A fairly large number of venous diseases require strict accounting. Medical statistics are based on the international classification of diseases (ICD 10), in which all vascular problems are collected in class IX “Diseases of the circulatory system”. It is easier for the doctor to determine the diagnosis: any disease of the veins of the lower extremities can be found in ICD 10, indicating the code in the medical documentation and starting the correct treatment.
All variants of venous problems of the legs are classified in the ICD 10 group, for which code I83 is allocated:
It is very important to divide all cases of venous problems into complicated and uncomplicated forms. ICD 10 code determines the tactics of examination and treatment: the doctor knows what to do for each type of venous disease.
Vein diseases during pregnancy and after childbirth are removed from class IX. Varicose veins of the legs, which complicate pregnancy, are designated by code O22.0, and venous disorders during lactation are identified by code O87.8.
Problems with the venous system of the esophagus are encrypted with the following codes:
Only 2 options can be used to designate all types of pathology of the esophageal veins, which greatly facilitates the doctor’s work. If there is bleeding, then emergency treatment measures must be taken. In the absence of esophageal bleeding, it can be treated conservatively, gradually preparing the patient for surgery and creating conditions to eliminate the increased pressure in the venous system of the liver.
Serious complications of varicose veins in ICD 10 are indicated in several subsections. Depending on the level and location of the lesion, all types of phlebitis and thrombophlebitis are designated by codes I80.0 - I80.9. Thrombosis and embolism of large venous trunks are determined by codes I81 – I82. For hemorrhoids in various variants with complications and risk of thrombosis, codes I84.0 – I84.9 are allocated. Varicose veins in the pelvic and perineal area are classified by codes I86.2 and I86.3.
Effective treatment is based on a correct diagnosis. If diagnostic factors are underestimated or significant symptoms and manifestations of the disease are not identified, the doctor may make an erroneous diagnosis. There is nothing wrong with this if the wrong code is placed within one subsection. It is much worse if complications are underestimated: undetected thrombophlebitis can cause thrombosis that is life-threatening. When using ICD 10, the doctor should always clearly monitor the definition of the type of disease and the possibility of complicated forms of the disease.
Thrombophlebitis, a common and dangerous disease, is classified by ICD 10 as a disease of the circulatory system. A blood clot forms inside the inflamed vein, disrupting blood flow. In 70% of cases, the disease develops in the lower extremities.
The causes that provoke the development of the disease (ICD code 10 I 80) are divided into 3 factors:
These factors are diagnosed individually or in combination. They contribute to the development of varicose veins, which is the cause of acute thrombophlebitis.
Vein thrombosis is a rather dangerous disease that can be fatal if a blood clot breaks off and enters the arteries of the lung or heart.
Thrombophlebitis (ICD code 10 I80) develops with forced immobility of a limb (with a fracture).
Thrombosis of the veins of the lower extremities is caused by taking estrogen-containing hormones prescribed for infectious and autoimmune diseases. Oncological diseases provoke thrombophlebitis of the lower extremities. Installation and long-term presence of a catheter in the venous bed and frequent injury to the walls by injections lead to the formation of blood clots.
In 65% of cases, thrombophlebitis is diagnosed in women. The pattern is associated with wearing high-heeled shoes, tight jeans and taking hormonal contraceptives. The cause of the disease may be pregnancy. During this period, physiological activation of coagulation processes occurs, preventing bleeding in the postpartum period, and the inflamed vessel wall leads to the formation of a blood clot. People aged 40-55 years are at risk. At this age, the condition of the body's vascular system deteriorates significantly.
Thrombosis is hereditary. Causative factors include obesity, unbalanced diet, physical activity, smoking and drinking alcoholic beverages.
Deep vein thrombosis has a specific code in the ICD-10 classification – I80
ICD 10 code I80 includes phlebitis and thrombophlebitis. Symptoms vary depending on the location of the clot. There are 2 types of diseases:
Superficial thrombophlebitis develops in the great saphenous vein. It is easy to diagnose. Inflammatory changes occur in the area of the affected vessel, but if varicose veins are not observed, then thrombophlebitis is interpreted by ICD 10 as a complication of gynecological pathology or a symptom of a malignant tumor in the organs of the digestive system. Thrombophlebitis ICD 10 also includes thrombosis in the intestine.
When palpating the inflamed saphenous vein, the patient experiences stabbing pain. Symptoms of superficial thrombophlebitis: scarlet stripes on the skin, swelling of the ankles and feet, increased body temperature.
Without treatment, thrombosis spreads to the deep veins. The patient's health worsens. Infiltration and hyperemia are observed in the area of the thrombosed vessel.
There are 2 types of thrombosis that require special attention:
Such an acute inflammatory process of the lower extremities is dangerous for human life, and ignoring it can lead to death
Thrombosis of the lower extremities according to the clinical picture is classified into:
The main factors that can provoke deep vein thrombophlebitis are: tissue nutritional disorders and the development of aseptic inflammation
When the inferior vena cava is blocked, bilateral swelling of the limb is observed. If the thrombus is located in the iliac segment, then unilateral edema is noted. When walking for a long time, aching pain appears in the calf muscle.
Thrombosis is manifested by numbness of the limbs, loss of sensitivity, tingling of the skin, chills and hardening of the lymph nodes. The first symptoms of the chronic form may appear a year after the exacerbation. The disease can be migratory in nature. This form is characterized by rapid development. The migratory form affects the superficial veins. Dense thrombosed nodules can change their position, appearing in different parts of the limb. Seals are accompanied by swelling and increased body temperature.
