Pain in the leg

By Chris Fernando

Dr. Maiya says: 

Varicose veins are a fairly common occurrence in the legs and are more common in females than in males. These visible veins you see in your legs are dilated tortuous superficial veins which lie just under the skin.

These veins have dilated because of valvular incompetence. The veins in the leg have valves, which are directed upwards so that blood in them is carried towards the heart. These valves also stop blood from flowing backward. 

If for some reason or the other, these valves become incompetent, the blood then flows backwards and excessive pressure is added to the veins. This causes the veins to distend, thereby making the adjacent valves also incompetent. This goes on as a vicious cycle. The result is that the superficial veins of the legs normally not seen and which have a fully competent valve system, become enlarged and very visible due to the incompetency of the valves.

Let me explain further. As shown in the diagram, there are two sets of veins in the legs, a superficial set and a deep set. Both systems have valves, which ensure the flow of venous blood towards the heart. The deep system of veins lies in the muscles of the legs and when the muscles contract, blood is pushed towards the heart. The superficial set of veins have communications around the ankle, the knee joint with the deep set of veins. These communicating veins also have valves directed towards the deep veins so that when the muscles contract and push the blood that is in the deep vein upwards, the blood from the superficial veins is sucked into the deep veins. The valves in the communicating veins ensure this function, so in a normal person ,the veins will not be very visible or totally invisible.

In your case, however, probably due to repeated pregnancies and additional pressure on the veins, the major valve at the groin in the superficial venous system could have been subject to pressure and therefore have becomes incompetent. This could have put an additional load of blood pressure on the next valve below this, which would have given way due to pressure and the vein becomes terribly tortuous, dilated and visible. The communicating veins which are placed in strategic points around the ankle and knee in the medial aspect can also become incompetent due to this and when the muscle contracts, they will push blood out into the superficial system rather than direct it upwards.

If a patient who has these superficial varicose veins, finds considerable relief on wearing a bandage or stocking which compress the superficial veins, then he or she can be sure that the pain experienced was due to varicose veins. These superficial veins can then be removed surgically without any problem. However, if someone with dilated veins complains that the pain gets worse after wearing a bandage or stockingnet, that would indicate that the only pathway available for the blood to return to the heart has been compressed. Therefore it is probable that these veins have surfaced as a result of the deep veins getting blocked for some reason or the other. These veins cannot be removed.

There is also another test called the venogram where you inject a dye into a superficial vein of the leg and take a series of x-ray films to see the path along which the dye travels.

If you have superficial varicose veins and if the x-rays show that the dye travels freely through the deep veins and also through the superficial veins, then you can also safely remove the superficial veins which are dilated, tortuous and causing pain in the leg.

If this condition of superficial varicosity of the leg veins goes untreated, the veins will continue to dilate and at times can even bleed spontaneously and therefore lead to torrential haemorrhages. Especially around the ankle joint in the inner aspect, because of the constant high pressure the veins are subjected to due to incompetent valves, a patient can get ulcers in these areas. These ulcers are due to the high venous pressure caused by the veins, which in turn causes poor nutrition and tissue healing in these areas. In this situation, once the veins are treated surgically, the ulcers will heal.

So in a nutshell, I can gather from your complaint that you have varicosities of the superficial venous system. If your deep veins are ok, the superficial veins can be dealt with surgically. This brings me to the question of injections to the varicose veins which are useful, but if the main superficial system of veins (the long saphinous vein) of the leg which runs down the inner aspect of the leg from the groin to the ankle joint is incompetent, no amount of injections will help. This vein will have to be dealt with surgically, and however, subsequently, if a few veins crop up, then this can be injected. Also, if one has varicosities of a few superficial veins and a competent long saphinous system, injections will be most helpful.

A garbage dumping nation and Dengue

There has been some public response to the calls to work towards the eradication of this killer disease and the health authorities are no doubt doing their best to tackle the spread of the epidemic, within the framework of their limited resources. But a very pertinent question that is being asked is why Dengue rears its ugly head once every two to three years at the cost of a few dozen lives in every epidemic. 

The microbiologists and the epidemiologists will have their own answers but is that good enough? After all, in this day and age when technological advances in medicine are such that one can survive with a transplant even after discarding one's own kidney, lung, liver or even heart, it appears to be a crime to sacrifice one's life to a mosquito-borne disease! 

