Venous & Lymphatic System Disorders/Tumours Flashcards
(25 cards)
What is a Varicose vein?
- a vericose vein is an enlarged and tortuous vein
- results from chronic increased intraluminal pressure
What is the most common sites for Varicose Veins?
- Superficial Saphenous veins (most common)
- Distal Esophagus (Esophageal varices due to portal hypertension from Liver cirrhosis)
- Anorectal region (Hemorrhoids)
- Left scrotal sac (Varicocele)
What are Superficial Saphenous Vein Varicosities and risks?
- they are the most common type of varicosity seen
Risk Factors:
1. Age: incidence increases with age as veins get weaker
2. Sex: Women more than men due to hormonal factors/mensturatopm contribute to this
3. Heredity: inherited structural defects
4. Posture: standing increases venous pressure
5. obesity: increased intra-abdominal pressure
6. DVT: secondary to deep vein thrombosis
What is the pathogenesis of Superficial Saphenous Vein Varicosities?
- There is an increased intraluminal pressure causing a dilation of lumen and stretching of vein walls. This causes valves to become incompetent leading to the development of localized bulging and tortuosity = Varicose Vein
🔬 Pathogenesis
* Increased intraluminal pressure (e.g., due to prolonged standing, obesity, pregnancy) causes:
* Dilation of the lumen (the inside space of the vein)
* Stretching of the vein wall
* This leads to valve incompetence (valves don’t close properly), allowing blood to pool backward.
* The resulting localized bulging and tortuosity (twisting of the vein) produces varicose veins.
What are complications of Superficial Saphenous Vein Varicosities?
⚠️ Complications
1. Venous stasis → Congestion → Edema (swelling) → Pain
2. Persistent edema and congestion cause skin changes, such as:
* Stasis dermatitis (inflammatory skin condition from poor circulation)
* Ulceration, especially varicose ulcers (chronic non-healing wounds due to poor venous return)
❗ Important Note
* Embolism is not a complication of superficial vein varicosities.
(This differentiates it from deep vein thrombosis, where embolism is a serious risk.)
What is Stasis Dermatitis (Brawny Induration) and Varicose Ulcers?
🟠 Stasis Dermatitis (Top Half of Slide)
* Also called venous eczema, this is inflammatory skin disease caused by chronic venous stasis (poor blood return from the lower extremities).
* The term “brawny induration” refers to:
* Brownish discoloration of the skin (from hemosiderin deposition as red blood cells break down).
* Thickened and hardened skin (fibrosis from long-standing edema and inflammation).
🔴 Varicose Ulcers (Bottom Half of Slide)
* These are chronic, non-healing wounds resulting from prolonged venous insufficiency and pressure.
* Caused by tissue hypoxia and inflammation due to blood pooling in the superficial veins.
🧠 Pathophysiological Connection:
1. Venous hypertension (from valve incompetence in varicose veins) →
2. Interstitial fluid leaks into tissues →
3. Edema →
4. Inflammation and skin breakdown →
* Stasis dermatitis
* Varicose ulcers
What is Phlebothrombosis?
Definition: Thrombosis (clot formation) in a vein without significant inflammation of the vessel wall.
🔬 Pathogenesis – Follows Virchow’s Triad (with emphasis on 2 components):
1. Stasis of blood flow:
* Risk factors:
* Prolonged immobility (e.g., bedrest, post-op, long flights)
* Pregnancy
* Obesity
* Congestive heart failure (low-flow state)
2. Hypercoagulability:
* Genetic:
* Antithrombin III deficiency
* Factor V Leiden mutation
* MTHFR deficiency (linked with elevated homocysteine that leads to irritation of blood vessels and increased clot risk)
* Acquired:
* Oral contraceptive pills
* Cancer (e.g., adenocarcinoma → mucin-producing tumors cause thrombosis)
* Trousseau sign: Migratory thrombophlebitis – thrombi appear in different locations
📍 Location:
* Most commonly occurs in the deep veins of the calf (lower extremities).
What is Deep Venous Thrombosis? (DVT)
🔴 Deep Venous Thrombosis (DVT)
Definition: A form of phlebothrombosis that specifically affects deep veins, most commonly in the lower limbs.
