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Buerger's disease

Buerger's disease (also known as thromboangiitis obliterans) is an acute inflammation and thrombosis (clotting) of arteries and veins of the hands and feet. It is strongly associated with use of tobacco products, primarily from smoking, but also from smokeless tobacco. more...

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Features

There is an acute 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.

Diagnosis

A concrete diagnosis of thromboangiitis obliterans is often difficult as it relies heavily on exclusion of the conditions. The commonly followed diagnostic criteria are below although the criteria tend to differ slightly from author to author. Olin (2000) proposes the following criteria:

  1. Age younger than 45 years
  2. Current (Or recent) history of tobacco use
  3. Presence of distal extremity ischemia (indicated by claudication, pain at rest, ischemic ulcers or gangrene) documented by noninvasive vascular testing such as etc
  4. Exclusion of autoimmune diseases, hypercoagulable states and diabetes mellitus by laboratory tests.
  5. Exclusion of a proximal source of emboli by echocardiography and arteriography
  6. Consistent arteriographic findings in the clinically involved and noninvolved limbs.

Pathophysiology

There are characteristic pathologic findings of acute inflammation and thrombosis (clotting) of arteries and veins of the hands and feet (the lower limbs being more common). The mechanisms underlying Buerger's disease are still largely unknown. It is suspected that immunological reactions play a role.

Treatment

Immediate and absolute cessation of tobacco use is necessary to prevent any further progression of the disease. Even a few cigarettes a day or nicotine replacements can keep the disease active. Vascular surgery can sometimes be helpful in treating limbs with poor perfusion secondary to this disease.

Prognosis

Buerger's disease is rarely fatal, but amputation is common in patients who continue to use tobacco. It often leads to vascular insufficiency.

Prevention

The disease occurs exclusively in tobacco users, so not using tobacco prevents you from getting the disease. Diet has no influence.

Epidemiology

Prevalence of the disease has decreases with the decreased prevalence of smoking. It is more common among men. It is more common in Israel, Japan and India than in the United States and Europe. The disease is most common among natives of Bangladesh, who smoke special cigarettes made of raw tobacco (bidi).

History

Buerger's disease was first reported by physician Leo Buerger in 1908.

Read more at Wikipedia.org


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Update on Thromboangiitis Obliterans - Buerger's Disease
From American Family Physician, 3/15/01 by Jeffrey T. Kirchner

Thromboangiitis obliterans, also known as Buerger's disease, is a nonatherosclerotic inflammatory disease of the small-sized and medium-sized arteries and veins of the arms and legs. Although inflammatory by nature, it spares the blood vessel walls. Unlike other types of vasculitis, the acute-phase reactants (such as the erythrocyte sedimentation rate and C-reactive protein) are normal in patients with Buerger's disease. A pathologic finding of acute disease is an occlusive, highly cellular, inflammatory thrombus. The disease is found worldwide, but the highest incidence of thromboangiitis obliterans occurs in the Middle East and Far East. Prevalence ranges from about 12 percent in the United States to 63 percent in India to 80 percent among Jews of Ashkenazi ancestry living in Israel. Part of this difference in disease incidence may be due to variability in diagnostic criteria. Olin reviewed the current concepts of this disease.

Although the cause of Buerger's disease is unknown, the strongest association is with tobacco use. Occurrences of the disease have been reported, but uncommonly, in persons who use smokeless tobacco or snuff. A current or previous history of smoking is usually a required diagnostic criterion.

The onset of Buerger's disease occurs between 40 and 45 years of age, and men are most commonly affected. It begins with ischemia of the distal small vessels of the arms, legs, hands and feet (see accompanying table). Patients often present with claudications in affected limbs and progress to ischemic pain at rest and ulcerations of the toes or fingers. Claudications in the foot or arch may be misdiagnosed as an orthopedic problem. More proximal arteries may bcome involved as the disease progresses.

There are no specific serologic markers to diagnose Buerger's disease. Recommended tests to rule out other causes of vasculitis include a complete blood cell count, liver function tests, serum creatinine determination, fasting blood sugar level, sedimentation rate, antinuclear antibody, rheumatoid factor, serologic markers for CREST syndrome and scleroderma, and screening for hypercoagulability. If a proximal source of embolization is suspected, transthoracic or transesophageal echocardiography and arteriography should be performed. Angiographic findings include severe distal, segmental occlusive lesions, but the more proximal arteries (below the popliteal and distal to brachial branches) are normal.

The only truly effective treatment for thromboangiitis obliterans is smoking cessation or discontinuation of tobacco-containing products. In one study, 94 percent of affected persons who quit smoking avoided amputations compared with 57 percent who continued to smoke. Therapy with intravenous iloprost (a prostaglandin analog) has been studied. This agent was found to be superior to aspirin in producing clinical improvement and decreasing the need for amputation. It is not currently available in the United States. Experience with intra-arterial thrombolytic therapy is limited to a few trials that have shown moderate success, but more studies are needed. Surgical revascularization is not feasible because of the diffuse segmental involvement and the distal nature of the vascular involvement.

COPYRIGHT 2001 American Academy of Family Physicians
COPYRIGHT 2001 Gale Group

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