静脉性溃疡
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– Evidence supports topical cadexomer iodine for healing – No evidence supports use of systemic antibiotics
When should clinicians consider obtaining a biopsy or referring the patient to a surgical or nonsurgical specialist for diagnosis?
Venous leg ulcer
• Common causes of lower extremity ulcers
– – – – – – – – CVI Arterial insufficiency Diabetic neuropathy Prolonged pressure Trauma Inflammatory or metabolic conditions Cancer Infections
What symptoms and physical findings are suggestive of CVI?
• Swelling and aching of legs, worse at end of day and improved by leg elevation • History of ulcer recurrence, particularly at same location • Dependent edema, telangiectasias, varicose veins, reddish-brown pigmentation and purpura, and subsequent hemosiderin deposition • Eczematous changes with redness, scaling, pruritus • Smooth, ivory-white, stellate atrophic plaques of sclerosis with telangiectases (atrophie blanche) • Chronic lipodermatosclerosis (LDS) and acute LDS
What is the role of noninvasive tests, such as ankle-brachial index and duplex ultrasonography?
• Ankle-brachiLeabharlann Baidul index should be performed
– For PAD screening: concomitant arterial disease in ~20% – Compression therapy could worsen an arterial ulcer
Skeletal and joint disease of the lower extremities Compression stockings For primary and secondary prevention Venous intervention For secondary prevention
What other conditions should be considered during evaluation of a patient with possible VLU?
• Less common causes
What is the role of laboratory testing?
CVI is the leading cause of VLU
Venous hypertension with calf muscle pump dysfunction Manage comorbid risk factors
CVI, obesity, hypercoagulable states
Are there measures that can prevent VLU or their recurrence?
• Aggressive management of reversible risk factors
– Control of relevant comorbid conditions (CHF, PVD) – Healthy diet, appropriate exercise, weight control – Management of a hypercoagulable state
Some important points in Venous Leg Ulcers
Why do patients with chronic venous insufficiency develop VLU?
• CVI most common cause of VLU • VLU patients have venous hypertension, or abnormally sustained elevation of venous pressure on walking
• No single laboratory test is diagnostic • Testing may be indicated depending on specific patient history, comorbidities, and family history • In patients with history of recurrent ulceration or thrombosis, evaluate for hypercoagulable states
• Stockings that achieve at least 20-30 mm Hg pressure
– Patients should use highest level of compression tolerable
• Surgical venous ablation
CLINICAL BOTTOM LINE: Prevention...
– Severity of CVI correlates with decreased range of motion at ankle and is associated with peripheral neuropathy – VLU pain neuropathic in origin in some patient
CLINICAL BOTTOM LINE: Diagnosis...
Typically based on clinical history and physical examination Presence of CVI Single, painful ulcer with irregular, flat borders and granulating or fibrinous bed on medial lower third of legs
• Color duplex ultrasonography
– For accurate diagnosis and to provide prognostic info
• Photo and air plethysmography
– Whole-limb venous hemodynamics at rest and after exercise
• CT exam
– Intractable edema associated with pain despite compression
What is the role of routine testing for infection?
• Swab culture testing unwarranted w/o signs of infection • If atypical infection suspected: send tissue from wound biopsy for microscopic examination and culture • Use antibiotic therapy only for clinically infected ulcers
– Caused by vein valve reflux, outflow problems or both
• Venous outflow issues
– Venous obstruction – Poor function of calf muscle pump impairs venous system's ability to return venous blood to heart – Ankle movement limitations contribute to calf muscle pump failure
What are the risk factors for VLU?
• • • • • • • • • • Age older than 55 years Family history of CVI Ulcer history, parental history of ankle ulcers Higher body mass index History of pulmonary embolism Venous reflux in deep veins, history of superficial/DVT Lower extremities skeletal or joint disease Number of pregnancies Physical inactivity Severe lipodermatosclerosis
Chronic venous insufficiency
Atrophie blanche
What symptoms and physical findings suggest that VLU are due to CVI?
• • • • • • • VLU may be painful—dull, aching, or burning pain Location over medial lower third of the legs Usually 1 ulcer w/ irregular, flat, or only slightly steep borders Ulcer bed shallow, with granulation tissue or fibrinous material Wound surface rarely shows necrosis, exposed tendons, bone Venous dermatitis, LDS, or atrophie blanche around ankle Assessment: Test for neuropathy
Color duplex ultrasonography to characterize venous disease in all patients
Ankle-brachial index to exclude concurrent PAD If VLU do not improve within 4 weeks of active therapy: consider referral to specialist or biopsy
• To rule out other causes of VLU, especially cancer
– When ulcers are atypical-appearing ulcers – When ulcers have not healed after 4 weeks of active treatment
When should clinicians consider obtaining a biopsy or referring the patient to a surgical or nonsurgical specialist for diagnosis?
