Ever since the NICE report of July 2013 (NICE CG 168) we have known that one of the optimal ways to treat leg varicose veins is endovenous laser treatment (EVLT). However many of my patients ask if haemorrhoids (or "piles") can be treated in the same way. There are certainly some doctors who do so and some companies that make equipment for this procedure - but is it the right way to treat them or is it just a fad because "lasers are sexy"?
To answer this we need to know firstly if piles or haemorrhoids have any link to leg varicose veins and secondly what would be the optimal way to treat them.
Looking at the first of these questions, ever since I set up my first website on veins in 1999 (www.veins.co.uk) I have had a regular stream of enquiries asking if haemorrhoids are the same as varicose veins. Back in 1999 we thought they were very different, being varicose veins in the anal canal and nothing to do with the legs.
However, over the last decade, our understanding of how leg varicose veins are linked with pelvic varicose veins has increased significantly (See my previous post, Varicose Vein Surgery Fails One In Five Women), and we have discovered that vulval and vaginal varicose veins in women are just examples of how leg and pelvic varicose veins are linked as one condition (www.vulval-varicose-veins.co.uk).
Therefore it was only a progression of our studies that led us to our recent peer-reviewed research publication showing that haemorrhoids were associated with pelvic varicose veins in women who we tested ("Haemorrhoids are associated with internal iliac vein reflux in up to one-third of women presenting with varicose veins associated with pelvic vein reflux"). This research showed that just as leg varicose veins have a long hidden truncal vein feeding blood into the visible bulging varicose veins, haemorrhoids have a hidden underlying vein called the internal iliac vein, letting blood "reflux" or fall back into the haemorrhoid and causing it to bulge.
Over the last 100 years or so, it has become evident that to treat leg varicose veins successfully, we need to treat the underlying hidden vein first. This stops the blood from refluxing into the bulging varicose veins and so when they are treated, there is no pressure of flow from the deeper hidden vein trying to make them come back again.
A far as haemorrhoids are concerned, the anatomy has many parallels and so the principles of treatment should be the same or similar.
However, as haemorrhoids are usually treated by bowel surgeons with little research or interest in venous surgery, traditionally haemorrhoids have just been chopped out - not only a very painful operation but also leading to recurrence in a large proportion of cases.
More recently doctors have been treating the artery taking blood into the haemorrhoid (the "haemorrhoidal artery") either ligating this or closing it with laser. However this is totally illogical, as it does not get to the underlying cause - the deeper hidden internal iliac vein that is allowing blood to reflux backwards with gravity and straining into the haemorrhoid.
As the internal iliac vein lies within the pelvis, passing a laser into this vein itself would result in the risk of burning sensitive structures such as bowl or ureter. Hence research is now focussing on the treatment of these veins using techniques that destroy this pelvic vein and the haemorrhoid itself without heat - such as foam sclerotherapy and coil embolisation of the vein under x-ray control.
Thus despite the love that both the public and the medical profession have for any treatment that includes a "laser", when it comes to the future treatment of haemorrhoids (or "piles") it is likely that other treatments that destroy the underlying feeding vein in the pelvis and that do not cause heat to be produced, will turn out to be...
Over the last year, there have been an increasing number of reports in the national media about health problems linked with sitting all day at work. Being seated all day seems to be associated with a plethora of problems not least of which include heart disease, diabetes and of course, obesity. Many reports have focused upon the obvious opposite of this - to stand all day at work. They have even gone so far as to suggest desks that can be raised to different levels, allowing workers to adjust their workstations to their own height allowing them to stand rather that sit all day. However, is this what the research has actually suggested?
There is a world of difference between saying that sitting all day causes health problems due to inactivity and supposing that standing all day is the solution.
Standing for long periods of time has its own problems. Most importantly in my world, professions that demand long periods of time standing such as hairdressers, teachers and even surgeons, have been shown to have far more severe venous diseases when they have varicose veins than those in more sedentary jobs. It is important to highlight that it is not the standing that causes varicose veins; rather it is in the 20 to 30% of people who have venous reflux disease (varicose veins or "hidden varicose veins") that deteriorate far faster when having to stand for long periods throughout the day. This deterioration increases the risks of thrombophlebitis, skin changes such as brown stains or venous eczema around the ankle and even leg ulcers.
So before advocating standing for all office workers, we have to be pretty certain that standing all day is beneficial.