For thrombophlebitis, doctors prescribe treatment based on the diagnostic results obtained. Treatment includes:
Thrombophlebitis has several forms: acute and chronic
If thrombosis affects the superficial veins, then treatment is carried out with medication. The patient is prescribed phlebotonics, anti-inflammatory drugs, ointments. Conservative treatment relieves swelling, reduces pain and restores blood flow. Anti-inflammatory drugs include drugs such as Ibuprofen, Aspirin and Diclofenac. Heparin ointment and Troxevasin have a local effect.
For thrombosis of superficial veins, doctors prescribe electrophoresis with anticoagulants, UHF therapy and magnetic therapy. Physiotherapeutic procedures dissolve blood clots and reduce swelling and pain.
Conservative treatment is carried out in combination with compression therapy. For thrombophlebitis, elastic bandages and compression stockings (stockings or tights) should be worn. The degree and class of compression is prescribed by a phlebologist depending on the severity of the disease.
For superficial thrombophlebitis, treatment with folk remedies is effective. Verbena leaves will help eliminate swelling, heaviness and relieve pain in the legs. Pour 20 g of leaves into 200 ml of boiling water. Take the drink 100 ml 3 times a day during the day.
Deep vein thrombosis of the lower extremities requires a radical method of treatment. Depending on the stage and nature of the disease, the method of surgical intervention is selected. The endoscopic procedure is a low-traumatic method of treatment. During the procedure, the vessel is “sealed” above the site of phlebitis. In modern medicine, radiofrequency obliteration and laser coagulation are used. Minimally invasive methods do not cause complications and are carried out even during pregnancy. Due to the low-traumatic nature of the operations, the rehabilitation period is minimal. As the disease progresses, the thrombosed vessel is completely removed. In case of deep venous thrombosis, elastic compression is prohibited. Bandaging leads to the development of complications.
12/07/2014 | Author admin
Material from Wikipedia - the free encyclopedia
Varicose veins. Varicose veins of the right lower limb. ICD-10 I8383. mkb-9 454454
Varicose veins of the lower extremities ( varicose ) - expansion of the superficial veins of the lower extremities, accompanied by valve failure and impaired blood flow. The term "varicose veins" comes from the Latin. varix . genus. n. varicis - “swelling”.
Varicose veins have accompanied humanity since its inception. Mentions of this disease can be found both in the Old Testament [ source not specified 97 days ] and in Byzantine authors. Its antiquity is also confirmed by excavations of the Mastaba burial in Egypt (1595-1580 BC), where a mummy was found with signs of varicose veins and a treated venous trophic ulcer of the leg. Outstanding doctors of antiquity - Hippocrates, Avicenna, Galen - also tried to treat this disease.
Considering the cause of varicose veins to be the presence of reflux through the saphenofemoral junction, Friedrich Trendelenburg ( German ) in 1880 proposed performing ( German ) ligation and intersection of the great saphenous vein (GSV) through a transverse incision in the upper third of the thigh. Alexey Alekseevich Troyanov (1848-1916) used a test similar to Trendelenburg to diagnose insufficiency of the GSV valves, and for the treatment of varicose veins he recommended using a double ligature of the great saphenous vein “with cutting out”. However, both authors did not insist on the need for ligation of the GSV at the level of the saphenofemoral junction, which caused a large number of relapses in those days.
At the turn of the 19th - 20th centuries, existing operations were supplemented with extremely traumatic dissections of the tissues of the thigh and leg with deep (to the fascia) circular or spiral incisions according to N.Schede (1877,1893), Wenzel, Rindfleisch (1908), with the aim of damaging the saphenous veins with subsequent by bandaging or tamponade to heal by secondary intention. The severe consequences of these operations due to extensive scarring, damage to nerves, arteries and lymphatic pathways led to their complete abandonment. At the beginning of the 20th century, there were about two dozen methods of surgical treatment of varicose veins. Of the entire arsenal of proposed methods, only a few were most often used, namely: the methods of OWMadelung, W. Babcock, S. Mayo, N. Schede. The method of removing the GSV, proposed by WWBabcock in 1908, was a breakthrough in the treatment of varicose veins of the lower extremities. The use of a metal probe was the first intravascular effect on venous vessels, the first step towards minimal invasiveness, which made it possible to reduce the negative consequences of other surgical techniques. In 1910, M. M. Diterikhs proposed mandatory ligation of all trunks and tributaries of the great saphenous vein, for which he used an arcuate incision 2 cm above the inguinal fold, descending to the thigh, widely opening the area of the oval fossa and allowing the large saphenous vein and its tributaries to be resected. The basic principles of surgical treatment of primary varicose veins were determined in 1910 at the X Congress of Russian Surgeons. It was emphasized that a carefully performed operation eliminates the possibility of relapse of the disease. The next stage in the development of methods for treating chronic venous diseases was due to the development and implementation of radiological diagnostic methods.
The first X-ray contrast study of veins in Russia was carried out in 1924 by S. A. Reinberg, who injected a 20% solution of strontium bromide into varicose nodes. The further development of phlebography is also firmly connected with the names of Russian scientists A. N. Filatov, A. N. Bakulev, N. I. Krakovsky, R. P. Askerkhanov, A. N. Vedensky.
