Fatal haemorrhage from varicose veins: is the correct advice being given?

Summary

A case report is presented illustrating the occasional sinister nature of varicose veins, revealing the need for assessment of haemorrhage risk of the patient and appropriate advice.

Introduction

An 85-year-old man was referred to the vascular outpatient department at Worcestershire Royal Hospital by his GP for assessment of his varicose veins, which had bled quite briskly on the morning of the referral letter being written.

He was seen in the outpatient clinic where he underwent full clinical assessment, and a venous duplex scan revealed a right sapheno-femoral junction incompetence. Very superficial varicosities were noted in the gaiter area of the right leg. The left leg was unremarkable, and there were no previous medical conditions or medications reported. The patient was booked for an urgent foam sclerotherapy using 3% Sodium TetraDecyl Sulphate (STD). An appointment was made for this sclerotherapy six weeks after the outpatient clinic.

Four weeks following this clinic visit police found the man dead in his bath, with the bath full of blood. Forensic pathologists investigated as there was concern about the apparent violent nature of the death. A Coroner's post mortem was carried out and this found that the cause of death was circulatory collapse secondary to hypovolaemia following a bleed from the varicose veins on the patient's right leg.

Discussion

Varicose veins are a very common condition, with the 1992 London Study¹ showing a prevalence of 25% amongst 35–70 year olds, while the 1999 Edinburgh Study,² in contrast with other studies, demonstrated that 32% of women and 40% of men had truncal varices.

Advice regarding haemostatic control is not routinely given to varicose veins patients. The cause of the severity of this patient's haemorrhage is debatable. A predilection for bleeding is suggested by the initial haemorrhage that precipitated referral, but he had no documented coagulation anomaly. The venous system is under low pressure and hence coagulation via the coagulation cascade should occur spontaneously.

A degree of venous hypertension is found in varicose vein patients and poor healing due to venous compromise could have led to ulcer formation at the site of initial bleeding, though this was not documented. Warm bathwater may have been a contributing factor due to peripheral venodilatation.

A degree of venous hypertension would be present in these patients, but sitting or lying in the bath would have alleviated this. An ulcer may have formed at the site of the previous bleed due to the impaired healing caused by venous compromise, and indeed the site of the previous bleed may not have healed fully or may have re-bled in the intervening period. It is certain, however, that a warm bath will cause venous bleeding to be more pronounced.

As this gentleman was living alone, there was nobody to provide assistance when he began to bleed, and nobody present to call for an ambulance. This case highlights the importance of this part of the social history, both in the primary and secondary healthcare settings.

The paucity of literature on this topic belies the rarity as a documented cause of death. In 1973 Evans et al.³ reported 23 cases from postmortem records in England and Wales. There were sociological inferences made in this retrospective paper, with all but one of the fatalities living alone at the time of death. Wigle and Anderson reported one case of a 48-year-old woman who died secondary to haemorrhagic shock following a very large haemorrhage from a varicosity on her right leg in 1988.⁴ Morrow et al. reported three cases in 1994,⁵ and Racette and Sauvageau also reported two cases in 2005.⁶

Conclusion

Fatal haemorrhage is a rare but well-documented complication of varicose veins. Patients with particularly prone varicosities, coagulation anomalies or anticoagulation therapies and those who have had previous bleeds are especially at risk. Those living alone may be at risk of overwhelming haemorrhage or hypovolaemia.

All varicose vein patients should receive haemostasis advice. This advice should explain leg elevation and bleeding point pressure to ease or cease bleeding. This case highlights the point that varicose veins are not always as benign as they are often perceived. Haemorrhage should be treated seriously and appropriately, and prompt varicosity treatment should be sought if the patient is at particular risk of haemorrhage.

With hindsight, other than haemorrhage advice the best treatment for this patient may have been in a one-stop clinic, in which evaluation, assessment and treatment could all have been undertaken in the same visit. Attempts to start such a one-stop clinic at Worcester Hospital have been made, and hopefully this will begin in the near future.

Footnotes

DECLARATIONS —

Competing interests None declared

Funding None

Ethical approval The patient consented to publication

Guarantor IKN

Contributorship Both authors contributed equally