Venous leg ulcer
• Common causes of lower extremity ulcers
– – – – – – – – CVI Arterial insufficiency Diabetic neuropathy Prolonged pressure Trauma Inflammatory or metabolic conditions Cancer Infections
What symptoms and physical findings are suggestive of CVI?
• Swelling and aching of legs, worse at end of day and improved by leg elevation • History of ulcer recurrence, particularly at same location • Dependent edema, telangiectasias, varicose veins, reddish-brown pigmentation and purpura, and subsequent hemosiderin deposition • Eczematous changes with redness, scaling, pruritus • Smooth, ivory-white, stellate atrophic plaques of sclerosis with telangiectases (atrophie blanche) • Chronic lipodermatosclerosis (LDS) and acute LDS
What is the role of noninvasive tests, such as ankle-brachial index and duplex ultrasonography?
• Ankle-brachiLeabharlann Baidul index should be performed
– For PAD screening: concomitant arterial disease in ~20% – Compression therapy could worsen an arterial ulcer
Skeletal and joint disease of the lower extremities Compression stockings For primary and secondary prevention Venous intervention For secondary prevention
What other conditions should be considered during evaluation of a patient with possible VLU?
• Less common causes
What is the role of laboratory testing?
CVI is the leading cause of VLU
Venous hypertension with calf muscle pump dysfunction Manage comorbid risk factors
CVI, obesity, hypercoagulable states
Are there measures that can prevent VLU or their recurrence?
• Aggressive management of reversible risk factors
– Control of relevant comorbid conditions (CHF, PVD) – Healthy diet, appropriate exercise, weight control – Management of a hypercoagulable state
Some important points in Venous Leg Ulcers
Why do patients with chronic venous insufficiency develop VLU?
• CVI most common cause of VLU • VLU patients have venous hypertension, or abnormally sustained elevation of venous pressure on walking
• No single laboratory test is diagnostic • Testing may be indicated depending on specific patient history, comorbidities, and family history • In patients with history of recurrent ulceration or thrombosis, evaluate for hypercoagulable states
• Stockings that achieve at least 20-30 mm Hg pressure
– Patients should use highest level of compression tolerable
• Surgical venous ablation
CLINICAL BOTTOM LINE: Prevention...
– Severity of CVI correlates with decreased range of motion at ankle and is associated with peripheral neuropathy – VLU pain neuropathic in origin in some patient
CLINICAL BOTTOM LINE: Diagnosis...
Typically based on clinical history and physical examination Presence of CVI Single, painful ulcer with irregular, flat borders and granulating or fibrinous bed on medial lower third of legs
• Color duplex ultrasonography
– For accurate diagnosis and to provide prognostic info
• Photo and air plethysmography
– Whole-limb venous hemodynamics at rest and after exercise
• CT exam
– Intractable edema associated with pain despite compression
What is the role of routine testing for infection?
• Swab culture testing unwarranted w/o signs of infection • If atypical infection suspected: send tissue from wound biopsy for microscopic examination and culture • Use antibiotic therapy only for clinically infected ulcers
– Caused by vein valve reflux, outflow problems or both
• Venous outflow issues
– Venous obstruction – Poor function of calf muscle pump impairs venous system's ability to return venous blood to heart – Ankle movement limitations contribute to calf muscle pump failure
What are the risk factors for VLU?
• • • • • • • • • • Age older than 55 years Family history of CVI Ulcer history, parental history of ankle ulcers Higher body mass index History of pulmonary embolism Venous reflux in deep veins, history of superficial/DVT Lower extremities skeletal or joint disease Number of pregnancies Physical inactivity Severe lipodermatosclerosis
Chronic venous insufficiency
Atrophie blanche
What symptoms and physical findings suggest that VLU are due to CVI?
• • • • • • • VLU may be painful—dull, aching, or burning pain Location over medial lower third of the legs Usually 1 ulcer w/ irregular, flat, or only slightly steep borders Ulcer bed shallow, with granulation tissue or fibrinous material Wound surface rarely shows necrosis, exposed tendons, bone Venous dermatitis, LDS, or atrophie blanche around ankle Assessment: Test for neuropathy
Color duplex ultrasonography to characterize venous disease in all patients
Ankle-brachial index to exclude concurrent PAD If VLU do not improve within 4 weeks of active therapy: consider referral to specialist or biopsy
• To rule out other causes of VLU, especially cancer
– When ulcers are atypical-appearing ulcers – When ulcers have not healed after 4 weeks of active treatment