VENOUS STASIS ULCER

What are ulcers?

Chronic venous insufficiency (CVI) with ulceration is a common condition affecting 2-5% of the population. Ulcers are wounds or open sores that will not heal or keep returning. Historically, CVI was known as postphlebitic syndrome and postthrombotic syndrome, both of which refer to the aetiology of most cases. However, these names have been abandoned because they fail to recognize another common cause of the disease, the congenital absence of venous valves.

What are the symptoms of Ulcers?

Ulcers may or may not be painful. The patient generally has a swollen leg and may feel burning or itching. There may also be a rash, redness, brown discoloration or dry, scaly skin.

What are the types of leg and foot ulcers?

The three most common types of leg and foot ulcers include:

• Venous stasis ulcers
• Arterial (ischemic ulcers)
• Neurotrophic (diabetic)

Ulcers are typically defined by the appearance of the ulcer, the ulcer location, and the way the borders and surrounding skin of the ulcer look. 

Venous stasis ulcers - Appearance

Typically, these lesions occur around the inner side just above the ankle, where venous pressure is greatest due to the presence of large communicating veins. The base of a venous ulcer is usually red. It may also be covered with yellow fibrous tissue or there may be a green or yellow discharge if the ulcer is infected. Fluid drainage can be significant with this type of ulcer.

The borders of a venous ulcer are usually irregularly shaped and the surrounding skin is often discoloured and swollen. It may even feel warm or hot. The skin may appear shiny and tight, depending on the amount of oedema (swelling). The skin may also have brown or purple discoloration about the lower leg, known as "stasis skin changes."

Venous stasis ulcers are common in patients who have a history of leg swelling, long standing varicose veins, or a history of blood clots in either the superficial or the deep veins of the legs. Ulcers may affect one or both legs.

Venous ulcers affect 100,000 people in the UK every year and account for 80 to 90% of all leg ulcers.

What causes venous ulcers?

Risk factors associated with chronic venous insufficiency

• Age: Incidence of CVI rises substantially with age.
• Family history: History of deep vein thrombosis (DVT), which renders venous valves incompetent, causing backflow and increased venous pressure, is a risk factor.
• Lifestyle: A sedentary lifestyle minimizes the pump action of calf muscles on venous return, causing higher venous pressure. CVI occurs more frequently in women who are obese. Vocations that involve standing for long periods predispose individuals to increased venous pressure in dependent lower extremities. A higher incidence of CVI is observed in men who smoke.
• Diseases like diabetes and polyneuropathy

How are leg ulcers diagnosed?

Clinical history and inspection of venous ulcer

First, the patient's medical history is evaluated. Lack of appropriate clinical assessment of patients with limb ulceration in the community has often led to long periods of ineffective and often inappropriate treatment. It is therefore advisable that diagnosis of ulcers should be based on a thorough clinical history and physical examination, as well as appropriate laboratory tests and haemodynamic assessment. This will assist identification of both the underlying cause and any associated diseases and will influence decisions about prognosis, referral, investigation and management. If the practitioner is unable to conduct a physical examination, they must refer the patient to an appropriately trained professional.

Following may be indicative of venous disease

. family history

. varicose veins (record whether or not treated)

. proven deep vein thrombosis in the affected leg

. phlebitis in the affected leg

. suspected deep vein thrombosis (for example, a swollen leg after surgery, pregnancy, trauma or a period of enforced bed rest)

. surgery or fractures to the leg

. episodes of chest pain, haemoptysis, or history of a pulmonary embolus

Continue to Treatment of Ulcers

More information on functional testing for venous disease