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Vascular

CASE 55: inveStigation oF a SWollen limb

history

A 43-year-old Caucasian woman presents to the surgical outpatients with right leg swelling. This first appeared 3 weeks ago and has gradually increased such that she now finds it difficult to put on her shoe. She is otherwise symptomless. There is no history of trauma to the limb. Apart from a tonsillectomy as a child, there is no past history of note. She is on an oral contraceptive pill.

examination

There is unilateral swelling of the right lower leg from the foot to just above the knee (Figure 55.1). There is no associated erythema and no stigmata of venous disease. The oedema pits when the skin is pressed. All pulses in the leg are palpable. The general examination is otherwise unremarkable.

Figure 55.1 unilateral right leg swelling.

Questions

•What is the differential diagnosis of leg swelling?

•What investigations are required?

•What are the two most likely diagnoses in this patient?

•What are the treatment options?

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100 Cases in Surgery

ANSWER 55

The common causes of unilateral limb swelling are:

•Long-standing venous disease (e.g. post-thrombotic syndrome)

•Acute deep vein thrombosis

•Lymphoedema

•Extrinsic pressure (e.g. pregnancy, tumour, retroperitoneal fibrosis)

•Klippel–Trénaunay syndrome

•Lipoedema

•Disuse/hysterical oedema

Bilateral symmetrical limb swelling is usually caused by systemic factors such as:

•Heart failure

•Renal failure

•Liver cirrhosis

•Hypoproteinaemia

•Hereditary angioedema

Useful investigations include:

•Blood tests: full blood count, urea and electrolytes, liver function test, albumin

•Electrocardiogram/echocardiography

•Abdominal ultrasound

•Duplex scanning of deep and superficial veins if a venous cause is suspected

•Isotope lymphography

•Contrast lymphography, if diagnosis of lymphoedema equivocal

The most likely diagnoses are either deep vein thrombosis or lymphoedema. Lymphoedema is either primary or secondary. Secondary causes include:

•Surgical excision of local lymph nodes

•Radiotherapy to local lymph nodes

•Tumour infiltrating the lymphatics

•Trauma

•Filiriasis

•Lymphoedema artifacta: patient tying a tourniquet around the limb

In lymphoedema, the vast majority of patients (>90 per cent) are treated conservatively. Interstitial fluid is driven from the limb using intermittent pneumatic compression devices. Compression is maintained using elastic stockings. Massage of the leg may also be beneficial. Patients are advised to elevate the leg when possible and to be vigilant for signs of cellulitis, which should be treated promptly. Diuretics are not useful.

Debulking operations (e.g. Charles and Homan’s reduction) are only considered for a selected few patients where the function of the limb is impaired or those with recurrent attacks of severe cellulitis.

KEY POINT

• the majority of patients with lymphoedema are managed conservatively.

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Vascular

CASE 56: variCoSe veinS

history

You are asked to see a 47-year-old hairdresser in the vascular clinic. She has been complaining of pain in the right leg on prolonged standing and has noticed unsightly, distended veins in that leg for the past 2 years. For the past 3 months she has also had itching of the skin just below the knee with a red patch in that area. She is currently on treatment for hypertension with no other past history of note. She has two children.

examination

A distended vein can be felt in the medial aspect of the mid-thigh running down to the knee. There are numerous varicosities around and below the knee. There is an erythematous patch of skin approximately 3cm in diameter overlying one of the below-knee varicosities. A thrill is palpable at the sapheno-femoral junction when the patient coughs. Foot pulses are strongly palpable.

Questions

•What is the most likely diagnosis?

•What information would the Trendelenburg test provide?

•What is the significance of the erythematous patch of skin?

•What imaging studies would you consider?

•What are the possible complications if left untreated?

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100 Cases in Surgery

ANSWER 56

This patient has varicose veins in the distribution of the long saphenous vein, a common condition that is more common in women. Working as a hairdresser involves prolonged standing, which increases venous hydrostatic pressure leading to distension of the veins and secondary valve incompetence within the superficial venous system.

The Trendelenburg test can confirm superficial as opposed to deep-vein incompetence and identify the point of incompetence along the superficial system. The leg is elevated to collapse all the veins and pressure is applied on the long saphenous vein just below the saphenofemoral junction. The patient then stands up, and if the distal varicosities remain empty, the point of reflux from the deep to the superficial system has been identified. If the varicosities fill, then the procedure is repeated, this time applying the pressure at a lower point until the point of reflux is identified.

The itching erythematous patch represents varicose eczema and is an indication for operative intervention.

Imaging identifies all areas of reflux and obstruction within the superficial and deep-venous system. Duplex ultrasound is now the standard diagnostic modality for this purpose. Alternatives include contrast varicography/venography and magnetic resonance imaging.

!Sequelae of varicose veins

•pain

•leg swelling

•bleeding

•eczema

•Skin ulceration

KEY POINTS

•Further skin changes may be prevented with surgical correction of the superficial venous reflux disease.

•Surgery on the superficial venous system should be avoided in patients with an incompetent deep venous system.

