GPAtlas🧭 When to suspect
Suspect chronic venous disease in any patient with the symptoms and signs of sustained venous hypertension in the legs.
The clinical spectrum runs:
• From visible varicose veins and aching, heavy legs.
• Through dependent oedema and skin changes (venous eczema, haemosiderin staining, lipodermatosclerosis).
• To frank venous ulceration, classically over the medial malleolus – the gaiter area.
Disease is diagnosed clinically. Duplex ultrasound is a specialist investigation that maps reflux for treatment planning, not a primary-care screening test.
The two jobs in primary care are simple:
• First, recognise the venous pattern and refer appropriately.
• Second, exclude the dangerous mimics – deep vein thrombosis, an arterial or mixed ulcer, and an underlying abdominopelvic cause.
Suspect abdominopelvic venous disease where there is lower-limb incompetence with recurrent DVT, or pelvic congestion (chronic pelvic pain, or left flank pain with haematuria).
| CEAP clinical class | What you see |
|---|---|
| C0–C1 | No visible disease (C0), or telangiectasia or reticular veins (C1) |
| C2 | Varicose veins (≥ 3 mm on standing) |
| C3 | Venous oedema |
| C4 | • Skin changes – pigmentation or venous eczema (C4a) • Lipodermatosclerosis or atrophie blanche (C4b) |
| C5 | Healed venous ulcer |
| C6 | Active venous ulcer |
Clinical, Etiological, Anatomical, Pathophysiological (CEAP) is a useful shared vocabulary for documenting severity, but note that NICE does not use CEAP stage as the basis for referral – referral is driven by the clinical criteria below (symptoms, skin changes, thrombosis, ulceration, bleeding).
Source: NICE CG168
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