SURGERY SEMINAR-1

SERIAL NO. - 120,171&213

A 30-year-old woman attends the surgical outpatient clinic complaining
of painful fingers. She notices the pain particularly during the winter
months. When she is outside, the fingers firstly become white, then
blue, and then become red and start to tingle.
Differential Diagnosis – Upper limb ischemia
• Raynaud’s disease/syndrome
• Atherosclerosis/Embolism
• Cervical rib
• Thoracic outlet syndrome
• Vasculites
Aetiology
• Primary
• Secondary
1. Autoimmune – SLE, RA, Scleroderma, Sjogren syndrome
2. Occupational – Vibration injury, Frostbite, As, Pb, PVC
3. Endocrine – DM, Acromegaly
4. Infectious – HBV, HCV, Mycoplasma
5. Haematological – PNH, Cryofibrinogenaemia
6. Neoplastic – Lymphoma, Adenocarcinoma of lung
7. Drug induced – Cisplatin, OCP, Beta blockers
Pathophysiology
1. Stage of syncope
• Stressor precipitates arteriolar vasospasm
• Blanching, fine movements impaired
2. Stage of asphyxia
• Capillary dilation
• Slow flowing deoxygenated blood
• Swelling, cyanosis
3. Stage of recovery
• Arteriolar relaxation
• Capillaries engorged with oxygenated blood
• Pain, rubor
Clinical features
• Bilateral episodic digital ischemia
• Precipitated by cold, stress
• Tingling, pain, numbness
• Colour changes – pallor, cyanosis, rubor
• Thumb usually spared
• Peripheral pulses present
• Recurrent attacks – gangrene patches, ulceration
Evaluation/Investigation
serial no. 171
History Taking
• Obtain history of INJURY or FROSTBITE.

• Occupational history eg- JACKHAMMERS

• Industrial exposure to POLYVINYL CHLORIDE

• history of AUTOIMMUNE DISORDERS

Clinical Examination
• observe the colour of digits.

• Peripheral pulses are normally felt.

• look for ischemic ulceration or gangrene along the tips of fingers.

• look for clinical signs of any autoimmune disorder.

Assessment of segmental blood pressure gradient
from brachial-forearms-wrist-fingers
• Finger tip thermography
Cold recovery time is measured ( normally is less than 10 minutes,
but in Raynaud's it is more, often upto 30 minutes).

• Reactive Hypermia Time (pneumatic cuff is inflated and kept for 5

minutes and released to observe hypermia).

• Laser Doppler Flux to assess microvascular perfusion of finger skin.

Tests for Identifiaction of Type of Raynaud's
• Primary Raynaud's
its an idiopathic vascular disorder without underlying identifiable
causes. No significant pain present. Common in females and younger
age group. Usually it is bilateral.

• Secondary Raynaud's
vasospasm is due to some underlying cause. Significant pain is present.
There are positive autoantibodies, equal in both sexes, occurs at any
age group, need not be bilateral.
Tests for Differentiation-

Nail Fold Capillaroscopy

• the doctor places a drop of oil on the patient’s
nailfold - the skin at the base of the fingernail.
The doctor will then examine the nailfold
under a microscope or a hand-held
ophthalmoscope to look for abnormalities of
the capillaries.
• usually the 4th and 5th digits are preferred.
• Abnormal findings in the nail fold capillary
network include :
1. Architectural derangement
2. Capillary density changes
3. Megacapillary and enlarged loops
4. Microhemorrhages
5. Angiogenesis.
• If there are mega-capillaries with a decreased capillary density, then these changes
are indicative of Secondary Raynaud's.

• Further positive ANA assay and increased ESR are indicative of a autoimmune
disease confirming Diagnosis of Secondary Raynaud's.

• Other tests for differentiating are Agiogram of Hand & Arterial Doppler.

• Other routine Investigations are

Ø X-Ray - can look for an extra rib at the base of the neck, called a cervical rib. This can
cause Raynaud's phenomenon by putting pressure on the blood vessels that supply
blood to your arms.
Ø Blood Sugar
Ø Lipid Profile
Ø Hypercoagulability Status
Management of
Raynaud’s Disease

BY- GAGAN AGGARWAL

160101524 (213)
 Establishing the Diagnosis

 This is the first principle of management.

