Buerger disease

Symptoms

Symptoms include paresthesias of the foot, easy fatigability, and foot and leg cramps. In patients with severely limited blood flow to the legs, skin ulceration or moist gangrene of the extremities may develop. Amputation is sometimes needed to remove dead tissue.

Treatment

Absolute, permanent abstinence from tobacco in all forms is crucial. The patient should avoid excessive use of the affected limb, exposure to temperature extremes, use of drugs that diminish the blood supply to extremities, trauma, and fungus infections. Aspirin and vasodilators may be prescribed. If gangrene, pain, or ulceration is present, complete bedrest is advised with a padded foot-board or bed cradle to prevent pressure on the extremities; if these are absent, the patient should walk at a comfortable pace for 30 min twice daily. For arterial spasm, blocking of the sympathetic nervous system by injection of various drugs or by sympathectomy may be done.

Patient care

The history should document occurrences of painful, intermittent claudication of the instep, calf, or thigh, which exercise aggravates and rest relieves; the patient's walking ability (distance, time, and rest required); the patient's foot response to exposure to cold temperatures (initially cold, numb, and cyanotic; later reddened, hot, and tingling); and any involvement of the hands, such as digital ischemia, trophic nail changes, painful fingertip ulcerations, or gangrene. Peripheral pulses are palpated, and absent or diminished radial, ulnar, or tibial pulses documented. Feet and legs are inspected for superficial vein thrombophlebitis, muscle atrophy, peripheral ulcerations, and gangrene, which occur late in the disease. Soft padding is used to protect the feet, which are washed gently with a mild soap and tepid water, rinsed thoroughly, and patted dry with a soft towel. The patient is instructed in this daily care routine and advised to inspect tissues for injury such as cuts, abrasions, and signs of skin breakdown (redness or soreness) and to report all injuries to the health care provider for treatment. The patient is advised to avoid wearing tight or restrictive clothing, sitting or standing in one position for long periods, and walking barefoot; also, shoes and cotton or woolen stockings should be carefully fitted, but stockings should not be tight enough to hinder venous return from the legs. He should obtain medical care following any local trauma. Extremities must be protected from temperature extremes, esp. cold. The patient is taught the Buerger postural exercises if prescribed and is cautioned to avoid use of over-the-counter drugs without the attending health care provider's approval. The patient who smokes is referred to a smoking cessation program, but nicotine patch therapy should not be prescribed given the patient's associated hypersensitivity to nicotine. For the patient with ulcers and gangrene, bedrest is prescribed; a padded footboard or cradle is used to prevent pressure from bed linens. If hospitalization is required for treatment of ulcers or gangrene, or if amputation is required, rehabilitative needs are considered, esp. regarding changes in body image, and the patient is referred for physical and occupational therapy and for social services as appropriate.