CHRONIC VENOUS INSUFFICIENCY ( CVI )-A STUDY OF 100 CASES

This study was carried out in the out patient department of Dhaka Medical College Hospital. 100 patients presented with chronic venous insufficiency during the period of January 2005 to June 2005 were studied to find out the various modes of presentation, risk factors and relationship of symptoms with age, sex and Body Mass Index of the patients. It was found that, maximum patients presented with heaviness in the leg (87%), followed by aching leg pain (75%), leg swelling (70%), cramping leg pain (68%), tiredness (48%), burning pain (43%), engorged leg vein (39%), restless leg at night (21%), throbbing leg pain (18%), itching (13%), various skin changes without active ulceration (7%) and active leg ulceration only 3% of cases. Increasing age of the patients, obesity, increasing number of pregnancy, prolonged standing and sitting position at work were found to be positively correlated with CVI. Advanced age is associated with more advanced stage of CVI according to clinical CEAP classification. There is almost equal sex distribution among the stages of CVI except in advanced stage, in stage C4, C5 and C6 there is 10 patients out of them 9 are male and only 1 is female. Relationship of symptoms with BMI of the patients were also sort out and found that, in C3 group of CEAP classification out of 61 patients 46 are obese according to BMI, of which 32 are female and 14 are male and only 17 patients have BMI within normal range, but in other group there is no significant difference in incidence between two groups. Hospital. Hundred patients presented with CVI (chronic venous insufficiency) during the period of January 2005 to June 2005 were enrolled in the study. Chronic venous insufficiency was diagnosed on the basis of clinical criteria including leg swelling, heaviness, aching pain, cramp, itching, burning, throbbing, visible veins, skin pigmentations, active or healed ulceration in the leg. Each patient came to medicine out patient department of DMCH with various leg problems mentioned above was carefully interviewed, initially to exclude other cause of leg swelling such as cardiac failure, chronic liver disease, renal failure, nephrotic syndrome, thyroid disease, fileriasis, obvious arthritis in legs & taking drugs which causes fluid retention such as NSAID’s, steroids, calcium channel blockers . After apparent exclusion informed written consent was taken from the patients about the motive of the study. Detailed history was taken and relevant clinical examination was done to all patients. After that, relevant investigations were done to those having suspicion of other cause responsible for edema. Findings of history, clinical examinations and laboratory investigations were recorded in a case record form. Serum albumin and 1. MD Student (Gastroenterology), Thesis Part, Bangabandhu Sheikh Mujib Medical University, Dhaka 2. Clinical Pathologist (Attatched to Medicine Unit White), Dhaka Medical College Hospital, Dhaka 3. Clinical Pathologist (Attatched to Medicine Unit Blue), Dhaka Medical College Hospital, Dhaka 4. Registrar, Department of Nephrology, Dhaka Medical College Hospital, Dhaka 5. Professor of Medicine, Dhaka Medical College Hospital, Dhaka J MEDICINE 2008; 9 : 20-26


Introduction:
Chronic venous insufficiency (CVI) is one of the most prevalent, frequently unrecognized & underestimated disease world wide. 1 It is a progressive disease. 2 CVI includes all changes resulting from dilatations of the veins of the lower limbs, incompetence of their valves & resultant venous hypertension.Presentation of CVI varies, ranging from uncomplicated ankle edema to the most severe forms of post-thrombotic syndrome. 35][6] Venous leg ulcer is certainly one of the most severe complications of CVI.Its prevalence in the general population is between 0.1% and 3.2%. 7here is no study on CVI in our country.This study was designed to see various mode of presentation of Chronic Venous Insufficiency, to find out the risk factors and to see relationship of various symptoms of Chronic Venous Insufficiency with age, sex & body mass index of the patients.

Materials and methods:
This prospective study was carried out in the OPD (out patient department) of Dhaka Medical College

Abstract:
This study was carried out in the out patient department of Dhaka Medical College Hospital.100 patients presented with chronic venous insufficiency during the period of January 2005 to June 2005 were studied to find out the various modes of presentation, risk factors and relationship of symptoms with age, sex and Body Mass Index of the patients.It was found that, maximum patients presented with heaviness in the leg (87%), followed by aching leg pain (75%), leg swelling (70%), cramping leg pain (68%), tiredness (48%), burning pain (43%), engorged leg vein (39%), restless leg at night (21%), throbbing leg pain (18%), itching (13%), various skin changes without active ulceration (7%) and active leg ulceration only 3% of cases.Increasing age of the patients, obesity, increasing number of pregnancy, prolonged standing and sitting position at work were found to be positively correlated with CVI.Advanced age is associated with more advanced stage of CVI according to clinical CEAP classification.There is almost equal sex distribution among the stages of CVI except in advanced stage, in stage C4, C5 and C6 there is 10 patients out of them 9 are male and only 1 is female.Relationship of symptoms with BMI of the patients were also sort out and found that, in C3 group of CEAP classification out of 61 patients 46 are obese according to BMI, of which 32 are female and 14 are male and only 17 patients have BMI within normal range, but in other group there is no significant difference in incidence between two groups.
Hospital.Hundred patients presented with CVI (chronic venous insufficiency) during the period of January 2005 to June 2005 were enrolled in the study.Chronic venous insufficiency was diagnosed on the basis of clinical criteria including leg swelling, heaviness, aching pain, cramp, itching, burning, throbbing, visible veins, skin pigmentations, active or healed ulceration in the leg.Each patient came to medicine out patient department of DMCH with various leg problems mentioned above was carefully interviewed, initially to exclude other cause of leg swelling such as cardiac failure, chronic liver disease, renal failure, nephrotic syndrome, thyroid disease, fileriasis, obvious arthritis in legs & taking drugs which causes fluid retention such as NSAID's, steroids, calcium channel blockers .After apparent exclusion informed written consent was taken from the patients about the motive of the study.Detailed history was taken and relevant clinical examination was done to all patients.After that, relevant investigations were done to those having suspicion of other cause responsible for edema.Findings of history, clinical examinations and laboratory investigations were recorded in a case record form.Serum albumin and urinary albumin was done in all cases and patients having hypoalbuminaemia or proteinuria are finally excluded from the study.A serum albumin < 35 mg/ dl was taken as hypoalbuminaemia and urine albumin "+" or more was taken as proteinuria in this study.Serum creatinine, ECG, CXR P/A view, echocardiography, USG of whole abdomen, CFT for fileriasis, serum TSH level were performed in suspected cases and patients having one of the disease may cause leg edema was excluded from the study.Data were coded, edited and entered into computer and were analyzed by using Microsoft Excel program keeping in view the objectives of the study.

