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Buergers Disease


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Alternative name:

thromboangiitis obliterans

Definition:

Is a recurring progressive inflammation and thrombosis (clotting) of small and

medium arteries and veins of the hands and feet. It is strongly associated with

use of tobacco products, [1] primarily from smoking , but also from smokeless

tobacco .

History

King George VI and Buergers Disease

- As reported by Alan Michie in God Save the Queen, published in 1952 (see

pages 194 and following), King George VI was diagnosed with the disease in

late 1948 and early 1949 . Both legs were affected, the right more seriously than the

left. The King's doctors prescribed complete rest and electric treatment to stimulate

circulation, but either unaware of the connection between the disease or smoking

(the King was a heavy smoker) or unable to persuade the King to stop smoking, the

disease failed to respond to their treatment. On March 12, 1949, the King underwent

a lumbar sympathectomy , performed at Buckingham Palace by Dr. James R.Learmonth . The operation, as such, was successful, but the King was warned that it

was a palliative, not a cure, and that there could be no assurance that the disease

would not grow worse. From all accounts, the King continued to smoke.

Felix von Winiwarter

- Buerger's disease was first reported by Felix von Winiwarter in 1879

in Austria . It wasn't until 1908, however, that the disease was given its first accurate

pathological description, by Leo Buerger at Mount Sinai Hospitali n New York City .[6] Buerger called it "presenile spontaneous gangrene" after studying amputations in

11 patients
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Prevalence:

Buerger's is more common among men than women. It is more common

in Israel , Japan , India , and Manipur along the "old silk route" than in the UnitedStates and Europe . The disease is most common among South Asians.

Causes:

Tobacco smoking

Prognosis

Buerger's is not immediately fatal, but it is life-shortening. Amputation is common

and major amputations (of limbs rather than fingers/toes) are almost twice as

common in patients who continue to smoke. Death rate has not been consistently

shown as higher in patients who do not cease smoking but for this and other

health concerns quitting is highly recommended. Female patients tend to show

much higher longevity rates than men. Despite the clear presence of

inflammation in this disorder, anti-inflammatory agents such as corticosteroids

have not been shown to be beneficial in healing, but do have significant anti-inflammatory and pain relief qualities in low dosage intermittent form. Similarly,

strategies of anticoagulation (thinning of the blood with aspirin or other agents to

prevent clots) have not proven effective. The only way to slow the progression of

the disease is to abstain from all tobacco products.

Feature:

There is a recurrent acute andchronic inflammation and thrombosis of arteries and veins of the hands and feet.

The main symptom is pain in the affected areas. Ulcerations and gangrene in the

extremities are common complications , often resulting in the need

for amputation of the involved extremity.
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This disease was first reported by Leo Buerger in 1908, who described a disease

in which the characteristic pathologic findings acute inflammation and

thrombosis (clotting) of arteries and veins affected the hands and feet.

Another name for Buergers disease is thromboangiitis obliterans.

Diagnosis:

M.Buerger

A concrete diagnosis of thromboangiitis obliterans is often difficult as it relies heavily on

exclusion of other conditions. The commonly followed diagnostic criteria are outlined

below although the criteria tend to differ slightly from author to author. Olin (2000)

proposes the following criteria: [2]

1. Typically between 2040 years old and male, although recently females

have been diagnosed.

2. Current (or recent) history of tobacco use

3. Presence of distal extremity ischemia (indicated by claudicating , pain at

rest, ischemic ulcers or gangrene) documented by noninvasive vascular testing

such as ultrasound
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clotting disorders

and diabetes, along with other diseases and conditions.

Allens Test

- Your doctor may conduct a simple test called the Allen's test to check blood

flow through the arteries carrying blood to your hands. In the Allen's test, you make a

tight fist, which forces the blood out of your hand. Your doctor presses on the arteries

at each side of your wrist to slow the flow of blood back into your hand, making your

hand lose its normal color. Next, you open your hand and your doctor releases the

pressure on one artery then the other. How quickly the color returns to your hand

may give a general indication about the health of your arteries. Slow blood flow intoyour hand may indicate a problem, such as Buerger's disease.


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Angiogram

- An angiogram, also called an arteriogram, helps doctors see the condition of

your arteries. Doctors

inject dye into an artery and then take X-rays or other types of images. Images show

any blockages in

the artery. Your doctor may order arteriogram be performed on both of your armsand your legs

even if you don't have signs and symptoms of Buerger's disease in all of your limbs.