 RP (Raunaud’s Phenomenon) is not in itself a diagnosis: it is a symptom
complex requiring a diagnosis, which can usually be made with a
combination of careful history and examination.
 If RP is primary,  then the episodes or attacks should be entirely reversible,
the peripheral pulses should be easily felt and symmetrical, there should be
no evidence of digital pitting, the antinuclear antibody (ANA) should be
negative or only weakly positive (titre < 1/100), the erythrocyte
sedimentation rate (ESR) normal (although the newer Maverakis et al.
criteria do not require this) and the nailfold capillaries
(examined via capillaroscopy) normal.
1. Primary (idiopathic)
2. Secondary
qConnective tissue diseases:
Systemic sclerosis
Systemic lupus erythematosus
Sjögren’s syndrome
Vasculitis
qHand–arm vibration syndrome (‘vibration white finger’).
qExtrinsic vascular compression (e.g. cervical rib).
qLarge vessel disease [e.g. atherosclerosis, thromboangiitis obliterans (Buerger’s disease)],
consider this possibility especially if symptoms are asymmetrical
q Certain drugs, chemicals or other occupational exposures (e.g. β blockers, ergotamine,
clonidine, vinyl chloride)
 Treatment ( Managing a CASE )

Uncomplicated Case Complicated Case

• A Case with no • A case with Digital

ulceration or ischemia. Ulceration or critical
• Almost always the ischemia .
Primary case of RP. • Almost always Secondary or
repeated trauma to the
digits.
Interventions
1. Non Pharmacological
2. Pharmacological
3. Surgical
 Non- Pharmacological Intervention

Non-drug therapy may be all that is required for mild cases of primary Raynaud phenomenon.
 Reassurance
 Avoiding inciting environmental factors, such as direct contact with frozen foods or cold
drinks, walking bare foot in winters.
 Compression of the blood vessels by tight-fitting wrist bands, rings, or footwear should be
avoided
 Insulation against cold , including gloves or heavy socks and electric warming devices
 Avoid smoking ( Passive or Active ) – Nicotine causes vasoconstriction.
 Those with RP should guard their hands and feet from direct trauma and wounds.
 Manage stress: Because stress may trigger an attack, particularly for people who have
primary Raynaud’s phenomenon
 Prevent dryness or cracking of the skin by applying a liberal amount of moisturizer or hand
cream.
Ø Regular Exercise.
Ø Physical maneuvers for alleviating acute attacks that involve the hands
have been proposed.
• In the so-called windmill maneuver, the affected person
rotates the arms backward, in a motion similar to a softball pitcher;
the resulting centrifugal force enhances blood flow through the distal
arteries.
 Pharmacological intervention

Those patients not responding to general measures and secondary RP cases should be
offered drug treatment.
 Calcium channel blockers – CCBs are first-line, especially the dihydropyridines (eg,
nifedipine, nicardipine), which are the most potent vasodilators. Nifedipine being the
first choice.
 Phosphodiesterase type 5 inhibitors (sildenafil, tadalafil)- PDE5 inhibitors increase the
availability or effect of nitric oxide.
 Topical nitroglycerin (1% or 2%)- Local digital Vasodilation.
 Other drugs- Includes ACE inhibitors, angiotensin II receptor antagonists, α blockers,
nitrates, and the SSRIs (fluoxetine)
 Prostaglandin Analogues – These are sometimes used in patients with severe
uncomplicated RP.
 Complicated RP Treatment

Management are very similar for both digital ulceration and critical ischaemia,
and so will be considered together.
It must be emphasized that although digital ulceration may be a medical
emergency requiring immediate hospitalization, critical
ischaemia, always requires emergency admission to hospital (failure to act
quickly risks losing the digit)
Critical digital ischemia, which is more likely to occur in secondary Raynaud
phenomenon, necessitates aggressive management.
 Analgesia and antibiotics - Digital ulcers and critical ischaemia can be excruciatingly
painful
 Oral vasodilators
 Anticoagulant Therapy
 Surgery- surgical debridement, Digital or Cervical Sympathectomy and amputation
 Digital & Cervical Sympathectomy
Digital Sympathectomy
 Digital sympathectomy may be the only
alternative to amputation when medical
therapy has failed.
 In this procedure, to prevent blood-
vessel spasm, the nerves that stimulate
the constriction of the vessels
(sympathetic nerves) are surgically
interrupted. Usually, this is performed
during an operation that is localized to
the sides of the base of the fingers at
the hand. Through small incisions, the
tiny nerves around the blood vessels are
stripped away.
Cervical Sympathectomy
 It has either poor long term results, as
preganglionic sectioning does not
remove all the sympathetic stimulations
to the hand or unpleasant side effects
such as post operative compensatory
hyperhidrosis.
 The operation is now obsolete, having
been replaced by endoscopic
transthoracic sympathectomy ETS)
 Both open and ETS have high rate of
initial relief but higher rates of
recurrence.
A 30-year-old
woman attends the
surgical outpatient
clinic complaining of
painful fingers .She
notices the pain
particularly during  Management – Non Pharmacological
treatment and Pharmacological ( CCBs )
the winter months.
When she is outside,
the fingers firstly
become white, then
blue and then
become red and start
to tingle.
THANK YOU