Varices, varicosities and disorders of the lymphatic vessels

1. Varices / varicose veins

Varices = abnormally dilated, tortuous vessels in the venous system. Varicose veins (varicosities) are dilated, tortuous veins produced by prolonged ↑ intraluminal pressure + loss of wall support, typically in the superficial veins of the legs.

• Risk factors: female sex, pregnancy, aging, prolonged standing.
• Pathogenesis: dilation → venous valve incompetence → stasis, congestion, edema, thrombosis.
• Morphology: wall thinning (elastic degeneration) at points of maximal dilation; SMC hypertrophy + intimal fibrosis in adjacent segments; focal intraluminal thrombosis; valve deformity.
• Clinical course: valve incompetence → stasis → limb edema, ischemic skin changes/ulceration, poor wound healing, superimposed infection.

2. Varices at other sites (portal hypertension)

Liver cirrhosis → portal hypertension → opening of porto-caval anastomoses → dilated veins at:

• Gastro-esophageal junction → esophageal varices — clinically most important: rupture → massive, potentially fatal upper GI hemorrhage.
• Rectum → hemorrhoids.
• Periumbilical abdominal wall veins → caput medusae.

3. Thrombophlebitis & phlebothrombosis

Interchangeable terms for venous thrombosis + venous inflammation, mostly in the deep veins of the legs (also periprostatic / pelvic venous plexuses).

• Causes (Virchow stasis/hypercoagulability): prolonged immobilization (bed rest, long flights/drives), congestive HF, neoplasia, pregnancy.
• Trousseau syndrome: migratory thrombophlebitis (thrombi appearing in different beds at different times), classically with visceral malignancy.
• Symptoms: pain on pressure / calf squeeze, calf pain on dorsiflexion.
• Major significance: pulmonary embolism.

4. Vena cava syndromes

	Cause	Result
SVC syndrome	Neoplasm compressing/invading the SVC	Dilated head/neck/arm veins with cyanosis
IVC syndrome	Neoplasm compressing/invading IVC, or upward-propagating thrombus (hepatic/renal/lower-limb veins)	Lower-limb edema, distended lower abdominal veins, proteinuria

5. Lymphatic diseases

Primary lymphatic disorders are rare; secondary disease (malignancy, inflammation) is far more common.

• Lymphangitis: acute inflammation when bacterial infection spreads via lymphatics; dilated lymphatics filled with neutrophils + monocytes. Signs: red painful subcutaneous streaks, acute lymphadenitis, possible bacteremia/sepsis.
• Lymphedema: localized fluid retention from a compromised lymphatic system.
  • Primary: isolated or familial defect.
  • Secondary (obstructive): malignant tumor, surgical lymph node removal, post-irradiation fibrosis.
  • Consequences: ↑ hydrostatic pressure behind obstruction → interstitial fluid → persistent edema → ↑ interstitial CT deposition → brawny induration / “orange-peel” skin → ulceration; ruptured dilated lymphatics → chylous fluid accumulation.

💡 High-yield: Varicose veins = valve incompetence → leg stasis/ulcers; in cirrhosis/portal hypertension → esophageal varices (fatal UGI bleed), hemorrhoids, caput medusae. DVT/thrombophlebitis (immobilization, HF, cancer, pregnancy) → risk of PE; migratory = Trousseau (malignancy). SVC syndrome → facial/arm congestion + cyanosis. Lymphedema → brawny non-pitting “orange-peel” skin; commonest secondary cause = post-mastectomy/radiation.