Diagnostics of ulcus cruris venosum

Transcription

1 Review Article 85 Diagnostics of ulcus cruris venosum M. Stücker; A. Pljakic; M. Dörler Klinik für Dermatologie, Venerologie und Allergologie der Ruhr-Universität Bochum, Venenzentrum der dermatologischen und gefäßchirurgischen Kliniken der Ruhr-Universität Bochum, Germany Keywords Ulcer, Ulcus cruris venosum, CVI, duplex ultrasound Summary Clinical diagnostics of venous leg ulcers set the course for efficient therapy. Precise clinical findings with an objectification of signs and symptoms of chronic venous insufficiency are essential. Duplex ultrasound investigations of the leg veins are necessary in the very early stages after the appearance of leg ulcers. Furthermore, not only a clinical investigation of the arterial perfusion but also the determination of the ankle-brachial-index is obligatory. Microbiological diagnostics are currently seen as useful in Germany, due to discussions on MRSA, even though they don t have an immediate therapeutic consequence without the presence of clinical signs of infection. Therapeutic achievements can be objectified by a continuous documentation of the wound size, the wound bed, the wound exudate and signs of infection as well as the life quality of patients with chronic wounds. Correspondence to Prof. Dr. Markus Stücker Venenzentrum der dermatologischen und gefäßchirurgischen Kliniken Kliniken der Ruhr-Universität Bochum Hiltroper Landwehr 1113, Bochum, Germany Tel. 49/234/ od. 378, Fax m.stuecker@klinikum-bochum.de Gravitational ulcer is the most common cause of chronic wounds of the lower limb. It accounts for up to 70 % of all chronic wounds on the leg (1). Gravitational ulcer is defined as ulceration of the leg or foot in an area with venous hypertension. Venous hypertension is caused by refluxes or obstructions. Schlüsselwörter Ulkus, Ulcus cruris venosum, CVI, Duplexsonografie Zusammenfassung Die Diagnostik des Ulcus cruris venosum stellt die Weichen für eine erfolgreiche Therapie. Entscheidend ist eine präzise klinische Befunderhebung mit der Objektivierung der Zeichen einer chronischen Veneninsuffizienz. Sehr frühzeitig bei dem Auftreten eines Ulcus cruris ist eine duplexsonografische Untersuchung der Beinvenen zur Therapieplanung erforderlich. Obligatorisch ist ferner nicht nur die klinische Untersuchung der arteriellen Durchblutung, sondern auch die Bestimmung des Knöchel-Arm-Index. Eine mikrobiologische Diagnostik wird derzeit in Deutschland aufgrund der MRSA-Diskussion für sinnvoll erachtet, obwohl sie ohne das Vorliegen klinischer Infektionszeichen keine direkte therapeutische Konsequenz hat. Durch eine laufende Dokumentation der Wundgröße, des Wundgrunds, des Wundexsudats und der Infektzeichen sowie der Lebensqualität des Patienten mit chronischen Wunden können Therapieerfolge objektiviert werden. Diagnostik des Ulcus cruris venosum Phlebologie 2016; 45: Received: January 27, 2016 Accepted: January 28, 2016 However, other exceptional situations, such as arthrogenic congestion syndrome or functional chronic venous insufficiency in obesity-associated dependency syndrome, can also lead to signs of chronic venous insufficiency, sometimes progressing to gravitational ulcer (2). When analysing the causes of gravitational ulcer, impaired venous function in not only the leg, but also in the pelvis in the area of the iliac vein or the inferior vena cava should be considered. In addition to impaired venous function, other pathogenetically relevant mechanisms exist, such as activation of inflammatory cascades. However, as these are currently poorly accessible to routine diagnostics, they are not further considered in this article. The purpose of diagnostics in gravitational ulcer must be to define, as efficiently as possible, the pathogenetically relevant factors that are accessible to therapy. An essential step here is to decide whether the ulcer is a purely gravitational ulcer or whether other pathogenetic factors also play a part. Here, particular consideration should be given to peripheral arterial occlusive disease and other pathological conditions, such as scarring, lymphoedema, autoimmune diseases, infections and trauma (3). If other pathogenetically relevant factors beyond those of purely venous origin are present, protracted healing is likely. The main differential diagnoses for lower leg ulcers are listed in Table 1. The following specific steps are of proven efficacy in the diagnosis of gravitational