With the advent of complex ultrasound angioscanning with color mapping of blood flows and Dopplerography, it became possible to study the anatomy of the venous system of each individual patient, the relationship of veins to other superficial structures (fascia, arteries), the time of blood reflux, the extent of reflux along the trunk of the GSV; It became possible to study the functioning of perforating veins. The search for opportunities to minimize surgical trauma led to the idea of intravascular impact, which would distance the zone of trophic disorders from the impact zone. Sclerotherapy as a method of intravascular exposure to chemicals appeared after the invention of the syringe in 1851 by Charles-Gabriel Pravaz. Pravets administered iron sesquichloride to obtain aseptic phlebitis, other doctors administered chloral hydrate, carbolic acid, iodine tannin solution, and soda solutions. In 1998-1999, the first reports by Bone C. appeared on the clinical intravascular use of a diode laser (810 nm) for the treatment of chronic venous diseases.
The prevalence of varicose veins is unusually wide. According to various authors, up to 89% of women and up to 66% of men from the population of developed countries have its symptoms to one degree or another. A large study carried out in 1999 in Edinburgh[1] showed the presence of varicose veins of the lower extremities in 40% of women and 32% of men. An epidemiological study conducted in 2004 in Moscow[2] demonstrated that 67% of women and 50% of men have chronic diseases of the veins of the lower extremities. A study conducted in 2008 in another region of the Russian Federation - on the Kamchatka Peninsula - demonstrated a similar situation: chronic diseases of the veins of the lower extremities were more common in women (67.5%) than in men (41.3%)[3]. Increasingly, there are reports of this pathology being detected in schoolchildren.
Formation of varicose veins. A normally functioning vein without pathology of the venous valves (A). Varicose veins with a deformed valve, impaired blood flow, and thin, stretched vein walls (B).
The trigger mechanism in the development of varicose veins is considered to be a disruption of the normal functioning of the venous valves with the occurrence of reverse flow (reflux) of blood. At the cellular level, this is due to an imbalance in the physiological balance between muscle cells, collagen and elastic fibers of the venous wall.
At the initial stage, in the presence of genetic risk factors and provoking circumstances (for example, prolonged standing), a slowdown in venous blood flow occurs. In this case, the so-called shear-stress parameter changes, which is a set of indicators of blood movement through the vessel, to which the endothelium reacts. Endothelial cells respond to these changes and initiate a mechanism known as leukocyte rolling.
Due to interactions that have not yet been sufficiently studied, leukocytes rush to the endothelium and “roll” along its surface. If the provoking factor acts for a long time, then the leukocytes are firmly fixed to the endothelial cells, thereby activating the process of inflammation. This process of inflammation spreads along the venous bed of the lower extremities, causing and combining with dysfunction of endothelial cells, and then damage to the full thickness of the venous wall. This process occurs especially quickly in venous valves, which are subject to constant mechanical stress.
Typically, valves that are subject to maximum mechanical stress are the first to be affected.[4] In this case, pathological discharge of blood occurs through the mouth of the great and small saphenous veins, sometimes through large perforating veins. Excessive blood volume arising in the superficial veins gradually leads to overstretching of the venous wall. The total volume of blood contained in the superficial venous bed of the lower extremities increases. This increased blood volume continues to drain into the deep system through the perforating veins, overstretching them. As a result, dilatation and valvular insufficiency occur in the perforating veins.
Now, during operation of the muscular venous pump, part of the blood is discharged through incompetent perforating veins into the subcutaneous network. So-called “horizontal” reflux appears. This leads to a decrease in the ejection fraction during the “systole” of the muscular venous pump and the appearance of additional volume in the superficial bed. From this moment on, the work of the muscular venous pump loses its effectiveness.
Dynamic venous hypertension occurs - when walking, the pressure in the venous system ceases to decrease to the levels necessary to ensure normal blood perfusion through the tissues. Chronic venous insufficiency occurs. First, swelling appears, then, along with the fluid, blood cells (erythrocytes, leukocytes) penetrate into the subcutaneous tissue. Lipodermatosclerosis and hyperpigmentation occur. With further persistence and deepening of microcirculation and blood stasis disorders, skin cells die and a trophic ulcer occurs.
The leading symptom of varicose veins is the expansion of the saphenous veins, which is why the disease got its name. Varicose veins usually appear at a young age, and in women - during or after pregnancy. In the initial stages of the disease, few and very nonspecific symptoms appear. Patients are concerned about a feeling of heaviness and increased fatigue in the legs, bloating, burning and sometimes night cramps in the calf muscles.[5] One of the common symptoms that appears at the very beginning of the disease is transient swelling and pain along the veins (often not yet dilated). With varicose veins of the legs, there is slight swelling of the soft tissues, usually in the feet, ankles and lower legs. This whole symptom complex differs so much from patient to patient that practically the only successful name for it should be recognized as “heavy legs syndrome” (not to be confused with “restless legs syndrome”). The presence of this syndrome does not necessarily predispose to subsequent varicose veins. However, the majority of patients with varicose veins of the lower extremities at the onset of the disease noted any of the listed symptoms. All these symptoms are usually more pronounced in the evening, after work, or during prolonged standing, especially in hot weather.
The disease develops slowly - over years, and sometimes decades. Subsequently, the listed subjective symptoms are joined by swelling that regularly appears in the evening and disappears in the morning. Swelling is first observed in the ankles and dorsum of the foot, and then spreads to the lower leg. When such edema appears, one should speak of developed chronic venous insufficiency. The skin color takes on a bluish tint. If patients at this stage do not receive the necessary treatment, a certain part of them develop hyperpigmentation of the skin of the legs and lipodermatosclerosis. In more advanced cases, trophic ulcers occur.
