Occasionally, patients may attend the ED with complications of their varicose veins.
Bleeding from Varicose Veins
Patients with chronic venous hypertension associated with varicose veins have a significant risk of haemorrhage from the dilated thin-walled veins which commonly surround the area of lipodermatosclerosis at the ankle.
Haemorrhages may be profuse and sufficient to cause hypovolemic shock. In extreme cases, this may even cause death.
Treatment
Control bleeding by elevating the leg, applying a non-adherent dressing and pressing firmly. Follow this with appropriate bandaging; unless there is evidence of occlusive arterial disease (varicose veins and arterial disease frequently co-exist in the elderly).
Some patients may require resuscitation with IV fluids.
Refer for admission those who were shocked at presentation, those who have subsequently bled through the bandaging, those with occlusive arterial disease, and those who live alone.
All patients will require surgical outpatient follow-up—advise patients who are discharged about first aid measures in the event of a rebleed.
Superficial Thrombophlebitis
This occurs most frequently in patients with varicose veins or prothrombotic states (eg underlying inflammatory and malignant conditions).
It usually manifests itself with redness, tenderness and induration along the course of the involved vein.
Treatment
Bed rest, elevation, and analgesia (NSAID). Pain typically decreases over 1–2 weeks and the patient is left with a hard thrombotic cord.
Superficial thrombophlebitis is only rarely associated with DVT, but occasional thrombosis spreads from the long saphenous vein to involve the femoral vein.
If there is any question of deep vein involvement, request an USS.
If the thrombotic process involves the sapheno-femoral junction or the ilio-femoral system, refer for anticoagulation.
Venous Ulcers
Venous (varicose) ulcers tend to be chronic and recurrent.
They are typically found on the medial side of the ankle.
There is often associated dermatitis with surrounding brown discolouration, thickening of the skin and leg oedema.
There is often mixed venous and arterial disease, especially in the elderly.
Although ischaemic ulcers tend to lie on the lateral aspect of the ankle, exclude ischaemic ulceration by checking the peripheral pulses (request Doppler in patients with oedematous legs).
Look for areas suspicious of malignant change, which may rarely occur in chronic ulcers (Marjolin’s ulcer).
Treatment
Clean the ulcer with normal saline and dress it with either paraffin gauze or colloidal dressing.
Follow this with firm bandaging (unless there is co-existing arterial disease) and advise leg elevation when the patient rests.
Avoid dressings with topical antibiotics and indiscriminate use of oral antibiotics.
Prescribe oral antibiotics (eg co-amoxiclav) only if there is cellulitis.
Liaise with the GP about the need for surgical outpatient follow-up and to arrange for redressing by the district nurse.
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