ulcer: Medical history The medical history of patients with gravitational ulcer can be complicated by the limitations associated with the patients advanced age, their very long medical history and complex concomitant diseases. It has therefore proven effective to concentrate on a few questions that are particularly important for the management of gravitational ulcer. Of relevance in this context are the patients possibilities of independent actions in therapy and their social circumstances, in order to estimate to what extent supportive measures, such as a mobile nursing service, may be necessary. They should be asked about any concomi- Schattauer 2016 Phlebologie 2/2016

2 86 M. Stücker, A. Pljakic; M. Doerler: Diagnosis of gravitational ulcer Tab. 1 Differential diagnosis of gravitational ulcer (according to 4). Vascular disorders Neuropathic Metabolic Haematological Exogenous Neoplasia Infection Drug Genetic defect Veins Arteries Lymph drainage disorder Vasculitis Microangiopathy Peripheral CNS Erythrocytes Leukocytes Platelets Dysproteinaemia Coagulation Primary cutaneous malignancy Bacteria Viruses Fungi Protozoa Chronic venous insufficiency: postthrombotic syndrome, varicosis, dysplasia Peripheral arterial occlusive disease, hypertension, arteriovenous fistula, arterial thrombosis, embolism, dysplasia, thromboangiitis obliterans, aneurysm Lymphoedema, dysplasia Rheumatoid arthritis, leukocytoclastic vasculitis, polyarteritis nodosa, Wegener s granulomatosis, Churg- Strauss syndrome, Bazin s disease, lupus erythematosus, Sjögren s syndrome, scleroderma, Behçet s disease Diabetes mellitus, livedoid vasculopathy Diabetes mellitus, alcohol, medicines Tabetic neurosyphilis, myelodysplasia, syringomyelia, spina bifida, poliomyelitis, multiple sclerosis Diabetes mellitus, gout, prolidase deficiency, Gaucher s disease, amyloidosis, calciphylaxis, porphyrias, hyperhomocysteinaemia Sickle cell anaemia, thalassaemia, polycythaemia vera Leukaemia Thrombocythaemia Cryoglobulinaemia, lymphoma Plasmatic coagulation factors (factors I-XIII), coagulation inhibitors (antithrombin III, APC resistance, proteins C and S), fibrinolysis factors (t-pa, PAI, plasmin) Heat, cold, pressure, ionising radiation, artefacts, chemical noxae, allergens Basal cell carcinoma, squamous cell carcinoma (Marjolin s ulcer), malignant melanoma, (angio)sarcoma, cutaneous lymphoma Furuncle, ecthyma, mycobacteriosis, syphilis, erysipelas, anthrax, diphtheria, chronic vegetative pyoderma, tropical ulcer Herpes, smallpox virus, cytomegalovirus infection Sporotrichosis, histoplasmosis, blastomycosis, coccidioidomycosis Leishmaniasis Hydroxycarbamide, leflunomide, methotrexate, halogens, Marcumar [phenprocoumon], vaccinations, ergotamine, paravasal cytostatics Klinefelter s syndrome, Felty s syndrome, TAP 1 mutation, leukocyte adhesion deficiency tant disease and their vaccination status (tetanus protection?). The questions should focus on the venous disease itself and the ulceration. Cf. Table 2 and Table 3. Clinical investigation Gravitational ulcer has a typical morphology. It is more frequently located on the medial malleolus than on the fibular malleolus. Other signs of chronic venous insufficiency are typically found around the gravitational ulcer, such as spider-burst veins, reticular veins, varicoses of the smaller leg veins, oedema, hyperpigmentation, stasis eczema, white atrophy, lipodermatosclerosis, scarred changes associated with status post ulcer healing. In the event of multiple ulcerations and an atypical location, further factors have to be considered, which, in addition to venous hypertension, can lead to the development and persistence of the ulceration or which are solely responsible for the ulceration. Early recognition of malignant tumours as the cause or sequelae of ulceration is important (5). One significant indication of a malignant transformation is a treatmentresistant course, in which the assumed gravitational ulcer has shown no healing tendency over 68 weeks, despite adequate compression therapy. Already at the initial examination, there will be further criteria that are indicative of a malignant tumour in the ulcerated area: atypical morphology with atypical position, form and wound surroundings, nodular proliferation, darkly livid colour of the granular tissue and a long duration with a small wound size. In the event of any clinical or anamnestic indications of malignant tumour growth in the ulcerated area, sufficiently large biopsies should be taken from various sites. Typical biopsy sites are the wound edge and areas of nodular proliferation in the various ulcerated areas. If ulcerated areas are biopsied, the biopsies must be deep enough to avoid obtaining only Phlebologie 2/2016 Schattauer 2016