It is not varicose veins that are dangerous, but the thrombophlebitis that appears against its background. Thrombophlebitis (inflammation of the inner wall of a vein) leads to the formation of blood clots, which can block the lumen of the vein with the formation of phlebothrombosis, and also, breaking away from the vessel wall, enter the lungs through the inferior vena cava system. In this case, pulmonary embolism may occur, which is a serious complication and sometimes ends in death. There are a number of therapeutic measures aimed at preventing this condition (for example, a vena cava filter), but they must begin with a consultation with a phlebologist and a blood clotting study.
The most pathogenetically substantiated is the classification proposed in 2000 in Moscow at a meeting of leading domestic specialists in the field of venous pathology [6]. This classification takes into account the form of the disease, the degree of chronic venous insufficiency and complications caused directly by varicose veins.
Forms of varicose veins
Based on the experience of treating tens of thousands of patients, the main clinical signs of chronic diseases of the veins of the lower extremities were selected. These signs were arranged into 6 clinical classes (“C”), in increasing severity (rather than stages), from telangiectasias (TAE) to trophic ulcers. In addition to the clinical part, an etiological section (“E”) has appeared, indicating whether the process is primary or not. The third, anatomical part of the classification (“A”) divided the entire venous system of the lower extremities into 18 relatively separate segments. This allows you to accurately indicate the location of the lesion in the venous system of the lower extremities. The last, pathophysiological section (“P”) indicates the presence of reflux and/or obstruction in the affected venous segment. In 2004, this classification was refined[7] and recommended for use in phlebological practice throughout the world. Undoubtedly, the negative side of the Cear classification is its cumbersomeness. It is very difficult, and sometimes impossible, to keep all 40 points in memory.
I. Clinical classification. (WITH)
II. Etiological classification (E)
iii. Anatomical classification (A)
IV. Pathophysiological classification.
V. Clinical scale (scoring).
VI. Disability scale
To facilitate the perception and use of this classification, the concepts of “basic” ceap and “extended” ceap are introduced. The first means an indication of the clinical sign with the greatest significance, an indication of the cause, an anatomical indication of one of the three venous systems, and an indication of the leading pathophysiological sign. The extended version indicates absolutely all the indicators that a given patient has. In addition, it is advisable to indicate the clinical level of examination in the diagnosis:
The date of the examination must also be indicated. Thus, the diagnosis: Varicose veins. Varicose veins of the right lower limb with reflux along the great saphenous vein to the knee joint and perforating veins of the leg. hvn 2 is encrypted as follows:
Varicose veins of the lower extremities are a surgical disease, so radical treatment is possible only by surgical methods. People with risk factors and a hereditary predisposition to varicose veins need to consult a phlebologist once every 2 years with a mandatory ultrasound examination of the veins.
Phlebectomy is a surgical procedure to remove varicose veins. Modern phlebectomy is a combined intervention and includes three stages:
Endovasal (endovenous) laser coagulation (obliteration) of varicose veins (evlk, evlo) is a modern minimally invasive method of treating varicose veins. The method does not require incisions or hospitalization.
Radiofrequency coagulation (ablation) of varicose veins (rchk, rcha) is a method of endovenous treatment of varicose veins of the saphenous veins of the lower extremities, the purpose of which is to eliminate reflux through the great and/or small saphenous vein. The procedure for radiofrequency coagulation of varicose veins is performed under ultrasound guidance, under local anesthesia, without incisions and without hospitalization.
A modern method of eliminating varicose veins consists of injecting a special drug into the vein that “glues” the vein. Sometimes it is performed under ultrasound control.
Conservative treatment of varicose veins should not be opposed to surgical treatment. It is used in conjunction with it, complementing it. It is used as the primary treatment when surgery is not possible. Conservative treatment does not lead to a cure for varicose veins, but they help improve well-being and can slow down the rate of progression of the disease. Conservative treatment is used:
The main objectives of conservative treatment of varicose veins are:
Compression treatment of chronic venous insufficiency has ancient roots; it is known that Roman legionnaires used bandages made of dog skin, which were used to tighten the calves of the legs during long marches to prevent swelling of the legs and bursting pain. The leading component in the conservative treatment program is compression treatment. Its effectiveness has been confirmed by numerous studies. The effect of compression treatment is multicomponent and consists of the following:
Depending on the nature of the pathology and the goals pursued, compression treatment can be used for a limited or long period. In clinical practice, elastic bandages and compression hosiery are most often used for compression treatment. Despite the widespread use of the latter, elastic bandages have not lost their importance. Bandages with short and medium stretch are most often used. Medium stretch bandages are used in the treatment of varicose veins, when for one reason or another it is impossible to use compression stockings. They create a pressure of about 30 mmHg. Art. both in a standing and lying position. Short stretch bandages create high “working” pressure in a standing position (40-60 mm Hg). The pressure in the supine position is significantly lower. They are used in the treatment of advanced forms, accompanied by edema, trophic disorders, even ulcers. Sometimes, when it is necessary to achieve an even higher “working” pressure, for example, with the development of lymphovenous insufficiency, as well as trophic ulcers, a so-called elastic bandage is used. It involves the simultaneous use of bandages of varying degrees of extensibility. The pressure created by each bandage is summed up. An elastic bandage is wound from the base of the fingers, and the heel is necessarily bandaged. Each round of the bandage should cover the previous one by about 1/3. When choosing products such as stockings, tights or knee socks for compression therapy, it must be remembered that compression bandages must clearly correspond to the individual parameters of the patient. It is also necessary to take into account that different manufacturers offer their own measurement schemes. But the tables for determining the size of compression hosiery are always based on the circumference lengths of the ankle, shin and upper third of the thigh.