Although almost any doctor would agree that sitting all day with minimal exercise is not good for a variety of health reasons, it is not a logical step to think that standing will have the opposite effect. Indeed, it is much more likely that a far bigger benefit would be found from those that sit at work but who get up to their feet regularly, emulating a partial "squat" advocated at almost every keep fit class on the planet. The more a person stands up from their chair and then sits down onto it, the more exercise they are doing and the more benefit they will be doing their heart, muscles, bones and of course, veins. If they then decided to add a walk of a few paces on top of this action, it would only be to the good.
Before trendy businesses decide to jump on the standing only bandwagon and get rid of their chairs and sit-down desks, replacing them with more complicated and potentially more expensive variable height desks to stand at, I would suggest proper research is done. We already know sitting is not good for long periods of time for us. We need to identify what advantages, if any, standing all day might have over sitting and indeed what other health problems this might cause. Anyone sensible enough to start this research should also add in a third group - people who sit all day but every 15 to 30 minutes stand up and sit down 5 to 10 times a row or stand up, walk 20 paces and sit down again.
I suspect that as with many things in life, when a problem is found, the simple opposite of the cause of the problem is not always the solution. Sometimes common sense and understanding of the problem can lead to a far better solution which does not have increased economic and organisational...
*This video contains graphic images of leg ulcers
Leg ulcers are a horrible condition that can not only cause pain and suffering to the person with the condition but also affects everybody around them. Patients with leg ulcers often have to give up work, become housebound and can change from independent people to patients requiring constant help and assistance from family, friends, carers and healthcare professionals.
With an ageing population, the number of people with leg ulcers is set to increase if nothing changes.
What is absolutely amazing, as I discussed in a previous post here, is that at least half the patients with leg ulcers could be cured if only they were referred for proper assessment and treatment.
Last summer, research which was undertaken within my clinic was published showing that we can cure the majority of patients with leg ulcers with simple local anaesthetic procedures, less expensively than long-term compression dressings and nursing care.
In July 2013, the National Institute of Health and Care Excellence (NICE) produced guidelines about varicose veins that even recommended that patients with leg ulcers that had not healed after two weeks should all be referred to a specialist vascular unit for assessment.
So why isn't this happening?
Without doubt, leg ulcers are not sexy. As such many doctors do not treat them themselves and instead defer them to nursing staff to carry out the treatment.
Nurses are, of course, the caring profession and strive to provide the best possible care for their patients. However, I was very surprised to find that when a daily newspaper showed interest in publishing our research that the majority of leg ulcers can actually be cured, the article was pulled from publication following concerns from the nursing led "leg ulcer forum".
As such, most patients with leg ulcers are kept in the dark that there might be a cure for them, if only they were referred to a specialist vascular unit. In the UK this is not an NHS vs. Private Healthcare argument - the investigations and techniques needed to cure these ulcers are available in both sectors. The problem is whether the professionals in charge of the patient with leg ulcers know that there are cures available and advise the patient and help them to seek further investigation.
I have a great many patients whose lives have been changed from one of dependency and being house-bound to being active and able to enjoy family or social life outside of the home once again.
It is because I want to help other patients to follow this path that I have helped set up The Leg Ulcer Charity. The aims of this charity are clear - to help educate patients, their families and carers and any health professional who wants to learn in the new ways that leg ulcers can be cured in the majority of patients.
The charity also funds research and is currently funding a Ph.D. student through the University of Surrey who is measuring the social effects of leg ulcers on patients and their close circle of family and friends.
It is our hope that the Leg Ulcer Charity will grow to be instrumental in helping everyone understand that patients suffering from this horrible condition should not be left to suffer and instead should be helped to find a cure to get them back on their feet and get back to a fully active...
This week sees the 15th anniversary of the first minimally invasive varicose vein operation in the UK and what a massive difference has occurred.
On 12 March 1999, my colleague Judy Holdstock and I performed the first endovenous procedure in the UK for varicose veins. Using a device called the...
Pseudo-medical claims are nothing new. As far back as history can record, there have been claims made for "miracle cures" for a whole variety of medical conditions. Most of these are to promote a belief system to gain followers or promote a product to earn money.
Of course this does not mean that all claims of "miracle cures" should be dismissed. Some will have been based upon personal experience or observation of others whilst others may be correct, even if largely by luck. The role of medical science is to try to understand the disease processes, test any such claim of a "cure" and then to see if our understanding of the disease processes can be modified if an unexpected success or failure of a treatment can be found.
I personally do not believe in the distinction between medicine and "alternative medicine". I would simply say, if something works to cure or alleviate a medical condition it is medicine and if it does not, it is not medicine. To label something as "alternative medicine" seems to be more of a marketing ploy than a classification based on any logic. There will always be a proportion of the population that wants to prove that everybody else is wrong and who will spend money on something that is somewhat an antiestablishment. I do not mind this provided people are not misinformed by false claims.
