

+1

Pitting oedema (greater in symptomatic leg)

+1

Dilated collateral superíicial veins (non-varicose)

+1

Possible alternative diagnosis

Alternative diagnosis (e.g. musculoskeletal injury, haematoma, chronic oedema, cellulitis of the leg, arthritis of the leg, Baker’s cyst) as likely or greater than that of DVT

-2

Total score ≤0 1–2 ≥3
Risk of DVT 3% (low) 17% (moderate) 75% (high)

Management

This is discussed on page 239.

The main aim of therapy is to prevent pulmonary embolism. Anticoagula-tion is initially with heparin and subsequently with warfarin, continued for 3 months unless there had been a definite risk factor prior to presentation, e.g. bed rest, when treatment is usually for 4 weeks. Thrombolytic therapy is occasionally used for patients with a large iliofemoral thrombosis.

The main complications of DVT are pulmonary embolus, post-thrombotic syndrome (permanent pain, swelling, oedema and sometimes venous eczema may result from destruction of the deep-vein valves) and recurrence of thrombosis. Elastic support stockings are used for the post-thrombotic syndrome.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology

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