Medicines for the treatment of varicose veins must meet the following criteria:
Phlebotropic drugs used today can be divided into several groups:
For the prevention and treatment of varicose veins, a correct lifestyle is important.
14 Feb 2015, 18:30 | Author: admin
… the fate of a patient with acute venous thrombosis largely depends on timely and objective diagnosis, competent therapeutic and preventive measures.
The following factors can serve as triggers for ileofemoral thrombosis . trauma, bacterial infection, prolonged bed rest, postpartum period, contraceptives, disseminated intravascular coagulation. The causes of deep vein thrombosis of the lower extremities can be benign and malignant formations, mainly of the pelvis, as well as aneurysms of the abdominal aorta, iliac and femoral arteries, popliteal cysts, and the pregnant uterus. Among malignant tumors, cancer of the sigmoid colon, ovary, kidney and adrenal gland, pancreas, cervix or retroperitoneal sarcoma predominates. Other causes include retroperitoneal fibrosis and iatrogenic venous injury.
In the clinical course of acute ileofemoral thrombosis, a prodromal stage and a stage of pronounced clinical manifestations are distinguished. In peripheral paths of development, unlike the central one, there is no prodromal stage as such.
The prodromal stage is manifested by increased temperature and pain of various localizations. Pain can occur in the lumbosacral region, lower abdomen and in the lower limb on the affected side. More often, pain in one location or another begins gradually and is dull, aching in nature.
The stage of severe clinical manifestations is characterized by the classic triad: pain, swelling and discoloration. The fighting becomes intense, diffuse, covering the groin area, anteromedial surface of the thigh and calf muscle. The swelling is widespread, affecting the entire lower limb from the foot to the inguinal fold, sometimes spreading to the buttock and is accompanied by a feeling of fullness and heaviness in the limb. Compression of arterial vessels by edematous tissues and their spasm are the cause of acute ischemia of the limb, expressed in sharp pain in its distal parts, impaired sensitivity in the foot and lower third of the leg, absence of pulsation of the artery, starting from the popliteal and sometimes femoral level.
Changes in skin color can vary from pale (white sore phlegmasia, phlegmasia alba dolens) to cyanotic (blue sore phlegmasia, phlegmasia coerulea dolens). White painful phlegmasia occurs due to spasm of the accompanying arteries and is accompanied by pain. Blue painful phlegmasia is secondary to white phlegmasia. It occurs when there is almost complete disruption of the outflow of blood through the femoral and iliac veins due to their occlusion. Strengthening the “pattern” of the saphenous veins on the thigh, and especially in the groin area, is a very informative and important symptom.
The general condition does not suffer much. Therefore, if the development of acute ileofemoral thrombosis is accompanied by a sharp deterioration in general condition, then it is most often associated with some complication - incipient venous gangrene, thrombosis of the inferior vena cava, pulmonary embolism.
The diagnosis of acute phlebothrombosis of the deep veins of the lower extremities, including ileofemoral thrombosis, can be confirmed by the following main methods of special diagnostics: duplex (triplex) scanning; radiopaque descending or ascending venography; radionuclide phlebography Tc99m in case of intolerance to radiocontrast agents, scanning with fibrinogen labeled I131.
Differential diagnosis should be made with occlusive arterial diseases and erysipelas. Edema of the limb, characteristic of deep venous thrombosis, is possible with chronic lymphostasis (elephantiasis), cellulite, contusion of the calf muscle or rupture of the tendons of the foot. A calf muscle contusion or torn tendon in the foot can cause swelling, pain, and tenderness in the area. The acute onset of symptoms during exercise and ecchymosis in the calf area confirm the muscular origin of these symptoms.
In some cases, venography is required to establish the correct diagnosis to avoid unnecessary anticoagulant therapy and hospitalization. Bilateral lower extremity edema is usually due to cardiac or renal failure or hypoalbuminemia. In addition, pain can be caused by peripheral neuritis, lumbosacral radiculitis, arthritis and bursitis. If the patency of the arteries of the lower extremities is impaired, pain also occurs, but without swelling and dilatation of the superficial veins.
Principles of Therapy . All patients are prescribed treatment in a surgical (angiosurgical) hospital. The patient must be transported to the hospital in a lying position; bed rest is required before the examination. In cases where there are no conditions for a full examination of patients (ultrasound scanning, phlebography), they should be prescribed anticoagulants while the patient remains in bed for 7-10 days. For the treatment of acute venous thrombosis, three main groups of drugs are used: anticoagulants; fibrinolytics and thrombolytics; disaggregants.
Low molecular weight heparins, unfractionated heparin and fondaparinux pentasaccharide are used for anticoagulant therapy. With thrombolysis (streptokinase or urokinase), there is one problem - the incidence of bleeding and mortality increases. In addition, recanalization occurs only in 1/3 of cases. Therefore, thrombolysis is used only in exceptional cases - for example, in young people (less than 50 years old) with recent (less than 7 days) widespread thrombosis.
Thrombolytic therapy for ileofemoral thrombosis is carried out only after installing a vena cava filter, as it promotes the migration of blood clots into the pulmonary artery with the development of its thromboembolism. The vena cava filter is shaped like an umbrella with holes for blood to pass through. The filter was installed in the infrarenal segment of the inferior vena cava by percutaneous insertion of a special device in which the vena cava filter is in a collapsed state. The guidewire together with the vena cava filter can be inserted through the jugular vein or femoral vein of the contralateral side. Recently, local thrombolysis has become relevant.
