Alcantara, John Renefrank B.

BSN 301 AdU-CON

Buergers Disease
Buerger's disease (thromboangiitis obliterans) is a rare disease characterized by a combination of acute inflammation and thrombosis of the arteries and veins in the hands and feet. The obstruction of blood vessels in the hands and feet reduces the availability of blood to the tissues, causes pain and eventually damages or destroys the tissue. It often leads skin ulcerations and gangrene of fingers and toes. Rarely, in advanced stages of the disease, it may affect vessels in other parts of the body.

Buergers Disease: Appearance

Ulcers and Gangrene caused by Buergers Disease

Buergers Disease: Who It Affects

Buerger's disease affects approximately six out of every 10,000 people. It almost always affects men, ages 20 to 40, who smoke or chew tobacco. Recently, however, more women and men over the age of 50 have been diagnosed with Buerger's disease. This disorder is still very uncommon in children, but it may occur in those with autoimmune diseases. Buerger's disease is most common in the Orient, Southeast Asia, India and the Middle East, but is rare among African-Americans.

Buergers Disease: Symptoms:

Enlarged, red, tender cord-like veins Pain or tenderness Numbness and tingling in the limbs

Skin ulcers or gangrene of the digits

Discoloration Two or more limbs affected Pain may increase with activity such as walking and decrease with rest Pulse may be decreased or absent in the affected extremity Symptoms may worsen with exposure to cold or with emotional stress

Clinical Manifestations: Pain and weakness in your legs and feet or your arms and hands Swelling in your feet and hands Fingers and toes that turn pale when exposed to cold (Raynauds phenomenon) Open sores on your fingers and toes Pathognomonic sign: intermittent claudication (pain induced by insufficient blood flow during exercise) in the feet and/or hands, or pain in these areas at rest. Leg/foot numbness Leg/foot tingling Leg/foot burning Leg/foot paresthesia Leg/foot pain worse with exertion Insomnia Cold hyper sensibility Sudden sweating Weak/absent pulse posterior tibial and dorsalis pedis

Advance: Abnormal red/cyanotic particularly when dependent Color and temperature change Edema Ulceration of extremities, digits of hands and feet Gangrene of extremities, digits of hands and feet

Signs and symptoms:

Pain- it is the most outstanding symptom - due to intermittent claudication. Rest pain with persistent ischemia of 1 or more digits - due to occlusion of decreases blood flow. Paresthesia due to diminished nerve sensation. Fingers and toes turn pale when exposed to cold (Raynauds phenomenon) due to decreased blood

flow as affected by cold temperature. Absent or weak tibial pulse Cyanosis - ( cyanosis bluish discoloration of the skin and mucous membrane due to lack of oxygen in the blood) a later manifestation. Ulcerations and gangrene if there is prolonged insufficient blood supply.

PATHOPHYSIOLOGY
Precipitating Factor; Gender: Male Age: 20-60 y/o History (HPN, Hyperlipidemia Genetics Race: Southeast Asian Predisposing Factors; Lifestyle (Cigarette smoking, chewing of tobacco, sedentary lifestyle) Environment: exposure to cold, stressful environment

Plaques/Deposits of Nicotine on the veins

Inflammation of the small and medium-sized arteries and veins of the extremities

Thickened artery and veins

Platelets deposits on the thickened artery

Ffibrinoid occlusion

Impaired blood supply

Ischemia Early Signs and Symptoms Claudication type of pain Color Changes (Pallor) Temperature changes Cold Sensitivity (Reynauds phenomena) Ulceration Gangrene Injury to blood vessels

Advance/late Signs and Symptoms

Necrosis

Thrombophlebitis with trauma Ulceration Gangrene Pulsation of the posterior tibial and dorsalis pedis arteries are weak or absent. Color Changes (Cyanotic)

How is Buergers disease diagnosed?