🩺 Clinical Findings:
* Elevated D-Dimer: Indicates fibrin degradation (seen in DVT, PE, DIC)
* Swelling & bluish discoloration (from venous obstruction)
* Pain on calf compression or dorsiflexion of foot = Homan’s Sign (not very specific, but classically taught)
🫁 Major Complication:
* Pulmonary thromboembolism (PE): Most serious risk
* Clots break off → travel to lungs → block pulmonary arteries
* Often arise from femoral vein
🟢 Associated with:
* Deep venous insufficiency (chronic damage to valves post-DVT)
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🧠 Mnemonic: “SHE” for DVT Risk (Virchow’s Triad)
* Stasis
* Hypercoagulability
* Endothelial injury (more relevant in thrombophlebitis than phlebothrombosis)
Chronic failure of the deep venous valves to prevent backflow (reflux) of blood—often a consequence of DVT or prolonged venous hypertension.
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🔶 1. Stasis Dermatitis
* Mechanism: High venous pressure → capillary leakage → RBCs leak out → breakdown releases hemosiderin (iron pigment) → orange/brown discoloration, especially around ankles.
* Key point: This results from rupture of small veins (penetrating branches) due to chronic pressure.
* Symptoms: Itchy, inflamed, scaly skin over the medial lower leg.
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🔵 2. Superficial Vein Varicosities
* Mechanism:
* When deep veins are incompetent, blood gets shunted back into superficial veins through perforating veins.
* These superficial veins dilate and become tortuous (varicose) due to the increased pressure.
* These varicosities are prone to:
* Pain
* Swelling
* Ulceration in severe cases
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🧠 How They’re Connected:
DVI → ↑ venous pressure → both:
1. Capillary rupture and leakage → stasis dermatitis
2. Retrograde flow into superficial system → varicosities
Do both Superficial Saphenous Vein Varicosities and DVT have stasis dermatitis and superficial vein varicosities?
✅ What we see in Superficial Saphenous Vein Varicosities:
- Stasis Dermatitis
- Yes, it can occur here as well.
- Chronic venous hypertension in superficial veins (like the great saphenous) → capillary rupture → hemosiderin deposition → orange-brown skin discoloration, often around the medial ankle.
- Venous Ulcers
- Yes, particularly over the medial malleolus.
- Due to poor skin nutrition from venous stasis and local inflammation.
- Edema and Pain
- Common in superficial varicosities when longstanding.
- Caused by venous pooling and tissue congestion.
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❗ But important distinction:
* Superficial varicosities (like saphenous vein) are usually less dangerous than deep venous disease.
* They do not cause embolism (unlike DVT).
* But they can mimic deep venous insufficiency in symptoms due to venous hypertension in the superficial system.
What is Thrombophebitis?
🔴 Superficial Thrombophlebitis
Inflammation + thrombosis of a superficial vein, typically seen in the upper or lower limbs.
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🔬 Pathogenesis:
1. IV Cannulation:
* Mechanical trauma to the vein wall → endothelial damage → clot formation.
2. IV Drug Use:
* Direct trauma + infection, especially with Staphylococcus aureus → inflamed, thrombosed vein.
3. Pancreatic Cancer:
* Classically associated with Trousseau’s syndrome = superficial migratory thrombophlebitis.
* Tumor releases mucin → highly thrombogenic, causes clots in superficial veins at multiple changing sites.
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🧪 Clinical Findings:
* Pain, redness, and swelling along the superficial vein.
* Tender, firm, cord-like vein on palpation (classic).
* Localized erythema and warmth, sometimes low-grade fever if infected.
What is difference between Superficial Thrombophlebitis and Deep Vein Thrombosis?
What is Superior Vena Cava Syndrome?
- due to extrinsic compression of the SVC which can happen from:
1) Primary Lung Cancer (90% of cases)
2) Mediastinal Lymphoma (Hodgkin’s lymphoma)
Clinical findings:
- puffiness and blue to purple discoloration of the face, arms, and shoulders
- retinal hemorrhages
- stroke
- distended jugular vein
What is Inferior Vena Cava Syndrome? (IVC)
- it can be due to a compression of IVC by:
- neoplasm growth (gastric adenocardinoma)
- growth of certain tumours within IVC
- pregnancy
Clinical Findings:
- marked edema of the legs
- distension of veins of abdomen
🟠 Hepatocellular Carcinoma (HCC) — Liver Cancer
🔹 How it involves the IVC:
* The liver drains via the hepatic veins into the IVC.
* HCC can invade the hepatic veins and extend directly into the IVC.
* In advanced cases, tumor thrombus can reach all the way up to the right atrium.