Surgical interventions for deep vein thrombosis, including ileofemoral thrombosis, are performed only for health reasons and directly depend on their embologenicity (danger of pulmonary embolism). Embologenic thrombosis (floating head of a thrombus) is surgically treated; surgical treatment is also used when there is a threat of venous gangrene and the spread of the thrombotic process to the inferior vena cava.
The type of operation depends on the location of the thrombosis. In this case, the operation is possible only on veins of medium and large diameter (popliteal, femoral, iliac, inferior vena cava). Operations can be used to remove a blood clot, apply an arteriovenous shunt, install a vena cava filter, etc. Some operations, in addition to preventing the upward spread of thrombosis, also aim to remove thrombotic masses. However, radical thrombectomy is feasible only in the early stages of the disease, when thrombotic masses are not firmly fixed to the intima of the vessel.
Retrograde removal of a thrombus from the left iliac veins through a phlebotomy opening in the femoral vein is not always feasible due to its compression by the right iliac artery, the presence of intravascular septa and adhesions in the lumen of the common iliac vein. Thrombectomy from the right iliac veins is associated with the risk of pulmonary embolism.
Bypass operations have not become widespread due to the complexity of the technique and frequent thrombosis. When thrombectomy from the iliac vein requires careful adherence to measures to prevent pulmonary embolism - insertion of a second obturator balloon from the healthy side into the inferior vena cava with a closed method of operation or application of a provisional tourniquet to the vena cava with an open method.
Published by Laesus De Liro March 26, 2010, 2:02:04 pm · 0 Comments · 34176 Reads ·
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Varicose veins of the lower extremities pregnancy
Varicose veins of the lower extremities are dilation and lengthening of the saphenous veins of the legs as a result of pathological changes in their walls and valve apparatus, which are persistent and irreversible.
The incidence is 3 per 1000 pregnant women, which is 5–6 times more common than in non-pregnant women. In 80%, varicose veins appear for the first time during pregnancy. During pregnancy, thrombophlebitis of the superficial veins and deep vein thrombosis of the lower extremities are most often observed.
I82 Embolism and thrombosis of other veins.
O22 Venous complications during pregnancy.
O22.0 Varicose veins of the lower extremities during pregnancy.
International classification for assessing the state of the venous system CEAP:
• “C” (Clinical signs - clinical classification) - based on objective clinical signs with the addition: A - for asymptomatic and C - for symptomatic.
• “E” (Etiologic classification - etiological classification) - takes into account congenital primary and secondary disorders.
• “A” (Anatomic distribution - anatomical classification) – characterizes the anatomical localization of venous lesions (superficial, deep or perforating veins).
• “P” (Pathophysiologic dysfunction - pathophysiological classification) - based on the assessment of venous dysfunction - caused by reflux, obstruction or a combination of these factors.
Predisposing factors for the development of varicose veins of the legs during pregnancy include:
• compression of the inferior vena cava and iliac veins by the pregnant uterus;
• increased venous pressure;
• slowing down blood flow in the vessels of the legs.
The occurrence of varicose veins of the legs during pregnancy is facilitated by:
• weakness of the vascular wall as a result of disruption of the structure and function of connective tissue and smooth
• damage to the endothelium and valve apparatus of veins;
In the anamnesis, pregnant women with varicose veins of the lower extremities most often have :
• violation of fat metabolism;
• disorders of the blood coagulation system;
• long-term use of oral contraceptives;
• pregnancy complications (preeclampsia, anemia);
• long bed rest.
Inspection and palpation of varicose, deep and main veins of the legs.
Determination of the state of the blood coagulation system at 16–18 weeks, 28–30 weeks, 36–38 weeks, including :
• soluble complexes of fibrin monomers;
To diagnose the condition of leg veins in pregnant women, the following instrumental research methods are used:
• Ultrasound examination of leg veins with determination of:
G the size of the lumen of the main venous vessels;
G presence or absence of reflux.
G to assess the patency of deep veins;
G to detect the presence and location of blood clots;
G to identify areas of reflux in perforating veins and anastomoses.
Differential diagnosis is carried out with the following diseases:
• acute thrombosis of deep veins of the legs;
• chronic arterial insufficiency.
• osteoarthritis and polyarthritis.
INDICATIONS FOR CONSULTATION WITH OTHER SPECIALISTS
In case of severe varicose veins and the development of complications, consultation with a vascular surgeon or
• Prevent the development of thromboembolic complications.
Hospitalization occurs when:
• deep vein thrombosis,
• Use compression hosiery of I–II compression class (elastic bandages, stockings or tights) daily during pregnancy, childbirth and the postpartum period.
As part of drug treatment, one of the drugs is prescribed:
• Aescusan♥ orally, 12–15 drops 3 times a day.
• Glivenol♥ orally in capsules 400 mg 2 times a day.
• Venoruton♥ orally in the form of capsules 300 mg 3 times a day with meals.
• Troxevasin♥ orally in the form of capsules 300 mg 3 times a day.
• Detralex♥ orally, 1 tablet 2 times a day.
For symptoms of hypercoagulation and disseminated intravascular coagulation, the following anticoagulants are used:
• Heparin subcutaneously 5000–10000 units per day, 3–5 days.
• Fraxiparine 2850 IU (0.3 ml in a syringe) per day, up to 5–7 days.
• Fragmin♥ 2500–5000 IU (0.2 ml in a syringe) per day, up to 5–7 days.
Antiplatelet agents are also used in treatment:
• Dipyridamole orally at a dose of 25 mg 1 hour before meals 2-3 times a day.