The Internet has had a massive impact into the dissemination of information throughout the world's population. As with all technology, this can have both good and bad consequences. From a medical point of view and on the positive side, patients and interested parties are now able to access medical information and research, allowing virtually anyone to check information about possible diagnoses and treatments. However on the negative side, it also provides a highly effective medium for "miracle cures" to be peddled to an information hungry public.
By the very nature of the complexity of science and research, the number of people able to produce good quality and accurate medical articles are going to be far fewer than people who will write an article on a condition that they know little or nothing about and a treatment they either sell or are personally passionate about. These latter articles and associated adverts appear all over the Internet and often make it very difficult for those that have a medical condition to identify what is safe medical information and treatments.
One of the many pseudo-medical claims that now appear widely on the Internet is the use of yoga to "treat" varicose veins.
A brief search today on Google for "yoga treatment for varicose veins" resulted in over 250,000 links to journals, books, DVDs and classes for those with varicose veins wanting a cure.
Contrast this with a search of the PubMed database for any research published in a scientific journal anywhere in the world linking the two, and not a single relevant paper or case report is found.
Could it be that yoga is so effective for treating varicose veins that research publications are unnecessary? This, of course, is not the case as such a revolutionary treatment for such a common condition would have had at least one major trial to prove it so that healthcare providers would fund it for patients.
So is the successful treatment of varicose veins by yoga a "pseudo-medical" claim? Reading many of the websites promoting this idea, almost all of them has a brief description of varicose veins as "twisted" or "distended" veins in the legs and most state that they are caused by "damaged valves". We know that when we stand up, even normal veins in the legs swell like varicose veins, and when we lie down they disappear. Furthermore, exercise pumps the blood out of the leg reducing the pressure in the varicose veins.
However, simply elevating the leg or exercising the leg muscles doesn't "cure" varicose veins any more than elevating the legs in bed at night does. Following a yoga session, as soon as the sufferer stands up again, the valves will still fail and the varicose veins will still be there.
So what should we do about the pseudo-medical claims made by yoga enthusiasts that they can cure varicose veins? Simply, if anyone really does believe that yoga can cure varicose veins and are not just making such claims to sell products or promote classes, then all they need to do is to set up a clinical study to prove their point and publish the results.
Until such a trial is performed and reported, I think that it would be safe to conclude that yoga is excellent exercise with many positive benefits which can even relieve the aching of varicose veins - but any claims of a cure should be dismissed as...
Many people seem to think that varicose veins affect older people or women after pregnancy. A large number of my younger patients, who are otherwise fit and well, often express great surprise that they have varicose veins, as if they are "too young" to get them. Even more interestingly, the majority of the celebrities that I treat readily tell me that they are more embarrassed about having varicose veins than they would be about having a great many other medical conditions and treatments. They frequently say that to own up to having had varicose vein treatment would make them feel as if their peers would be judging them adversely.
As such, it should not be much of a surprise to find that many parents completely miss quite significant varicose veins on their children's legs, assuming that the bulges that they can see could not possibly be varicose veins.
Fortunately, severe varicose veins needing treatment is not common in children. However, as with all medical conditions, if varicose veins are present and if they are starting to cause symptoms or tissue damage, they should be investigated fully by a duplex ultrasound scan regardless of the age of the patient. In addition, any treatment required should also be based upon the severity of the veins and the duplex ultrasound scan, not based on whether the patient is a child or an adult.
Last year a mother and father, both of whom I had treated for their severe varicose veins, brought their 12-year-old son for assessment. He had very large bulging varicose veins on both legs which, when he laid down and elevated his legs, disappeared. Duplex ultrasound scanning showed that he had lost the valves in all four of his major truncal veins which were all massively dilated. He was offered the new pinhole endovenous surgery that we have been promoting since 1999 and has now been approved by the National Institute for Health and Clinical Excellence (NICE).
Despite being only 12 years old, his veins responded exactly the same as any adults to treatment. The biggest difference came when I phoned up the day following surgery to check he was all right, to find he was already out playing football with his friends!
Over the last decade, we have treated numerous 15, 16 and 17-year-olds patients with severe varicose veins. Of course this is a very small proportion of the total number of patients we have treated but it does show that this condition can affect children and young adults. In the last year we have also had a 19-year-old young man who had a persistent ulcer on one of his ankles. His local doctors believed that he was too young to have an underlying vein problem and so kept ordering him to have dressings being certain that this would heal.