A well-worn axiom in preventive health is that prevention is better than cure - and Dengue fever is a case in point. 

Our grouse is that those who plan health policy and those who practise preventive medicine are quick to jump on the publicity bandwagon during an epidemic- but quickly go into hiding when the epidemic wears off. Right now, there is almost a religious fervour in trying to clean up garbage dumps and trying to contribute towards the Dengue control effort. But experience tells us that this enthusiasm is quickly forgotten and we will once again become the dirty, garbage-dumping nation that we usually are, once this epidemic settles. 

A somewhat similar mosquito menace contributed to the spread of Malaria and Filaria some years ago. When the disease was taking its toll special campaigns were set up within the Health Ministry to tackle the menace and Malaria once came to the point of eradication thereafter. 

Even now, these diseases are by and large under control though they still cause some morbidity. 

Maybe there is a case now for similar action against Dengue. Preventive measures need not necessarily be a specialized campaign to combat the disease.

But, there should be adequate measures to ensure that mosquito control measures are in place and being implemented, long after the epidemic is forgotten. To blame the local urban council or pradeshiya sabha for dumping garbage when an epidemic erupts is to pass the buck and that is not enough. It is time then for some meaningful, long-lasting measures to be taken against Dengue. 

But the big question is how many more epidemics- and lives, most of them of children- will it take for all those responsible to be roused out of their intellectual slumber? 

Irritable bowel?

Because the cause is unknown, emotional or psychological factors are often blamed. While these can make it worse, they are not the answer. What research is starting to show is that people with IBS seem to have a colon (also called the large bowel) which is super-sensitive. In IBS the bowel responds with powerful contractions or spasms to stimuli which wouldn't bother other people, even to things such as simply eating food. 

While there is no permanent cure as yet for IBS there is a lot you can do to identify your triggers and avoid them: 

* Keep a food diary- Try to work out how your diet relates to your symptoms by comparing what you have eaten with bad attacks. 

*The gut normally responds to food by contracting, and the strength of the response seems to be linked to the amount of fat in the meal. So try to cut down on the fat in your diet. Avoid fat-rich foods such as dairy foods, make sure your milk is skimmed, and cook with minimal fat by baking or microwaving food rather than frying or roasting. 

* Make sure you are getting enough fibre, which can help to reduce IBS symptoms by keeping the bowel slightly distended and preventing spasms. Good sources include whole grain breads and cereals, beans, fruit and vegetables. Avoid large meals which can trigger spasms and eat small amounts more often. Yoghurt and curd may also help. 

* Don't self medicate, get expert help -There are medicines which can help to reduce spasm in IBS. Talk to your doctor, especially if symptoms are really bothersome. 

Occasionally chronic gastro-intestinal infections can lead to symptoms such as yours, so it is important that you see your own doctor so that they can make sure the diagnosis is IBS. Also if you ever notice that you pass blood when you open your bowels, get checked by your doctor as this isn't normal even in IBS.

College of Forensic Pathologists inaugurated 

In his presidential address, Dr. Alwis observed that Forensic Medicine has been a neglected branch of medicine in Sri Lanka owing to the shortage of forensic pathologists for whom there was a cadre in the Department of Health for 44. There are only twelve forensic pathologists in service. 

A wrong impression that forensic pathologists deal only with the dead when they in fact undertake clinical medical examinations on a vast array of patients has contributed to this, Dr. de Alwis noted. He called for greater incentives for young doctors to take to Forensic Medicine as a career in the form of better avenues for postgraduate studies, compensation for lack of private practice and better working conditions. 

Dr. Alwis also called for the creation of a separate medico-legal service in the Department of Health with an efficient administrative set-up under a director who will be responsible for providing a satisfactory medico-legal service to the entire country. This would entail the provision of adequate trained staff and facilities within each province and remove the need for all major medico-legal examinations to be done in Colombo as it presently happens, he observed. 

Dr. de Alwis also said the new College hoped to collaborate with the Judicial Services Commission and the Department of Health to rectify the issue of non-availability of medical reports which he said could be a major cause for delays in legal work. He also proposed the setting up of a Medico-Legal Institute in Colombo to train and employ specialists in the sub-specialties in Forensic Medicine in advancing fields such as DNA studies. 