• Acetylsalicylic acid 60–80 mg per day at a time.
Surgical treatment is carried out in case of development of thromboembolic complications (deep vein thrombosis,
thrombophlebitis proximal to the upper third of the thigh).
TIMELINES AND METHODS OF DELIVERY
The method of delivery depends on the obstetric situation. Preferable delivery through the natural birth canal. During childbirth, the use of elastic compression (leg bandaging, stockings) is mandatory. 2 hours before the birth of the child, regardless of the method of delivery, it is advisable to administer 5000 units of heparin.
ASSESSMENT OF TREATMENT EFFECTIVENESS
To assess the effectiveness of treatment, Doppler sonography and angioscanning are used to determine the nature of the venous blood flow of the lower extremities.
The prognosis for life is favorable.
THROMBOPHLEBITIS OF SUPERFICIAL VEINS
Thrombophlebitis is a disease of the veins characterized by inflammation of their walls and thrombosis.
O22.2 Superficial thrombophlebitis during pregnancy.
A pregnant woman complains of moderate pain when walking. Along the vein, a painful dense infiltrate in the form of a cord is palpated. Above the infiltrate there is hyperemia of the skin and thickening of the subcutaneous fatty tissue. The body temperature rises to low-grade levels, and the pulse quickens.
Diagnosis of thrombophlebitis of the superficial veins is based on an assessment of complaints and anamnesis, the results of a clinical examination, data from laboratory and instrumental studies.
The history of a pregnant woman with thrombophlebitis of the superficial veins most often includes:
• profession associated with long periods of standing;
• disorders of the blood coagulation system;
• long-term use of combined oral contraceptives;
The superficial veins of the legs are examined and palpated.
A general blood test is performed, which reveals moderate leukocytosis with a shift of the leukocyte formula to the left, the ESR is slightly increased. The state of the coagulation system is determined and the following indicators are assessed:
G the size of the lumen of the venous vessels;
G vein patency;
G nature of venous blood flow;
G to assess venous patency;
G to determine the consistency of the valve apparatus;
G to detect the presence and location of blood clots.
If the results of this study are negative, and the clinical picture does not allow deep vein thrombosis to be excluded, then venography is performed.
Before starting treatment, it is advisable to consult with a vascular surgeon to decide on the possible hospitalization of the pregnant woman in the appropriate department of a multidisciplinary hospital.
EXAMPLE OF FORMULATION OF DIAGNOSIS
Pregnancy 32 weeks. Thrombophlebitis of the superficial veins of the right leg.
Restoration of venous outflow of blood in the superficial veins of the lower extremities.
In the presence of thrombosis in the lower leg and lower third of the thigh, cold is prescribed as local therapy for the first 2-3 days, ointment applications (ointments with sodium heparin, troxerutin or phenylbutazone), elastic compression of the legs and their elevated position.
As drug therapy, use phenylbutazone 0.15 g orally three times a day with or after meals, rheopirin ♥ 5 ml intramuscularly, xanthinol nicotinate orally 0.15 g three times a day, acetylsalicylic acid orally 0.125 g per day , diphenhydramine 0.05 g orally or other antihistamines (promethazine 0.025 g orally, chloropyramine 0.025 g orally, clemastine ♥ orally 0.001 g twice a day). To improve microcirculation and provide a phlebodynamic effect, use troxerutin 5 ml of a 10% solution intramuscularly or 0.3 g three times a day orally, escin 12-15 drops before meals three times a day. In case of severe thromboembolic complications in the anamnesis, as well as in case of pathological hypercoagulation confirmed by hemostasiogram, it is possible to prescribe sodium heparin 2500–5000 IU subcutaneously or low molecular weight heparins (nadroparin calcium, enoxaparin sodium, dalteparin sodium) 1–2 times a day subcutaneously under the control of the coagulation state blood systems. According to current international recommendations, low molecular weight heparins are the drugs of choice for pregnant women, taking into account their effectiveness and safety compared to unfractionated heparin.
In the case of ascending thrombophlebitis of the great saphenous vein, due to the risk of thromboembolism, ligation of the great saphenous vein of the thigh should be performed in the area where it flows into the femoral vein (Troyanov-Trendelenburg operation).
INDICATIONS FOR HOSPITALIZATION
Hospitalization is indicated in the presence of superficial vein thrombophlebitis and the development of associated complications, including ascending thrombophlebitis of the great saphenous vein, deep vein thrombosis, and pulmonary embolism.
ASSESSMENT OF TREATMENT EFFECTIVENESS
The criterion for the effectiveness of treatment is the restoration of blood flow through the affected vessels, which is determined using Doppler measurements.
CHOICE OF DATE AND METHOD OF DELIVERY
If there is an effect from the treatment of thrombophlebitis of the superficial veins of the lower extremities, in the absence of other contraindications and with an appropriate obstetric situation, vaginal delivery is possible
birth canal. Management of childbirth does not differ from that during the physiological course of pregnancy. During childbirth and the postpartum period, elastic compression of the legs (leg bandaging, stockings) is used. 2 hours before the baby is born, it is advisable to administer 5000 units of heparin or low molecular weight heparin.
The Moscow Center for the International Classification of Diseases, collaborating with the West, took a direct part in the preparation of the next 10th revision of B, using in this work the experience of specialists from the leading clinical institutes and their proposals for adapting this international document to the practice of medical institutions in Russia. B has become the international standard diagnostic for all general epidemiological purposes and many health management purposes. You can help the project by adding to it. The letter U is left vacant as a reserve. Thus, possible code numbers extend from A00. In both cases, the primary location is considered unknown. Consciousness and the ability to concentrate are also often reduced, but obvious impairment of intelligence and memory does not always occur. Four-Digit Subcategories Most three-character categories are subdivided by the fourth digit after the decimal point to allow for up to 10 additional subcategories. The direction of change usually depends on the nature of the individual before the disease. In the Russian Federation, B has another specific goal.
