BUERGER’S DISEASE

www.mayoclinic.org

Buerger’s disease is characterized by recurring inflammation of the intermediate and small arteries and veins of the lower and (in rare case) upper extremities. It results in thrombus formation and occlusion of the vessels. It is differentiated from other vessel diseases by it microscopic appearance. In contrast to atherosclerosis, Buerger’s disease is believed to be an autoimmune disease that results in occlusion of the distal vessel.

The cause of Buerger’s disease is unknown, but it is believed to be an autoimmune vasculitis. It occurs most often in men between 20 and 35 years of age, and it has been reported in all races and in many areas of the world. There is considerable evidence that heavy smoking or chewing of tobacco is a causative or aggravating factor (Mills, 2003). Generally, the lower extremities or viscera can also be involved. Buerger’s disease is generally bilateral ans symmetric with focal lesions. Superficial thrombophlebitis may be present.

  CLINICAL MANIFESTATION

                  Pain is the outstanding symptom of Buerger’s disease. the patient complain of foot cramps, especially the of the arch (in-step claudication), after exercise. The pain is relieved by rest; often, a burning pain is aggravated by emotional disturbances, nicotine, or chilling. Cold sensitivity of Raynaud type is found in half of the patients and is frequently confines to the hands. Digital rest pain is constant, and the characteristics of the pain do not change between activity and rest.

                 Physical signs include intense rubor (reddish-blue discoloration) of the foot and absence pedal pulse, but normal femoral and popliteal pulses. Radial ans ulnar artery pulses are absent or diminished.  Various type of paresthesia develop.

As the disease progresses, definite redness or cyanosis of the part appears when extremity is in dependent position. Involvement is generally bilateral, but color changes may affect only one extremity or only certain digits. Color changes may progress to ulceration, and ulceration with gangrene eventually occurs.

ASSESSMENT AND DIAGNOSTIC METHODS

              Segmental limb blood pressures are taken to demonstrate the distal location of the lesions or occlusions. duplex ultrasonography is used to document patency of the proximal vessels and to visualize the extent of distal disease. Contrast angiography is used to identify the diseased portion of the anatomy.

Gerontologic Considerations

              In older patients, Buerger’s disease may be followed by atherosclerosis of the larger vessels after involvement of the smaller vessels. The patients ability to walk may be severely limited. Patients are at higher risk for non healing wounds because of impaired circulation.

MEDICAL MANAGEMENT

              The treatment of Buerger’s disease is essentially the same as that for atherosclerotic peripheral arterial disease. The main objectives are to improve circulation to the extremities, prevent the progression of the disease, and protect the extremities from trauma and infection. Treatment of ulceration and gangrene is directed toward minimizing infection and conservative debridement of necrotic tissue. Tobacco use is highly detrimental, and patients are strongly advised to completely stop using tobacco. symptoms are often relieved by cessation of tobacco use.

             Vasodilators are rarely prescribed because these medications cause dilation of only healthy vessels; vasodilators may divert blood away from the partially occluded vessels, thus exacerbating the manifestations of the disease. A regional sympathetic blocker or ganglionectomy may be useful in some instances to produce vasodilation and increase blood flow.

            If gangrene of a toe develops as a result of arterial occlusive disease in the leg, it is unlikely that toe amputation or even transmetatarsal amputation will be sufficient; often, a below-knee amputation pr occasionally above-knee amputation is necessary. The indications for amputation include gangrene, especially if the infected area is moist; severe rest pain; or fulminating sepsis.

NURSING MANAGEMENT

            The patient is assisted in developing and implementing a plan to stop using tobacco and to manage pain. The patient may need to be encouraged to make the lifestyle changes necessary to adequately manage a chronic disease, including modifications in diet, activity, and hygiene (skin care). The nurse determines whether the patient has a network of family and friends to assist with ADLs. The nurse ensures that the patient has the knowledge and ability to assess for any postoperative  complications such as infection and decreased blood flow.

Reference: Suzanne C. Smeltzer, et.al., Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition

Lippincott Williams & Wilkins pp. 995-996

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