第五十章-周围血管和淋巴管疾病.doc

第五十章 周围血管和淋巴管疾病1 Try to depict the diagnostic basis of simple superficial varicose veins of lower limbs.Patients present with superficial varicose veins along the course of greater saphenous vein and / or lesser saphenous vein and their tributaries, and complain of heaviness, fatigue of involved lower extremities should be considered of superficial varicose veins. Physical examinations revealed superficial varicose veins along the course of greater saphenous vein and / or lesser saphenous vein and their tributaries, some patients have skin alterations such as pigmentation over varicose veins in calf, especially at gaiter area. For severe ones, even have mild edema around ankle and ulcer above medial malleolus level. Perthes test and Trendelenburg test might be help to identify the patency of blood reflux in deep vein and valvular function in perforator, respectively. Duplex ultrasound, venography will help confirm the diagnosis, and differentiate from deep venous thrombosis and primary deep venous insufficiency. For moment, venography is the “golden standard” for the diagnosis of simple superficial varicose veins.2. Try to depict the etiology of deep venous thrombosis (DVT) in lower limbs.The etiology of deep venous thrombosis (DVT) includes venous stasis, venous injury and hypercoagulation. Any reasons which can caused abovementioned states will result in DVT. Long-time bedding, peripheral venous ectasia caused by epidural anesthesia or general anesthesia, thus result in venous stasis. Left iliac vein compressed by both crossed right common iliac artery and the third lumbar vertebra in about 2/3 population, its the most often location where thrombosis will occur. Intravenous infusion of stimulus or hyperosmotic solution, venous injury caused by fracture, local contusion will result in venous thrombosis. Major operations are most frequent causes for hypercoagulation. Burn injury or severe dehydration will pachyhemia, thus result in hypercoagulation. Factors produced by neoplastic tissue, contraceptive drugs, abuse administration of hemostatic and dehydrator will also cause hypercoagulative state in blood. Those factors might coexist and eventually caused DVT.3. 一名患者因下肢浅静脉曲张就诊，病史询问、体检要注意哪些方面，进一步检查需要哪些？考虑哪些诊断？病史询问需问清病程几年，出现下肢浅静脉曲张前有无同侧肢体肿胀病史，肢体有无发热等不适症状，不适症状在哪些情况下加重，患者从事什么工作，是否长期站立，是否存在慢性咳嗽和便秘。专科体检主要包括患肢是否肿胀，曲张浅静脉分布是否沿大、小隐静脉及属支行径，外侧行径，或无规则分布，或同时伴有毛发增生；皮肤颜色变化，特别是小腿下1/3和曲张静脉上方，是否合并溃疡；皮温变化，曲张静脉部位及周围是否皮温增高或扪及震颤，下肢感觉、运动及动脉搏动情况，并与对侧肢体作比较。如患者下肢浅静脉曲张是沿大、小隐静脉及属支行径，进一步可行血管无损伤检查，包括空气容积描记和超声检查，行初步筛选，进一步明确诊断再行下肢静脉顺行造影，以鉴别单纯性下肢浅静脉曲张和原发性深静脉瓣膜功能不全。如患者下肢浅静脉曲张分布不规则，且既往有下肢肿胀病史，体检患肢可有增粗或正常，则高度怀疑下肢深静脉血栓后遗症，无损伤检查可行空气容积描记和超声检查，明确诊断行下肢静脉顺行造影。如患者下肢浅静脉曲张伴局部皮温明显增高，可及震颤或听诊可及杂音，高度怀疑动静脉瘘或先天性血管畸形。根据患者病史，外伤史初步判断先天性或后天性，无损伤检查可行CT血管成像或磁共振血管成像帮助明确诊断，有创检查包括动脉造影。