⚠️ Complications:
* Budd-Chiari Syndrome (if hepatic vein outflow is blocked): Budd–Chiari Syndrome (BCS) is an Obstruction of hepatic venous outflow — anywhere from the small hepatic veins to the junction with the inferior vena cava (IVC).
🧬 Cause:
Blockage of hepatic venous drainage leads to:
* Liver congestion
* Increased sinusoidal pressure
* Ischemia and hepatocyte death
* Obstruction of venous return → ascites, hepatomegaly, lower extremity edema.
* Rarely, embolism or cardiac involvement.
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🔴 Renal Cell Carcinoma (RCC) — Kidney Cancer
🔹 How it involves the IVC:
* The renal veins drain directly into the IVC.
* RCC is notorious for growing into the renal vein and extending as a tumor thrombus into the IVC.
* May propagate upward toward the heart (seen on imaging like CT/MRI).
⚠️ Complications:
* IVC obstruction → bilateral lower extremity edema.
* Varicocele (especially left-sided) due to compression of the left gonadal vein. A varicocele is an abnormal dilation of the pampiniform venous plexus (the network of veins draining the testicle), most commonly seen on the left side.
* Risk of pulmonary embolism from tumor thrombus fragments.
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📸 Classic Radiologic Signs:
* CT or MRI shows a filling defect or mass within the IVC.
What is Thoracic Outlet Syndrome?
🟠 Thoracic Outlet Syndrome (TOS)
✅ Definition:
Compression of the neurovascular bundle (brachial plexus, subclavian artery, and/or subclavian vein) in the thoracic outlet — the space between the clavicle and first rib, extending into the axilla.
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⚙️ Causes:
1. Cervical rib (an extra rib arising from C7)
2. Spastic or hypertrophied anterior scalene muscle
3. Abnormal fibrous bands
4. Repetitive overuse (e.g., weightlifters, swimmers)
5. Trauma (e.g., whiplash injury)
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🩺 Clinical Findings:
✴️ Neurogenic TOS (most common type):
* Paresthesia (tingling), numbness, and pain in the entire upper extremity or hand
* Often nocturnal symptoms
* Weakness or atrophy of hand muscles in chronic cases
* Pain in supraclavicular region, shoulder, neck, or occipital area (can mimic cervical radiculopathy)
🔴 Vascular TOS:
* Compression of subclavian artery:
* Cold, pale hand
* Diminished radial pulse
* Compression of subclavian vein:
* Swelling
* Venous distention
* Cyanosis of the arm
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🧪 Physical Exam Signs:
✅ Adson’s Test:
* Patient extends neck, turns head to affected side, and takes a deep breath
* Positive if radial pulse diminishes or disappears
→ Indicates compression of subclavian artery between scalene muscles.
What is Acute Lymphangitis?
✅ Definition:
Inflammation of the lymphatic vessels, usually due to bacterial infection spreading from a distal site of skin or soft tissue infection.
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🦠 Cause:
* Most commonly:
→ Streptococcus pyogenes (Group A Strep)
→ Occasionally Staphylococcus aureus
* Typically begins with:
* Cellulitis
* Wound infection
* Skin abrasion or abscess
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🧬 Pathophysiology:
1. Bacteria from local infection invade lymphatic vessels.
2. Infectious agents are transported toward regional lymph nodes.
3. This leads to:
* Lymphangitis (inflamed vessels)
* Lymphadenitis (inflamed nodes)
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🩺 Clinical Presentation:
🌡️ Hallmarks of Lymphangitis:
* Tender subcutaneous red streaks extending up the limb from the site of infection.
* Streaks follow the path of superficial lymphatic vessels that are involved
* Painful regional lymph nodes may also be accompanied (sign of acute lymphadenitis).
* May also see:
* Fever, chills
* Malaise
* Localized edema
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🔍 Diagnosis:
* Clinical — based on appearance
* Labs may show elevated WBC count
* Rule out DVT or cellulitis alone in confusing cases
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💊 Treatment:
* Empiric antibiotics targeting streptococci:
* Penicillin, cephalexin, or clindamycin
What is Lymphedema?
✅ Definition:
A chronic condition caused by impaired lymphatic drainage, resulting in:
* Accumulation of protein-rich lymph fluid
* Chronic swelling
* Fibrosis and thickening of skin/subcutaneous tissues
⸻
🔍 Pathophysiology:
1. Obstruction or absence of lymphatic vessels
2. Leads to interstitial accumulation of lymph
3. Chronic stasis → triggers fibroblast proliferation and fat deposition
4. Skin thickens → classic “brawny” edema
⸻
🧪 Clinical Features:
* Persistent, non-pitting edema (early stages may be pitting)
* Most commonly affects limbs
* Overlying skin changes:
* Hyperkeratosis
* “Peau d’orange” (orange peel texture)
* In advanced cases: elephantiasis (massive swelling + fibrosis)
What is Strawberry Hemangioma?