3 M. Stücker, A. Pljakic; M. Doerler: Diagnosis of gravitational ulcer 87 superficial wound detritus or pathological granulation tissue and leaving behind the possibly underlying cancerous process. Microbiology It is often considered unnecessary to start a routine microbiological culture for venous ulcerations. A microbiological culture should only be started in the presence of clinical signs of wound infections (3). By contrast, in many health care institutions, particularly in hospitals, meticillin-resistant Staphylococcus aureus (MRSA) screening is performed at admission, if MRSA risk factors are present. Skin ulcerations are assessed as MRSA risk factors. In such patients, a combined throat/nose swab and a swab from the wound area should be taken. Independently of this, a microbiological culture should be obtained from patients showing clinical signs of infection, such as fever, increasing pain, increased redness, increased wound exudate, an offensive wound odour, biofilm formation, tissue necrosis or ulcer progression (3). In specialised centres, in which patients present with secondary or tertiary disease, crural ulcerations often show such features, so that primary microbiological diagnostics are frequently indicated in such centres. For this, a bacterial swab should be obtained by guiding the swab in a spiral circular motion from the outside to the inside, covering as large an area of the wound as possible (6). Peripheral arterial occlusive disease In all patients with chronic crural wounds, the ankle-brachial index should be determined. Whereas only 3 % of patients below 60 years of age suffer from peripheral arterial occlusive disease, there is a dramatic rise in the frequency of this disease in later years, increasing to over 20 % in those aged 75 years and above (7). The ankle-brachial index is determined with the patient lying down using a blood pressure cuff and a continuous wave (CW) Doppler probe. The blood pressure cuff should be placed immediately above the ankle, as the Tab. 2 Basic medical history in gravitational ulcer Tab. 3 Specific history in gravitational ulcer Weight, height, BMI Concomitant disease, particularly Allergies Angiological risk factors Social history Mobility Duration of current ulceration Current symptoms Last therapy Recurrent ulceration Previous interventions on the legs affecting the ulceration Epicutaneous testing History of multiresistant pathogens Tetanus protection pressure is recorded under the cuff during the measurement. The ulceration will often have to be covered appropriately, in order to achieve a sufficiently distal measure- Peripheral polyneuropathy Vasculitis Diabetes mellitus Heart failure and other cardiac diseases Current internal medication Nicotine abuse Hypercholesterolaemia Arterial hypertension Marital status: Children: Occupation: Residence: 1= standing up independently (if necessary, with walking aid) and walking at least 50 m, 2= standing up with outside help and walking at least 50 m, 3= moving at least 50 m in a wheelchair, 4= moving <50 m Pain, discharge, increase in size of the ulceration Intermittent claudication with a maximum painless walking distance in metres Cramps in the calf muscles, tendency to swelling of the legs, sensation of heaviness in the legs Wound dressing Wound débridement Compression therapy Dressing change previously performed by: How many recurrences First occurrence of ulceration Varicose vein surgery Sclerotherapy Percutaneous transluminal angioplasty (PTA) Bypass surgery Split-skin graft No allergy pass available/ Allergy pass available MRSA/extended-spectrum beta-lactamases (ESBL) / multiresistant pseudomonads ment. Placing the blood pressure cuff further proximal to the wound can result in distal arterial occlusions or stenoses being overlooked. The Doppler probe records the Schattauer 2016 Phlebologie 2/2016

