VENOUS STASIS ULCER
Venous stasis ulcers commonly occur in the legs due to venous insufficiency or poor venous blood drainage. Veins of the legs have valves in then which ensures a proper unidirectional flow of blood towards heart. In venous stasis, these valves are damaged, thus the venous blood accumulates in the legs instead of being pumped upwards. A prolonged pooling of blood in the leg leads to increased pressure in the affected area thus causing a break in the skin and causing ulcers. The causes for venous stasis could be smoking, occupations requiring prolonged hours of standing, obesity or deep vein thrombosis.
Clinical manifestations : It begins with bluish or purplish discoloration of the skin, which gradually progresses to dryness of skin and itching. If left untreated at this level, it then leads to ulcer by breaking off the skin. The ulcer may be located anywhere between mid calf to below the lateral or medial malleoli. Although shallower than other ulcers, but the venous ulcers are large in size, oozing venous blood, with irregular border and a granulating base. The patient may complaint of pain, which reduces on keeping the leg elevated.
Diagnostics : Diagnosis can be easily made on the basis of clinical symptoms and proper history taking of the patient. Though a duplex Doppler ultrasonography can clearly determine the impeded flow of blood and its cause.
VALVES OF THE HEART
There are four valves in the heart : 1) Mitral valve 2) Aortic valve 3) Pulmonary valve 4) Tricuspid valve
- Mitral valve : It is located in the left side of the heart, separating the left atrium from the left ventricle. It ensures a unidirectional flow of blood from left atrium to left ventricle. It is also called as bicuspid valve due to presence of two cusps. Mitral valve can either have mitral stenosis or mitral regurgitation. Mitral stenosis may occur as a result of rheumatic heart disease or there are very rare chances of having congenital mitral stenosis. The patient will present with breathlessness, fatigue, haemoptysis, chest pain, oedema or cough. Loud first heart sound and crepitations may be heard on auscultation. Mitral regurgitation may result from either rheumatic heart disease, endocarditis, myocardial infarction or mitral valve prolapsed. The clinical features will be dyspnoea, fatigue, palpitation and oedema. Apical pansystolic murmurs may be audible, with or without thrill with a softer first heart sound.
- Tricuspid valve : Located between the right atrium and right ventricle, its function is same as that of mitral valve, the difference is only in the side and number of cusps present in the valve. There are three cusps in tricuspid valve. Tricuspid stenosis may occur as a result of rheumatic heart disease or may be found associated with mitral and aortic valve disease. Symptoms of mitral or aortic valve will be more predominating, symptoms of right heart failure may accompany, like hepatic discomfort, peripheral oedema, raised jugular venous pressure, mid diastolic murmur best heard at lower left or right sterna edge. Tricuspid regurgitation can occur as a result of right ventricular dilatation, endocarditis, rheumatic heart disease or Ebstein’s congenital anomaly. Symptoms are non specific. Fatigue, oedema and tiredness are usually present. A large systolic wave in the jugular venous pulse can be found. Pansystolic murmur on the left sternal edge and pulsation of the liver may be present.
- Aortic valve : It is located between the left ventricle and the aorta. It channels unidirectional blood flow from left ventricle to aorta. Aortic stenosis may be a result of senile changes, rheumatic origin or congenital. Clinically it will manifest with angina, exertional dyspnoea, narrow pulse pressure, thrusting apex beat and crepitation or it can be totally asymptomatic. Aortic regurgitation may occur from dilatation of aortic root, rheumatic disease or trauma. Features will be breathlessness or angina, early diastolic murmur, systolic murmur, fourth heart sound or presence of crepitations.
- Pulmonary valve : Present between the right ventricle and the pulmonary artery. Guards the unidirectional flow between the two. Pulmonary stenosis mostly occurs in carcinoid syndrome but can be congenital too. Clinical manifestations are ejection systolic murmur, thrill, splitting of second heart sound and loud harsh murmurs. Pulmonary regurgitation is mostly associated with pulmonary artery dilatation associated with pulmonary hypertension or may be secondary to Eisenmenger’s syndrome ot primary pulmonary vascular disease. Mostly the condition remains asymptomatic. The presenting features, if any are normally of the associated disorders.
REFERENCES
Venous skin ulcer- topic overview
http://www.webmd.com/skin-problems-and-treatments/tc/venous-skin-ulcer-topic-
overview
Vascular ulcers
http://emedicine.medscape.com/article/1298345-overview
Davidson, S. S. (2006). Davidson's principles and practiced of medicine. Toronto: Churchill livingstone elsevier.