4. Try to depict the diagnostic basis of deep venous thrombosis (DVT) in lower limb.Sudden swelling and pain in lower limb, that symptom most often occur in left. For mild cases, only heavy sensation in lower extremity and will be aggravated after standing. But for severe cases, obvious swelling, pain and even arterial spasm caused by interstitial hyper pressure exist, the latter is called phlegma cerulea dolens (股青肿), if left untreated, it will eventually result in limb gangrene. The life-threatening complication for DVT is pulmonary embolism. Physical examinations reveal swelling in involved limb with increased tissue tension, some patients have tenderness in femoral triangle or gastrocnemia region. Homans sign is positive in some patients with venous thrombosis in calf. For later cases, superficial varicose veins exist. Patient in acute stage presents sudden dyspnea, thoracic pain, hemoptysis, cyanosis or shock or should highly suspect of pulmonary embolism. Further eaxaminations for DVT include ultrasound and invasive venography, which will help to confirm the diagnosis. 5. Try to depict the therapeutic measures of deep venous thrombosis (DVT), which include non-operative and operative treatment.深静脉血栓形成(DVT)的治疗分急性期和慢性期的治疗，同时急性期的治疗又分为药物治疗和手术治疗。急性期药物治疗包括溶栓、抗凝和抗血小板治疗。溶栓药物有链激酶(Streptokinase)、重组链激酶、尿激酶(Urokinase)、基因重组人体组织型纤溶酶原激活物(tissue-type plasminogen activator)。其在早期用药疗效较好，治疗过程中注意局部出血倾向，包括注射局部瘀斑、伤口渗血、血尿、消化道出血等。抗凝药物有肝素、低分子肝素和口服的双香豆素类药物，其中低分子肝素相对肝素为安全，出血副作用较小。抗血小板药物主要有肠溶阿司匹林、潘生丁等，作为辅助用药。如患肢肿胀明显，组织张力较高，病程在3天内，或有进展至股青肿可能或已出现股青肿，则应行积极的手术取栓治疗，急性期髂股静脉血栓形成，取栓术后疗效较好。急性期预防肺栓塞可行下腔静脉滤网置入术。慢性期的治疗以保守治疗为主，可口服抗血小板药物和双香豆素类药物如华法令，但后者需密切检测凝血指标，如比正常增加2倍以上，或有明显的出血倾向，则需停药。患者辅以穿弹力袜。对于部分髂静脉血栓形成者，适当选择病例可行耻骨上自体大隐静脉或人造血管旁路转流术。6. Try to describe clinical manifestations and clinical stages of Buergers disease.Patients with Buergers disease are mainly male smokers less than 40 years. It is insidious onset with slow progression and periodical episode, and can be aggravated by smoking. Patients represent chronic ischemia in extremities, such as coldness and lowering skin temperature, pallor or cyanosis, paresthesia, intermittent claudication and even rest pain, tissue malnutrition and weakness or absence of distal pulses in affected limbs. Most of them have histories of recurrent migratory phlebitis. The clinical courses can be divided into 3 stages. Stage 1: Local ischemia. Patients have symptoms of chronic ischemia in affected limbs, later followed by intermittent claudication. As the disease is advancing, the claudicative distance becomes short. Patients have migratory phlebitis in this stage. Stage 2: Tissue malnutrition. As claudicative distance is shortened, patients represent rest pain, especially at night, which result in insomnia. Skin temperature is significant lowering, with pallor or cyanosis at distal part. Absence of distal arterial pulses is found, with no limb ulcer or gangrene. Stage 3: Tissue necrosis. Ulcer or gangrene can been seen in distal part of affected limbs, if infected, dry gangrene will changed into wet gangrene, and systemic toxemia occur in most severe cases. Rest pain is obvious in this stage.7. Try to depict the differential diagnosis of Buergers disease to arteriosclerosis obliterans (ASO) of lower extremities.血栓闭塞性脉管炎(TAO, Buergers 病)多见于青年男性，患者往往有吸烟病史，不合并高血压、冠心病、糖尿病等疾病。病变主要累及四肢中、小动脉，上肢受累较动脉粥样硬化闭塞症为多见，30%患者发病早期有小腿反复游走性血栓性浅静脉炎，患肢肢端发生坏疽的几率较动脉粥样硬化闭塞症为多受累肢体有慢性缺血表现，包括肢体发冷、皮肤苍白、麻木、肢体远端动脉搏动减弱或消失、间歇性跛行、静息痛、皮肤营养障碍，严重者肢体坏疽、感染。下肢动脉造影提示中、小动脉病变，无虫蚀样改变，病变节段间的动脉可正常。病理提示病变动脉全层炎症反应，伴血栓形成、管腔闭塞。动脉粥