A 53-year-old woman comes to the office due to aching pain in her legs. She is a hair stylist and has cut down on her work hours due to the discomfort. The patient has a history of migraine and untreated chronic hepatitis C. She smokes a pack of cigarettes daily but does not use alcohol or illicit drugs. Physical examination findings are shown in the image below. An abnormality of which of the following is the most likely cause of this patient's symptoms?

Question

A 53-year-old woman comes to the office due to aching pain in her legs.  She is a hair stylist and has cut down on her work hours due to the discomfort.  The patient has a history of migraine and untreated chronic hepatitis C.  She smokes a pack of cigarettes daily but does not use alcohol or illicit drugs.  Physical examination findings are shown in the image below.  An abnormality of which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec160b_3a86_3d47_9249_eb9b99693d72_MD0001_00 Venous blood normally flows from superficial veins through perforating veins into the deep veins of the extremities. Blood from the deep veins then travels upward and eventually drains into the inferior vena cava. Valves located in the superficial, perforating, and deep veins prevent backward flow from deep to superficial veins. Chronically elevated intraluminal pressure can lead to dilation of the veins (varicose veins) and incompetence of the valves. This allows retrograde flow into superficial veins and results in a further increase in venous pressure. The resulting tissue ischemia causes venous stasis dermatitis and is associated with poor wound healing. Extravasation of red blood cells into the tissues leads to iron deposition and the characteristic brawny discoloration. This patient has dilated superficial veins (red arrows) and associated skin changes consistent with stasis dermatitis (black arrows). Common risk factors for varicose veins and stasis dermatitis include obstruction of venous return (eg, obesity, pregnancy) and conditions that damage the venous valves (eg, deep venous thrombosis). Prolonged standing and sedentary lifestyles are also associated with varicose veins. (Choice A) Atherosclerotic changes of the arterial intima predispose to peripheral arterial disease. Arterial occlusive disease of the lower extremities presents with leg pain during exercise (claudication) and, if severe, ischemic pain at rest and possible distal gangrene. (Choice B) Increased capillary permeability is associated with anaphylaxis and other allergic reactions, inflammation, and shock. Increased capillary permeability causes edema due to the extravasation of serum contents into the interstitium. Capillary permeability does not play a role in the development of varicose veins. (Choice C) Obstruction of lymphoid capillaries produces lymphedema, with marked swelling of the dorsum of the distal limb that may extend proximally. It is initially soft and pitting but eventually becomes firm and nonpitting due to progressive fibrosis and thickening of the overlying skin. (Choice D) Decreased plasma oncotic pressure results primarily from low plasma protein content, as may be seen in malnutrition, nephrotic syndrome, cirrhosis/liver failure, or protein-losing enteropathy; it results in generalized edema. Cirrhosis with portal hypertension can cause esophageal and anorectal varices as collateral channels from the portal to systemic circulation. However, lower extremity veins do not communicate with the portal circulation. (Choice E) Narrowing of the arterioles of the vasa vasorum in chronic hypertension can lead to medial ischemia of the aorta and contribute to aneurysm formation. Educational objective: Chronically elevated venous pressure in the lower extremities can lead to incompetent venous valves and venous dilation (varicose veins). Venous congestion and tissue ischemia can result in venous stasis dermatitis.

A 53-Year-Old Woman Comes to the Office Due to Aching