According to the ICD-10 code for expanding self-financing, its users have a natural concern about the ICD-10 code in the process of its revision. Factory B Periodic sleeves B, looking at the Ninth revision in Shatuny The classification is divided into 21 supervision.
When used in combination with inducers of liver microsomal conjectures, phenobarbital, carbamazepine, phenytoin, rifampicin, ICD-10 code, nevirapine, zfavirenz intensifies the metabolism of the genital organs, which can lead to a decrease in the flow of the drug.
In two cases, the primary location is considered unknown. ICD-10 code Four subscriptions I, II, XIX and ICD-10 code more than one woman in the first character of their codes. Sabers C76-C80 include court neoplasms code ICD-10 ill-defined by x-ray localization or those divided as code ICD-10 or spread without collision to the primary location.
Russian resistance B-10 prof. The effect of semi-synthetic penicillins and chloramphenicol wears off.
Deep vein thrombosis of the lower extremities is the formation of one or more blood clots within the deep veins of the lower extremities or pelvis, accompanied by inflammation of the vascular wall. May be complicated by impaired venous outflow and trophic disorders of the lower extremities, phlegmon of the thigh or lower leg, as well as pulmonary embolism • Phlebothrombosis - primary thrombosis of the veins of the lower extremities, characterized by fragile fixation of the blood clot to the vein wall • Thrombophlebitis - secondary thrombosis . caused by inflammation of the inner lining of the vein (endophlebitis). The thrombus is firmly fixed to the wall of the vessel • In most cases, thormbophlebitis and phlebothrombosis are combined: pronounced phenomena of phlebitis are found in the zone of primary thrombus formation, i.e., the head of the thrombus, while in the zone of its tail there are no inflammatory changes in the vascular wall.
Trauma • Venous stasis caused by obesity, pregnancy, pelvic tumors, prolonged bed rest • Bacterial infection • Postpartum period • Taking oral contraceptives • Oncological diseases (especially cancer of the lungs, stomach, pancreas) • DIC.
A “red” thrombus, formed during a sharp slowdown in blood flow, consists of red blood cells, a small amount of platelets and fibrin, attached to the vascular wall at one end of the thrombus, its proximal end floating freely in the lumen of the vessel • The most important feature of thrombus formation is the progression of the process: blood clots reach a large length along the length of the vessel • The head of the thrombus, as a rule, is fixed at the valve of the vein, and its tail fills all or most of its large branches • In the first 3–4 days, the thrombus is weakly fixed to the vessel wall, detachment of the thrombus and pulmonary embolism is possible • After 5– After 6 days, inflammation of the inner lining of the vessel occurs, which contributes to the fixation of the blood clot.
• Deep venous thrombosis (confirmed by venography) has classic clinical manifestations in only 50% of cases.
• The first manifestation of the disease in many patients may be PE.
• Complaints: a feeling of heaviness in the legs, bursting pain, persistent swelling of the lower leg or the entire limb.
• Acute thrombophlebitis: increased body temperature to 39 ° C and above.
• Local changes • Pratt's symptom: the skin becomes glossy, the pattern of the saphenous veins clearly protrudes • Payr's symptom: pain spreads along the inner surface of the foot, leg or thigh • Homans' symptom: pain in the lower leg when dorsiflexing the foot • Lowenberg's symptom: pain when the lower leg is compressed by a cuff device for measuring blood pressure at a value of 80–100 mm Hg. Art. while compression of the healthy lower leg is up to 150–180 mm Hg. Art. does not cause discomfort • The affected limb feels colder to the touch than the healthy one.
• With thrombosis, mild peritoneal symptoms and sometimes dynamic intestinal obstruction are observed.
Instrumental studies • Duplex ultrasound angioscanning using color Doppler mapping is the method of choice in diagnosing thrombosis below the level of the inguinal ligament. The main sign of thrombosis . detection of echo-positive thrombotic masses in the lumen of the vessel. Echodensity increases as the “age” of the thrombus increases • The valve leaflets cease to differentiate • The diameter of the affected vein increases by 2–2.5 times compared to the contralateral vessel, the vein stops responding to compression by the sensor (a sign that is especially important in the first days of the disease, when the thrombus visually indistinguishable from the normal lumen of the vein) • Non-occlusive parietal thrombosis is clearly identified by color mapping - the space between the thrombus and the vein wall is painted blue • The floating proximal part of the thrombus has an oval shape and is located centrally in the lumen of the vessel • X-ray contrast retrograde iliocavagraphy is used in cases when thrombosis extends above the projection of the inguinal ligament, since ultrasound of the pelvic vessels is difficult due to intestinal gas. The catheter for administering the contrast agent is inserted through the tributaries of the superior vena cava. During angiography, it is also possible to implant a cava filter • Scanning using 125I - fibrinogen. Serial scanning of both lower extremities is performed to determine whether radioactive fibrinogen is included in the blood clot. The method is most effective for diagnosing thrombosis of the veins of the leg.
Cellulitis • Rupture of a synovial cyst (Baker's cyst) • Lymphedema (lymphedema) • Compression of a vein from the outside by a tumor or enlarged lymph nodes • Stretching or tearing of muscles.