Buergers disease can be mimicked by a wide variety of other diseases that cause diminished blood flow to the extremities. These other disorders must be ruled out with an aggressive evaluation, because their treatments differ substantially from that of Buergers Disease (for Buergers, there is only one treatment known to be effective: complete smoking cessation). Diseases with which Buergers Disease may be confused include atherosclerosis (buildup of cholesterol plaques in the arteries), endocarditis (an infection of the lining of the heart), other types of vasculitis, severe Raynauds phenomenon associated with connective tissue disorders (e.g., lupus or scleroderma), clotting disorders of the blood, and others. Angiograms of the upper and lower extremities can be helpful in making the diagnosis of Buergers disease. In the proper clinical setting, certain angiographic findings are diagnostic of Buergers. These findings include a corkscrew appearance of arteries that result from vascular damage, particularly the arteries in the region of the wrists and ankles. Angiograms may also show occlusions (blockages) or stenoses (narrowings) in multiple areas of both the arms and legs. Pictured below on the left is a normal angiogram. On the right, is an abnormal angiogram of an arm demonstrating the classic corkscrew appearance of arteries to the hand. The changes are particularly apparent in the blood vessels in the lower right hand portion of the picture (the ulnar artery distribution).

In order to rule out other forms of vasculitis (by excluding involvement of vascular regions atypical for Buergers), it is sometimes necessary to perform angiograms of other body regions (e.g., a mesenteric angiogram). Skin biopsies of affected extremities are rarely performed because of the frequent concern that a biopsy site near an area poorly perfused with blood will not heal well.

Treatment and Course of Buergers

It is essential that patients with Buergers disease stop smoking immediately and completely. This is the only treatment known to be effective in Buergers disease. Patients who continue to smoke are generally the ones who require amputation of fingers and toes. Despite the clear presence of inflammation in this disorder, anti-inflammatory agents such as steroids have not been shown to be beneficial. Similarly, strategies of anticoagulation (thinning of the blood with aspirin or other agents to prevent clots) have not proven effective. The only way to prevent the progression of the disease is to abstain from all tobacco products.

Diagnostics:

Arteriography - may indicate a proximal source of emboli. It is the most conclusive diagnostic procedure for peripheral vascular diseases. Ultrasound - may indicate presence of distal extremity ischemia (indicated by claudication, pain at rest, ischemic ulcers or gangrene).

Medical Management
Analgesics are used for pain relief associated with Buergers disease and vasodilators to increase tissue perfusion. If wound care is required, topical antibiotics are applied with dressing changes. Enzymatic debridement agents may be used as a replacement to surgical debridement. Sympathectomy which involves the interruption of selected section of the sympathetic nervous pathways is used to treat vasospasms. Ulcerations may require debridement and possible skin grafting. In extreme cases, disease progression of Buergers disease there is circulation impairment, and amputation of digits or extremity may be needed.

Nursing Diagnosis
Ineffective peripheral tissue perfusion related to impaired circulation. Pain related to diminished oxygen flow to the affected extremity. Fear and anxiety related to actual or potential serious complications.

Nursing Management
Patient teaching, instruct the patient to do the following several times a day: Lie flat on a bed with both legs elevated above the level of the heart for two to three minutes. Next sit on the edge of the bed with the legs dependent for three minutes Then exercise the feet and toes by moving them up, down, inward, then outward. Lastly, return to the first position and hold for five minutes. Provide for ulcer debridement and healing Remove dead or damaged material from the wound, using wet-to-dry dressing with saline solution and coarse-mesh gauze filled with cotton. Use whirlpool therapy to debride the ulcer bed. Consider using an enzymatic debrider to aid removal of debris. Provide additional intervention to promote venous return and healing, maximize comfort and provide client education for measures to prevent venous stasis ulcer. Administer medications which may include antibiotics. The patient is encouraged to make the lifestyle changes necessitated by the onset of a chronic disease, including pain management and modifications in diet, activity, and hygiene (skin care). The nurse assists the patient in developing and implementing a plan to stop using tobacco- to prevent further occlusion of the blood vessels Assessing for pain to monitor if it being tolerated or needs medication to relieve pain. obtaining blood pressure serves as a baseline data for peripheral pulse assessing for signs of ulcer formation assessing for signs of gangrene Foot care to decrease the occurrence of infection and gangrene. protect from trauma to avoid source of infection enough rest

References: Brunner and Suddarths MEDICAL SURGICAL NURSING (volume 1) 10th edition. p.834-835 Ignatavicius Workman MEDICAL-SURGICAL NURSING (volume1) 6th edition. P. 815 http://www.scribd.com/doc/12589632/Buergers-Disease http://www.scribd.com/doc/27758648/BUERGER-s-Disease http://www.nursing-nurse.com/medical-and-nursing-management-of-buerger%E2%80%99s-diseasethromboangiitis-obliterans-398/ http://www.hopkinsvasculitis.org/types-vasculitis/buergers-disease/