Dr. de Alwis noted that every government medical officer is expected to be an expert in Forensic Medicine in performing his duties and that as such training in the subject should be adequate. He also noted that the teaching of the subject to foreign qualified medical graduates is either grossly inadequate or not suitable for the requirements of our country. The new College will rectify these shortcomings, he said. 

All future programmes and actions of the newly inaugurated College will aim to provide an efficient medico-legal service as it has a direct bearing on the administration of justice and maintenance of law and order, the cornerstones of a just and civilized society, Dr. Alwis concluded. 

A tied issue

Birth control is now no longer confined to the female partner. Increasingly more and more males are opting for a simple surgery- the 'vasectomy' - to plan their families. Here are some frequently asked questions about this procedure: 

Q: What is the process? 

A: Vasectomies usually done under local anaesthetic take about 30 minutes. This means the patient can have the procedure in the morning and return home in the afternoon. There are several different techniques for vasectomy. In the conventional operation, the skin is numbed and then the surgeon makes one or two cuts, in the skin of each side of the scrotum. He then cuts and removes a small piece of the vas, which is the tube that carries sperm out from the testes. The cut ends of the vas are then tied to close them off and the wound is sewn up. This procedure is then repeated on the other side of the scrotum. 

Q: When can you go back to work? 

A: Afterwards the patient may be a bit sore for a few days, but should recover fully within a week. Quite a lot of men have a vasectomy on a Friday and are back at work on Monday. Complications are fairly uncommon and usually minor. 

Q: When can you have sex again? 

A: A man can have sex again within a few days - when he feels comfortable. But he will still be producing active sperm for some time. 

The usual recommendation is for the couple to use alternative contraception until the man has had two semen samples free of sperm. 

Q: Are there any long-term risks? 

A: There are four facts that a patient needs to be aware of: 

- A recent major British study of side effects found that only one condition was more common after vasectomy. This was epididymitis or orchitis, which causes a painful, swollen, and tender testes. It most often occurs during the first year after surgery, but is easily treated. 

- Although it is extremely effective for preventing pregnancy, vasectomy does not offer protection against AIDS or other sexually transmitted diseases. Consequently, it is important that vasectomized men continue to protect themselves if there is a risk of sexually transmitted infection. 

- Very rarely the vas can recanalise - it can join up again and sperm get through, so you are again able to father a child. But this risk is extremely small with modern techniques. It occurs once in about 500 vasectomies, i.e. about 0.2% of men (compared to 0.5% of women who have their tubes tied). 

Q: Will it affect my sex drive? 

A: vasectomy does not affect production or release of testosterone, the male hormone responsible for a man's sex drive, beard, deep voice, and other masculine traits. The operation also has no effect on sexuality. Erections, climaxes, and the amount of ejaculate remain the same. 

Q: Does vasectomy mean permanent sterilization? 

A: Although vasectomies can be reversed, the success rate is not high. You should treat the operation as an irreversible step. 

Q: How much will it cost? 

A: Vasectomy is done free at government hospitals and state-run family planning clinics. In fact, as an incentive for family planning, a payment is made for males undergoing a vasectomy! 

Prevent a stroke - strike at risk factors 

Age - the risk of a stroke more than doubles with each decade of life after 55.

Family history - there is no doubt that you have a greater risk of having a stroke if someone else in the family has had one. This may be linked to factors such as high blood pressure, which also run in families. 

A previous stroke or TIA - once you have had a stroke, the risk of having another one is much greater than for a person who has never had one. A person who has TIAs (Transient Ischaemic Attacks or mini-strokes) is 10 times more likely than others to have a stroke. 

High blood pressure - the risk rises directly as blood pressure does. 

This is the most important risk factor for stroke, and you should make sure that your blood pressure is checked at regular intervals even if you are not a known patient with high blood pressure because some such patients are detected for the first time only after they have a stroke! 

Smoking - chemicals in cigarette smoke, such as nicotine and carbon monoxide, damage the heart and blood vessels, and greatly increase the risk of stroke. As this is a particularly important risk factor, there is something you can do about it - STOP smoking. 

Diabetes - this increases the risk, especially when badly controlled and associated with a raised cholesterol and being overweight. 

Heart disease - this doubles the risk, especially if you have a condition called atrial fibrillation. 

Stress- constant stress, even at work has proven to be a vital precipitant of strokes for many patients who may or may not have other risk factors. 

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