NICE has published Referral Advice - A guide to appropriate referral from general to specialist services, which deals with 11 common complaints. Last month we covered prostatism. In this issue we reproduce the advice on varicose veins, the last in the series.

The referral advice is set out in consensus statements based on the best available evidence. It is designed to help clinicians determine how urgently particular patients need to be referred.

For a summary of the consensus statements click here.

Varicose veins

In the UK varicose veins occur in around 15-20% of adults. Varicose veins are tortuous, distended and bulging veins (varicosities) beneath the skin of the legs. The majority arise from incompetent long and short saphenous veins.

Usually the varicosities are obvious, but in some patients they may be obscured by oedema or excessive subcutaneous fat. Varicose veins should not be confused with the more superficial intradermal spider, and thread veins. Complications of varicose veins include eczema, induration, pigmentation, bleeding, Thrombophlebitis, and venous ulceration.

In general varicose veins do not require medical intervention. However, some are sufficiently troublesome to require treatment, which for the NHS in England and Wales involved over 50 000 operations in 1999/2000.

The most common complaint about varicose veins is their appearance. Patients report symptoms such as aches, pains, restless legs, cramps, itchiness, heaviness and oedema. However, a link between symptoms and varicose veins can be difficult to establish.

Primary care

Most varicose veins require no treatment. The key role of primary care is to provide reassurance, explanation and education, including advice on exercise, leg elevation and weight reduction if necessary. Primary care is also involved in overseeing skin care and making recommendations about the use and application of support hosiery and compression bandaging.

Specialist services

These are in a position to:

  • investigate, diagnose and reassure
  • offer advice on, and/or provide, treatment
  • supplement advice given in primary care on the application of compression hosiery and bandaging
  • undertake surgery if indicated.
Referral Advice
Most patients with varicose veins can be managed in primary care. In patients in whom varicosities are present or suspected, referral to a specialist service is advised if:

they are bleeding from a varicosity that has eroded the skin

they have bled from a varicosity and are at risk of bleeding again
they have an ulcer which is progressive and/or painful despite treatment
they have an active or healed ulcer and/or progressive skin changes that may benefit from surgery
they have recurrent superficial thrombophlebitis
they have troublesome symptoms attributable to their varicose veins, and/or they and their GP feel that the extent, site and size of the varicosities are having a severe impact on quality of life
The starring system developed by NICE to identify referral priorities
Arrangements should be made so that the patient:
is seen immediately1
is seen urgently2
is seen soon2
has a routine appointment2
is seen within an appropriate time depending on his or her clinical circumstances (discretionary)

1 within a day
2 health authorities, trusts and primary care organisations should work to local definitions of maximum waiting times in each of these categories. The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks to be appropriate for the urgent category.

Reproduced with kind permission from: Referral Advice - A Guide to Appropriate Referral from General to Specialist Services. London: NICE, December 2001.
The complete document can be downloaded from the NICE website

Guidelines in Practice, November 2002, Volume 5(11)
© 2002 MGP Ltd
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