Buerger's disease

almost always affects more than one limb, so even though you may not have signs

and symptoms in

your other limbs, this test may detect early signs of vessel damage.


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Symptoms:

Pain

Foot cramps

Cold sensitivity in some cases

Rubor of the foot

Absence of pedal pulseRedness of cyanotic discoloration upon progression of disease

Gangrene

Intermittent Claudication (Pain even at rest)

Paresthesia

Poikilothermia


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Anatomy and Physiology

The disease is typically encountered in heavy smokers, often before the age of

35 years.

Thromboangiitis obliterans is marked by segmental thrombosing, acute, and

chronic inflammation of intermediate and small arteries and veins in the extremities.

It begins with nodular phlebitis, followed by Raynaud's-like cold sensitivity and legclaudication.

Acute lesions consist of neutrophilic infiltration of the arterial wall, with mural or

occlusive thrombi

Containing microabscesses, often with giant cell formation and secondary

involvement of the adjacent vein and nerve.

Late lesions show organization and recanalization.

The cause is unknown.

The vascular insufficiency can lead to excruciating pain and ultimately gangreneof the extremities


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Three layers of the arteries and veins

Tunica Intima

Tunica Media

Tunica Adventitia

Lumen-cavity of the blood vessels

Arteries-thicker than veins it is more elastic and can contract than veins

Arterioles-small arteries that delivers blood to the capillaries

Capillaries-connects arterioles with Venules and allows the exchange of gases, wastes,

and nutrients between blood and the tissue cells.

Venules -small vessels that connects the capillaries to veins

Veins-have more fibrous tissues and they have internal valves to ensure blood flow in

one direction

Venous sinuses -veins with thin walls.


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Pathophysiology

Predisposing Factors:Male

20 35 years of age

Precipitating Factors:Environment: Pollution

Smoking

Micro thrombi formation (nicotine)

Occlusion in the lining of the blood vessels

Impairment in the blood circulation

Neutrophil polymorphs


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Management:

A. Surgical InterventionSympathectomy

- is a surgical procedure that destroys nerves in the sympathetic nervous

system. The procedure is done to increase blood flow and decrease long-

term pain in certain diseases that cause narrowed blood vessels. It can also be used

to decrease excessive sweating. This surgical procedure cuts or destroys the

sympathetic ganglia, collections of nerve cell bodies in clusters along the thoracic or

lumbar spinal cord.

Inflammation in the blood vessels

Pain, intermittent claudation, cyanosis, numbness, swelling, absenceof pulse, poikilothermia and paresthesis

Buergers Disease

Untreated: Septicemia Treated: Amputation

Prosthesis
http://www.answers.com/topic/pain-1http://www.answers.com/topic/pain-1


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Amputations for gangrenous tissue

- An amputation usually refers to the surgical removal of the whole or part of

an arm/hand or a leg/foot. Amputation of a toe or leg is one of the oldest surgical

procedures.


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Ganglionectomy to remove ganglions

- ganglionectomy, also called a gangliectomy, is the surgical removal of

a ganglion . The removal of a ganglion cyst usually requires a ganglionectomy.

Such cysts usually form on the hand, foot or wrist and may cause pain or impair

body function. Aspiration of the cyst and steroid injections are typically performed

first. If they fail, the cyst is excised under local, regional or even
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general anesthetic . Ganglionectomies are also performed for other reasons, such

as the treatment of chronic pain .

B. Non Surgical Intervention

Calcium Channel Blockers

Anti-Platelet agents

Vasodilator (rare because it causes dilation of healthy vessels
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Nursing Interventions:

Encourage client to stop smoking.

Trauma to the extremities must be avoided.

Instruct client to use neutral soap and body lotion to prevent drying of the skin.

Fingernails and toe nails should be carefully trimmed.

Instruct to eat fruits and vegetables which promotes healing and prevents tissue

breakdown.

Well fitting shoes should be worn to prevent foot injury and blister.

Instruct client to take low fat and low cholesterol diet.

Discharge Planning

Medication

-As prescribed by the physician


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-Vasodilator

Exercise

-Ambulate as tolerated

Treatment

- Gradual cessation of smoking

- Amputation

- Ganglionectomy

- Sympathectomy

Health teaching

-Discuss the etiology of the condition-Ways to avoid injury

-Proper footcare including nail trimming.

Outpatient Care

-Follow up checkups as indicated by the physician.

Diet

-High in protein. Low in cholesterol diet.

Spiritual

-Continue Religious practices

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