🍓 Strawberry Hemangioma (Infantile Hemangioma)
✅ Definition:
* A variant of capillary hemangioma
* Benign vascular tumor seen in infants, especially newborns
🔬 Pathology:
* Composed of closely packed capillaries and proliferating endothelial cells
* Appears on skin, most commonly the face and scalp of new borns
🩺 Clinical Features:
* Bright red, raised, lobulated lesion
* Soft, compressible
* May look like a strawberry on the skin
* Appears a few days to weeks after birth
* Grows rapidly for 6–12 months, then involutes spontaneously
📊 Natural Course:
* Begins to regress between 1–3 years
* 80% fully resolve by age 8
* May leave mild skin changes (discoloration, atrophy)
💊 Management:
* Usually no treatment needed
What is difference between Capillary and Cavernous Hemangioma?
- Capillary Hemangioma
- Composed of small capillary-sized vessels
- Includes strawberry hemangioma
- Superficial, bright red
- Common in infants
- Often regress spontaneously
- they are composed of mature small capillary channels
- they can occur in the skin, mucuous membranes and visceral organs
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- Cavernous Hemangioma
- Composed of larger, dilated blood vessels
- Located deeper in the skin or internal organs (e.g. liver, brain)
- they are the most common benign tumour of the liver, spleen and placenta and may be associated with von Hippel-Lindau disease.
- Bluish hue, soft and compressible
- May not regress spontaneously
- Can cause mass effect if large
What is an Angiosarcoma?
- malignant proliferation of endothelial cells (these line blood vessels)
- Highly aggressive with early hematogenous spread (via blood)
- common sites include skin, breast, and liver (liver angiosarcoma is associated with exposure to polyvinyl chloride (PVC), arsenic, and thorotrast (radiological contrast material))
Clinical Findings:
- red papules or nodules
- become large flesht red-tan, grey
- blend into surrounding tissue (hard to define and remove)
What is Kaposi Sarcoma?
- low grade malignant proliferation of endothelial cells
- associared with HHV-8
- brownish/purple irregularly shaped nodules, macules and plaques on skin
- they may also involve visceral organs
Why is there no “Blanching” in Kaposi Sarcoma?
✅ What is blanching?
If you press on a red or purple skin spot, and it turns white temporarily, that’s called blanching.
* Why? You’re pushing the blood out of the blood vessels under your finger.
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🟥 Now, what does it mean if a spot doesn’t blanch?
That means:
* The red/purple color doesn’t go away when you press it.
* This means the blood isn’t inside normal vessels anymore — it’s either:
* Leaked out into the tissue (like a bruise or petechiae),
* OR the redness is caused by tumor cells (like Kaposi Sarcoma).
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🟣 Kaposi Sarcoma (KS):
* KS is a tumor, not a normal blood vessel.
* It has tumor tissue and leaked blood, so when you press on it:
* ❌ It doesn’t blanch (doesn’t turn white)
* ✅ Because the blood is outside vessels or part of solid tissue — not squeezed out
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🔁 In contrast:
* Hemangiomas = made of blood vessels → ✅ do blanch
* Rashes from allergy or inflammation = blood in vessels → ✅ do blanch
* Bruises, petechiae, KS = blood outside vessels or solid tumor → ❌ don’t blanch
What individuals more prone to Kaposi Sarcoma?
- older Eastern European males
- AIDS (AIDS can get HHV-8 infection in endothelial cells – give anti-retrovirals to kill HHV)
- Transplant patients
- Kaposi can cause brownish irregularly shaped macules and plaques on the skin of lower legs and feet and the mouth
What is a Simple Lymphangioma?
Benign
* Made of small lymphatic channels
* Common in skin (e.g., head, neck, axilla)
* Appears as small, soft, clear or skin-colored vesicles
What is Cavernous Lymphangioma? (Cystic Hygroma)
Larger and deeper form of lymphangioma
* Composed of dilated lymphatic channels
* Commonly found in neck and axilla of infants and children
* Associated with Turner Syndrome (45,X):
* Presents as puffy hands/feet at birth
* Cystic hygroma can cause webbed neck
* Soft, compressible, often transilluminates
