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;

Predisposing Factors;

Gender: Male
Age: 20-60 y/o
History (HPN,
Hyperlipidemia
Genetics
Race:
Southeast
Asian

Lifestyle
(Cigarette
smoking,
chewing of
tobacco,
sedentary
lifestyle)
Environment:
exposure to

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
Advance/late Signs and
Symptoms

Early Signs and Symptoms

Claudication type
of pain
Color Changes (Pallor)
Temperature changes
Cold Sensitivity
(Reynauds phenomena)
Ulceration
Gangrene

Ffibrinoid occlusion

Impaired blood supply

Ischemia

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

Injury to blood
vessels

Necrosis

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/