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INTRODUCTION

Treatment of deep venous valvular reflux syndrome will be successful only if the diagnosis is correct. In fact, the features of this syndrome usually make it quite easy to diagnose. Yet, there are many other nonvenous conditions that produce similar symptoms. Furthermore, many people with venous insufficiency have additional conditions which exaggerate and confound the symptom complex.

PART I EDEMA

Many conditions cause swelling of the legs. Failure of the heart, liver, or kidneys may be first signaled by edema. In these cases, there is a generalized expansion of body fluid. These systemic conditions tend to produce the same degree of swelling in each leg. Venous insufficiency, on the other hand, is almost always more severe on one side than the other, if present at all. This asymmetry is when measuring maximum calf/minimum ankle circumferences can be especially meaningful.

Hypoproteinemia

The amount of protein in the serum of blood is also an important factor in regulating a proper balance of fluid volume. The protein serves to draw in fluid from interstitial spaces by osmosis. Protein deficits—enough to cause edema—may result from severely deficient food intake (including anorexia nervosa) or from intestinal malabsorption. Massive loss of protein from the kidneys (nephrotic syndrome) or from the skin (extensive dermatitis or burns) can also lead to severe swelling of the legs. What is characteristically different from venous insufficiency is that edema occurs as well in the upper body. It is most obvious in the loose tissue around the eyes, especially after sleeping or on being recumbent for several hours.

Lymphedema

Lymphedema (obstruction of the lymphatic channels) causes intractable swelling of the affected extremity from defective draining of lymph particles from the interstitial fluid. The skin is often described as alabaster white, but color varies considerably. It is “non-pitting” with firm compression (that is, the free fluid in the interstitial space cannot be easily pushed away). There is a tendency for edema from lower limb lymphedema to first affect the top of the forefoot and spread out to the toes, an unlikely distribution in venous insufficiency. Gradually, edema then expands upward, eventually to form the wood-like consistency of fibrosis. Figure 9.1 depicts the typical findings of advanced lymphedema.

Venous Obstruction

Isolated edema occurring in one leg may be the first symptom of venous obstruction. The cause may lie in the pelvis when the terminal iliac artery crosses over and compresses the left iliac vein (the May-Thurner syndrome). This common anatomical variation may explain the curious observation that edema from prolonged and inactive sitting is predominantly on the left side, most especially in the elderly person.

Abdominal or pelvic masses can press against the major veins, leading to ...

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