Eventually he came to our clinic and we found the underlying "hidden varicose veins" medically known as venous reflux or chronic venous incompetence. It was obvious he had been suffering with the condition for many years and the constant damage had slowly affected the skin causing a leg ulcer. This story is the same as the majority of venous leg ulcers, the only surprising thing being his age. Not surprisingly, with good duplex ultrasound scan and endovenous surgery under local anaesthetic, the veins were cured and the ulcer also went away without any dressings whatsoever.
Back in 1999 when I was a junior doctor, I ran a research study looking at how common varicose veins are in school children. Rather than just look at visible varicose veins on the surface, we used Doppler and another method called PPG (photophlethysmography) to see how many school children had already lost their valves - the so-called "hidden varicose veins", that can lead to either varicose veins or inflammation around the ankles such as swelling, skin discolouration or eczema. Rather shockingly, we found that 1 in 20 schoolgirls had already lost valves in their leg veins at age 9, and by age 18, 1 in 9 had "hidden varicose veins" or venous reflux.
So all in all what can be said about children and varicose veins?
Firstly, significant varicose veins in children are uncommon. The underlying cause, valves in the leg veins becoming incompetent, starts surprisingly young. This probably means that the progression from the valves giving way to having symptomatic varicose veins or other venous problems such as swollen ankles, discoloured skin, venous eczema or venous leg ulcers, is very slow in the majority of people. However in some children, varicose veins and venous damage seems to occur early. Fortunately with the correct duplex ultrasound examination and endovenous surgery, they seem to respond exactly as an adult would.
Therefore it is important to know that children can have varicose veins or the associated complications with "hidden varicose veins" and, if symptomatic varicose veins or other signs of venous disease do appear, it should be investigated fully and not ignored because the person is "just too young to have varicose...
It is amazing how many people claim to have had "phlebitis". The term seems to be used by the general public and many doctors and nurses to mean any pain or inflammation in the lower legs. In fact, it is a term so commonly used that many people think they...
Recently I saw a charming 27-year-old lady with recurrent varicose veins in both legs. Two years ago, she had gone to a local "vein clinic" where a doctor had performed a scan and told her she could have the latest laser treatment for her veins. Happy she was having the...
There are few more exciting things in life than when someone completely redefines our whole understanding of a common problem. History is littered with such eureka moments - for example when Albert Einstein predicted that light could be bent by gravity. When this happened during an eclipse it led to...
Endovenous surgery (or "keyhole" surgery for varicose veins) started in the UK in March 1999 when I performed the first endovenous operation in the country. Since that time, myself and my team have been showing the advantages of this new approach over the old "tying and stripping" surgery.
Varicose veins and "hidden varicose veins" (medically called chronic venous incompetence) affect an awful lot of people. Research suggests 15 to 20% of the adult population suffer with visible varicose veins and around the same number suffer with hidden varicose veins.
Research also suggests that even if you could magically...
For the first time in my life I feel like a dinosaur. Not the big lumbering sort portrayed in Jurassic Park, but rather the rows of respectable dinosaurs that used to sit in medical conferences in late 1999 and the early 2000's, pouring scorn on my work into fixing varicose...
Treatments for varicose veins have changed beyond recognition over the last ten years.
Up until 1998, the only real option for the treatment of varicose veins and associated conditions (such as venous leg ulcers) was the infamous tying and stripping of varicose veins. This was painful, resulted in two weeks...
Deep vein thrombosis (DVT), a blood clot in the deep veins of the legs, is always going to be a matter of concern. Worryingly however, recent NICE guidelines have highlighted an additional concern for those found to be suffering from the condition - the fact that a DVT might indicate...
I recently managed to annoy vascular surgeons from around the world with an article I wrote for a magazine. In the article I suggested that patients should seek treatment for varicose veins from a doctor who is both actively involved in varicose veins research and who also performs varicose vein...
Many people are not really sure what leg ulcers are. However, once you have seen one for yourself or, worse still, developed one yourself, you will never forget it. Leg ulcers are non-healing open sores of the lower leg, that need constant dressing and cleaning. For many people, they can...
It's fair to say that there is somewhat of a baby boom sweeping across the celebrity world at the moment. For many of the leading ladies involved in this 'pregnancy epidemic' it is their first foray into motherhood, which undoubtedly will involve an array of physical and emotional experiences as...
How many people have botox and fillers?
This question vexes me.
I can hardly pick up a paper or magazine, or turn on the TV without seeing stories about aesthetic treatments - usually Botox and fillers. These treatments seem to be an obsession with the whole of the...
It has recently been reported that over 52,000 people across the UK have been denied NHS treatment for painful medical conditions such as varicose veins.
In healthcare, as in many areas of life, we are often told by 'the powers that be' that the best way forward is to...