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100 Cases in Surgery

ANSWER 57

This boy has testicular torsion until proven otherwise. It is likely that a year ago he had an episode of intermittent torsion with spontaneous detorsion. Testicular torsion is actually torsion of the spermatic cord and not of the testis. This results in irreversible ischaemia to the testicular parenchyma, which can occur within 4–6 h of cord torsion. The presentation can vary and includes vague loin or groin pain as well as scrotal signs and symptoms. There may be a history of excessive physical activity or trauma. Testicular torsion can occur at any age but commonly has a bimodal distribution. There is a small peak in the first year of life but is more common between late childhood (post puberty) and early adulthood, i.e. 12–18 years.

Normally, the tunica vaginalis envelops the body of the testis and only part of the epididymis (which is usually fixed), and the testis is unable to twist. In cases of torsion, there is an abnormal amount of free space between the parietal and visceral layers of the tunica vaginalis, which encompasses the testis, epididymis and the cord for a variable distance. This free space allows the now hypermobile testis and epididymis to rise in the scrotum and twist. This accounts for the abnormal horizontal lie of the testis (‘bell clapper deformity’). If the presentation is delayed, an acute hydrocoele may develop making examination difficult, and the scrotum may appear erythematous. Surgical exploration is essential if torsion is considered. Testicular salvage rates are directly correlated with the number of hours after the onset of pain with a significant drop off after 6 h. Urinalysis is often negative and the diagnosis should be made clinically.

!Differential diagnoses

•torsion of the appendix testis

•torsion of the appendix epididymis

•epididymo-orchitis

•infected hydrocoele

•testicular rupture

•Strangulated inguinal hernia

•a bleed into a tumour

In torsion of the appendix testis, the tenderness is usually localized above the upper pole of the testis and may be accompanied by the ‘blue dot’ sign, which represents necrosis in the appendix. Hydrocoeles may be tender if large and will transilluminate. If a patient is suspected of having epididymo-orchitis, the urine should be screened for infection. There may also be a history of urethral discharge or urinary symptoms such as frequency or dysuria.

KEY POINTS

•if testicular torsion is suspected, surgical exploration should be carried out as soon as possible.

•testicular salvage rates decline significantly after 6 h from the onset of testicular pain.

130

Urology

CASE 58: leFt loin pain

history

A 33-year-old female office worker presents to the emergency department complaining of severe left-sided abdominal pain. The pain woke her in the early hours of the morning and has persisted throughout the day. She is unable to keep still and has vomited bilious material on five occasions. She reports no diarrhoea or rectal bleeding. Previous medical history includes appendicectomy and irritable bowel syndrome. She has had a recent colonoscopy, which was normal. She takes mebeverine for irritable bowel syndrome and multivitamin tablets. She smokes 15 cigarettes per day.

examination

On examination, she has a temperature of 37°C, a blood pressure of 125/88 mmHg and pulse rate of 96/min. There is marked left loin tenderness, but the rest of the abdomen is nontender. Heart sounds are normal and the chest is clear.

INVESTIGATIONS

Questions

•What is the likely diagnosis?

•What investigation would you like to do to confirm your diagnosis?

•What are the indications for admitting this patient?

•What is the initial management?

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100 Cases in Surgery

ANSWER 58

The combination of left loin pain and microscopic haematuria, in the absence of abdominal peritonism, suggests a diagnosis of renal/ureteric colic. In 10–15 per cent of cases of renal colic, the dipstick will be negative for blood. The differential diagnosis includes pyelonephritis, diverticulitis, bowel obstruction, peptic ulcer disease and gynaecological conditions such as ectopic pregnancy, torted ovarian cyst or tubo-ovarian abscess. In addition to the above, on the right side, appendicitis and biliary colic should also be considered. In an older patient, it is important to exclude a ruptured abdominal aortic aneurysm.

The pain of renal colic is caused by the distension of the ureter or collecting system from an obstructing calculus. The pain may radiate from loin to groin and to the tip of the penis in males and to the labia in females (the latter being typical in males and females, respectively, of a stone at the vesico-uretric junction). Calculi may also irritate the bladder, causing urgency, frequency and strangury.

The gold standard investigation in the work-up of renal colic is a non-contrast computerized tomography (CT) KUB (kidneys, ureter, bladder) scan. This has a sensitivity of 94–100 per cent and specificity of 92–100 per cent. Advantages of CT KUB compared with more traditional tests such as intravenous urogram include the possibility to diagnose other conditions, accuracy of stone measurement, quick test and does not require administration of intravenous contrast and its potential pitfalls, e.g. allergy and chemotoxic reaction in patients with renal insufficiency. However, its use does involve a higher radiation dose.

Indications for admitting the patient include:

•Pain not controlled with simple analgesia

•Evidence of sepsis, e.g. pyrexia, raised white cell count or signs and symptoms of septic shock

•Obstructing calculi in a solitary kidney, or bilateral ureteric stones

•Deranged renal function

Renal drainage via percutaneous nephrostomy or retrograde ureteric stent insertion is required urgently in patients with sepsis and obstruction and is a urological emergency.

Figure 58.1 Ct Kub.

132

Urology

The analgesic of choice is rectal diclofenac, although in some cases opiates will be required. Fluids should be given and in cases of suspected infection, antibiotics with good Gramnegative cover administered.

The CT KUB in Figure 58.1 clearly demonstrated the offending urinary calculus, which is the opacification seen in line with the ureter.

KEY POINTS

•haematuria is present in 90 per cent of cases of renal colic.

•Sepsis and obstruction of the urinary system is a urological emergency and requires urgent renal drainage.

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