Best Examination Tips: Medcase, Interesting Medical Cases and Pictures

  • Sunday, July 7th, 2013

Case 20/Picture 22 (23.11.2014.) Could you identify the picture?

Caput Medusae Dr Yaha Ali AlThammary, Facebook; 19.10.2014

Answer

Engorged collateral veins in inferior vena cava obstruction. (30.11.2014.)

Chronic obstructions of the inferior vena cava (IVC) are associated with many odd features. Even total occlusions may remain entirely silent or present late with acute symptoms. The unusual clinical features of IVC obstructions seem related to the rich collateralization, which has an embryonic basis. The most common obstructions of the inferior vena cava involve the lower third of the vessel. The azygos-hemiazygos and vertebral venous plexus systems play the most significant roles, while the superficial systems are less prominently involved. In upper level inferior vena cava obstruction, reestablishment of venous circulation is less developed, which usually leads to a poorer clinical outcome. Common iliac vein patency seems to be a crucial link in collateral function, and its concurrent occlusion produces symptoms.

Patients fall into three clinical groups: (1) asymptomatic, (2) acutely symptomatic, and (3) chronically symptomatic.

Asymptomatic group

Only transient or cosmetic symptoms with little functional impairment of the limb; limb, scrotal or abdominal varices; superficial thrombosis of the abdominal varix; mild transient leg swelling, transient groin pain, a transient ulcer.

Acute symptom group

Acute deep venous thrombosis of the lower extremity without prior leg symptoms, limb symptoms.

Chronic symptom group

Chronic limb symptoms (the majority).

Assessment

The degree of swelling is assessed by physical examination (grade 0, none; grade 1, pitting, not obvious; grade 2, ankle edema; and grade 3, obvious swelling involving the limb). The level of pain is measured by using the visual analogue scale.

Investigations

Duplex scan, ambulatory venous pressure measurement (percentage decrease; venous filling time), arm/foot pressure test, air plethysmography (VFI90), and contrast studies. A valve closure time of longer than 0.5 seconds on duplex scan is defined as reflux.

Management

IVC Stent,  iliac vein stents, saphenous ablation (radiofrequency or laser), heparin, warfarin, balloon dilatation to relieve focal stenoses compressing the stent.

Follow-up and outcome assessment

At 6 weeks and 3, 6, and 9 months after stent placement and at yearly intervals thereafter. Venography and venous laboratory tests are performed during the first 6 months after stent placement and then annually.

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