4 88 M. Stücker, A. Pljakic; M. Doerler: Diagnosis of gravitational ulcer 1. Deep veins: patency and reflux 2. Junctions in the groin and knee: Refluxes (terminal valve and preterminal valve) 3. Main branches: measurement of diameter and reflux (in the saphenous compartment): 4. Lateral branches: if incompetent 5. Non-saphenous veins: if incompetent 6. Perforating vein: measurement of diameter and reflux Common femoral vein Popliteal vein Saphenofemoral junction Saphenopopliteal junction Great saphenous vein Anterior accessory saphenous vein Posterior accessory saphenous vein Small saphenous vein Thigh extension of the small saphenous vein/giacomini vein Tab. 4 Examination sites of venous duplex ultrasound according to the UIP consensus document 2011 (9) systolic pressure over the posterior tibial artery and the dorsal artery of the foot on each leg and is set in proportion to the pressure of the brachial artery in the arm that is used to calculate the ankle-brachial index. Peripheral arterial occlusive disease is assumed if the ankle-brachial index is <0.90 at rest. An ankle-brachial index of 0.50 usually corresponds to critical ischaemia. Compression therapy should not be performed if malleolar artery pressures are below 60 mmhg. At malleolar artery pressures between 60 and 80 mmhg, compression therapy should be attempted, but this may cause excessive pain for the patient. At malleolar artery pressures above 80 mmhg, Fig. 1 Questionnaire Wound QoL (11) Phlebologie 2/2016 Schattauer 2016

5 M. Stücker, A. Pljakic; M. Doerler: Diagnosis of gravitational ulcer 89 compression therapy can be performed, even in the presence of pathological anklebrachial indices. In the event of pathological ankle-brachial indices, particularly in patients with critical ischaemia, the option of arterial revascularisation should be investigated. Venous function measurements Using venous plethysmography, such as strain-gauge plethysmography, air plethysmography or photoplethysmography, it is possible to objectify functional impairment of the venous outflow. Venous reflux, impaired outflow and impaired muscle pump function correlate well with the findings of duplex ultrasound and can objectify changes in venous function through therapeutic measures on the venous system. Venous duplex ultrasound Venous duplex ultrasound is considered to be an indispensable reference standard in the examination of patients with gravitational ulcer. The examination should be performed directly at the outset of diagnostic tests. Although CW Doppler examinations yield important indications of venous disorders, duplex ultrasonography is essential when planning invasive treatment measures and is often suggested as the first-line diagnostic test (3). In patients with gravitational ulcer, duplex ultrasonography follows the general principles of duplex ultrasound diagnostics in chronic venous insufficiency in accordance with the UIP consensus document of 2006 (8). The following information is taken from this consensus document. Ultrasonic probes of MHz are proposed and only in the case of very voluminous and oedematous legs may 3.55 MHz probes be advisable. In order to standardise the measurements of venous diameters and refluxes, the UIP consensus recommends performing the examination with the patient standing up. Refluxes lasting longer than 0.5 seconds are considered to be pathological. The refluxes can be triggered by various measures, such as manual compression/decompression of the lower leg, the inner side of the thigh or varicose veins, but also by active dorsiflexion and relaxation of the foot or by the classic Valsalva manoeuvre. The main examination sites are presented in Table 4. Venous imaging Diagnostic investigation of the deep veins of the legs is currently gaining in importance. Obstructions in the deep veins of the legs as the cause of severe chronic venous insufficiency, sometimes progressing to gravitational ulcer, have probably been underestimated for a long time. Frequently, duplex ultrasound only provides insufficient information about the iliocaval veins, so that supplementary procedures are required, if insufficiency of the deep leg veins in the pelvic area is suspected. In such cases, CT angiograms and MRI angiograms are helpful and can be followed by targeted phlebography. As a practical procedure, it has proved advisable to conduct an initial analysis of the superficial and deep venous system of the leg, as already described, and to treat superficial refluxes. If the ulcerations fail to heal, duplex ultrasound should be repeated, in order to detect any untreated refluxes of the superficial leg veins and reflux Tab. 5 Diagram of wound documentation based on (12) < Wound bed score A B C D Wound exudate score Infection