Discussion:
The venous system is one of the largest organs of the body, and venous disease is a burden for the society and a cause of much disability. 8Chronic venous insufficiency may affect globally 25-50% of adult population and its costs both personal to individual and economic to society are well documented.Out of 100 patients 52 were female and 48 were male, this is almost equal in sex distribution, but in the most epidemiological study shows that prevalence of varicose vein is higher in females than in male. 20ifference of result may be due to that, in our community females are less aware of health related problem than male, beside this they almost reside in house and does not come out for any kind of job.So, I did not get any significant sex difference in my study.
In the Polish study, 21 they showed that, advanced form of venous pathology were more frequent in men compared with women.This finding is comparable to my study that, patient having C6 (the most advanced stage in clinical CEAP) are 3 in number and all are male.
In searching obesity, 63 patients (63%) out of 100 were obese/ overweight having BMI >25 kg/m 2 in case of male and >24 kg/m 2 in case of female.This finding is comparable with the study conducted at the Straub Clinic and Hospital in Hawaii, 22 they studied 272 patients and found that 61% of patients were overweight.Out of 63 overweight patients, 42 were female and 21 were male, this is also comparable with analysis of the Balse, 23 the Framingham, 24 and the Edinburgh 25 studies, which shows association between varicose vein and obesity or overweight, is more marked in female than in male.
According to mode of presentation, most patients of this study were presented with clinical C3 groups of CEAP classification, i.e. 61(61%) patients out of 100.We know from previous description that C3 means edema of legs without skin changes.But in the community based study of Tecumseh shows 20% of subjects affected by CVI presents with leg edema. 4umber of patients presented with active leg ulceration i.e.C6 were 3 (3%), this finding is comparable with the study conducted by Cornwall JV, Dore CJ, Lewis JD, they shows 0.1 -3.2% patients presented with leg ulceration. 7olong standing and sitting position at work has been believed to be associated with the development of varicose vein. 26Whereas some studies have pointed to a relationship between long periods of standing and increased incidence of varicose vein, a lack of association had been reported by others. 27In the women of the Edinburgh Vein Study, 25 a clear trend of prevalence was seen for the amount of time spent standing.In this study it was found that 27 (27%) patients have history of prolong standing (more than 6 hours in a day) and 35 (35%) patients have history of prolong sitting ( more than 6 hours in a day) position in work place.
In this study out of 52 female patients, 45 had 2 or more pregnancy.This finding is consistent with the results from Basle 23 and Framingham 24 studies, they shows woman with 2 or more pregnancy have an approximately 20% -30% increased risk of venous insufficiency compared to women with single or no pregnancy.

Conclusion:
CVI (Chronic Venous Insufficiency) is not so uncommon in our country.Majority of patients presented with the complains of heaviness of leg and unexplained leg swelling, sex predilection is almost same for male and female but advanced stages are more common in male patients.Increasing age is associated with more advanced stage of the disease.There are strong association of CVI with obesity, prolong standing and sitting at working place.

Table - I
Distribution of patients according to clinical CEAP classification atrophy etc and only 3 (3%) patients have active leg ulcer.(Table-V) Maximum patient presented with combination of two or more symptoms, they are shown in Table-VI, Fig.-1.
BMI of all patients were calculated and it shows that 65 (65%) patients are obese, out of them 42 were female and 23 were male.(Table-IV).N.B: LS-Leg swelling; OLS-Occasional leg swelling; P-Pain; EV-Engorged vein; U-Ulcer; SC-Skin changes

Table - VII
Distribution of patients according to family history of venous disease: Obesity is a major determinant, as we found 65 (65%) patients were obese in this study.Family history of venous disease also sorts out as a risk factor, but only 20 (20%) patients had positive family history of venous disease.Previous history of venous thrombophlebitis is also important risk factors of venous disease, but in my study only 5 (5%) patients had previous history of thrombophlebitis.Number of pregnancy is also associated with CVI, in this study 45 female out of 52 (86.53%) patients have 2 or more pregnancy, and this is shown in table-XI.Smoking is also risk factors for venous disease, in these study total 19 patients were smoker, out of them only 1 is female and 18 are male.
To find out the risk factors of CVI, age itself is a risk factor, as we have seen that increasing age is associated with advanced stage of CVI.Female sex is not such a risk, as we found sex incidence is almost equal among the 100 patients.