score k d i treatment should be repeated, if necessary. If an ulceration fails to heal despite sufficient reflux treatment or if no superficial refluxes occur despite apparent signs of chronic venous insufficiency, imaging of the deep pelvic veins should be considered. If occlusions or stenoses of the deep pelvic veins are evident, stenting of these veins can accelerate healing of the gravitational ulcer (10). Quality of life Evaluation of the quality of life of patients with chronic wounds is generally recommended. As quality of life questionnaires are often very extensive, a shorter, onepage quality of life questionnaire was specifically developed for patients with chronic wounds and reduced to 17 questions. This so-called Wound QoL ( Fig. 1) covers the three subscales of life, body and psyche (11). The form can be used in routine clinical practice. Contractual agreement with the creators of the form is only required for use in studies (Dr. Christine Blome, CVderm, Universitätsklinik Hamburg-Eppendorf, Martinistraße 52, Hamburg, Germany). Quality of life should be evaluated at regular intervals. Particularly in long-term diseases, it is an important follow-up par- Characterisation of the wound bed Granulation tissue 100 % % < 50 % Unlimited extension Amount of exudate no exudate/minimal moderate very heavy Signs of infection Wound area: Length x breadth in mm Fibrinous coatings no signs of infection signs of an imminent wound infection manifest wound infection Scabbing Schattauer 2016 Phlebologie 2/2016

6 90 M. Stücker, A. Pljakic; M. Doerler: Diagnosis of gravitational ulcer ameter for monitoring treatment and evaluating the course of disease. Wound documentation After the documentation at initial presentation, wound documentation should be conducted at regular intervals, at least once a month, in order to objectify the effect of therapy on the healing process. The number and position of the individual ulcers are particularly important parameters of wound documentation. The size of each individual wound (at least its length and breadth), the amount of exudate, the area of granulation and the wound coating and any signs of wound infection should be documented. This can be conducted, for example, on the basis of a proposal by Falanga from 2000 (12) ( Table 5). Conflict of interest The author declares that no conflict of interest exists. Ethical guidelines The article was written in accordance with national guidelines and the current Declaration of Helsinki. References 1. Tatsioni A, Balk E, OADonnell TF Jr, Lau J. Usual care in the management of chronic wounds: A review of the recent literature. J Am Coll Surg 2007; 205: Dörler M, Altmeyer P, Stücker M. Venous leg ulcer caused by obesity-associated dependency syndrome. Phlebologie 2013; 43: O Donnell TF Jr, Passman MA, Marston WA, et al.; Society for Vascular Surgery; American Venous Forum. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2014 Aug; 60(2 Suppl): 3S-59S. 4. Dissemond J, Körber A, Grabbe S. Differentialdiagnosen des Ulcus cruris. J Dtsch Dermatol Ges 2006; 4(8): Reich-Schupke S, Dörler M, Wollina U, et al. Squamous cell carcinomas in chronic venous leg ulcers. Data of the German Marjolin Registry and review. J Dtsch Dermatol Ges 2015; 13(10): Al Ghazal P, Körber A, Klode J, et al. Evaluation of the Essen Rotary as a new technique for bacterial swabs: results of a prospective controlled clinical investigation in 50 patients with chronic leg ulcers. Int Wound J 2014; 11(1): Criqui MH, Fronek A, et al. The prevalence of peripheral arterial disease in a defined population. Circulation 1985; 71(3): Coleridge-Smith P, Labropoulos N, Partsch H, et al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--uip consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg 2006 Jan; 31(1): De Maeseneer M, Pichot O, Cavezzi A, et al. Duplex ultrasound investigation of the veins of the lower limbs after treatment for varicose veins UIP consensus document. Eur J Vasc Endovasc Surg 2011; 42(1): Verma H, Tripathi RK. Algorithm-based approach to management of venous leg ulceration. Semin Vasc Surg 2015 Mar; 28(1): Blome C, Baade K, Debus ES, Price P, Augustin M. The Wound-QoL : A short questionnaire measuring quality of life in patients with chronic wounds based on three established disease-specific instruments. Wound Rep Reg 2014; 22: Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair Regen 2000 Sep-Oct; 8(5): Phlebologie 2/2016 Schattauer 2016