thromboangiitis obliterans
Introduction
Introduction to thromboangiitis obliterans Thromboangiitis obliterans is referred to as vasculitis. It refers to a chronic persistent, progressive vascular inflammatory lesion of the surrounding vessels (middle, small arteries, and veins) that causes thrombosis to occlude the vascular lumen. More common in the northern provinces of China. More common in men and young adults. The lesions mainly involve the middle and small arteries of the distal extremities, and the veins and superficial veins are often involved, and the lower limbs are dominant. basic knowledge The proportion of illness: 0.03% Susceptible people: more common in smokers Mode of infection: non-infectious complication:
Cause
Causes of thromboangiitis vasculitis
The etiology of thromboangiitis obliterans is still unclear and is generally considered to be related to the following factors:
(1) Smoking comprehensive domestic and foreign data, 60 to 95% of patients with thromboangiitis obliterans, clinical observations, smoking cessation can make patients with thromboangiitis obliterate, the re-smoking can make the disease worse, Erb et al. found in animal experiments in rats that tobacco extracts can cause vascular lesions. Harkavy et al. used tobacco extracts for intradermal tests. The positive rate of patients with thromboangiitis obliterans was 78-87%, while that of normal people was only 16~. 46%, but thromboangiitis obliterans in smokers is still a minority, and some patients with thromboangiitis obliterans have no history of smoking.
Therefore, smoking may be an important factor in the pathogenesis of thromboangiitis obliterans, but it is not the only cause.
(2) Cold, damp, trauma The incidence of thromboangiitis obliterans in China is higher in the colder north. Epidemiological investigations have found that 80% of patients with thromboangiitis obliterans have a history of cold and dampness before onset. Some patients have a history of trauma, which may cause vasospasm and vascular endothelial damage, and lead to vascular inflammation and thromboembolism.
(3) Infection, malnutrition Clinical observations found that many patients with thromboangiitis obliterans have a history of repeated fungal infections, Thompson found that patients with thromboangiitis obliterans have a positive rate of skin dermatan test of 80%, while the control group At only 20%, Craven believes that the body's immune response to mold, induced blood fibrinogen increase and hypercoagulability may be related to the pathogenesis of thromboangiitis obliterans.
Scholars in many countries have found that thromboangiitis obliterans is common in people with low economic income and low living standards. Hill et al analyzed the thromboangiitis obliterans in Indonesia and found that most patients lack protein in their diet, especially It is an essential amino acid, and some people have found that the lack of VitB1 and VitC in the diet can induce vasculitis in rats. Therefore, protein, vitamin B1 and vitamin C deficiency may be related to this disease.
(D) hormonal disorders thrombosis occlusive vasculitis patients are mostly male (80 ~ 90%), and all occur in young adults, some people believe that prostate dysfunction or excessive loss of prostatic fluid, can expand the body Vascular and prostaglandins that inhibit platelet aggregation are reduced, and may cause vasomotor dysfunction of the surrounding blood vessels, resulting in thrombosis leading to the disease.
(5) 1 to 5% of patients with hereditary thromboangiitis obliterans have a family history. Many scholars have found that certain special sites of human leukocyte antigen (HLA) are associated with the pathogenesis of thromboangiitis obliterans. Japanese scholars have discovered The positive rate of HLA-J-1-1 in thromboangiitis obliterans was 46%, compared with only 18% in normal subjects. HLA-BW54, HLA-BW52 and HLA-A were also reported in patients with thromboangiitis obliterans. The positive rate increased, and both HLA-J and HLA-BW54 were dominated by genetic factors.
(6) Vascular dysregulation The autonomic nervous system regulates dysfunction of endogenous or exogenous stimuli, which makes the blood vessels easy to be paralyzed. Long-term vasospasm can damage the wall, hypertrophy, and easily form thrombus leading to vascular occlusion. .
(VII) Autoimmune dysfunction In the past 10 years, the role of autoimmune factors in the pathogenesis of thromboangiitis obliterans has been paid more and more attention. Gulati et al found that IgG, IgA, and IgM in serum of patients with thromboangiitis obliterans were obvious. Increased, while complements CH50 and C3 decreased, and anti-arterial antibodies and immune complexes with strong affinity to arteries were found in the serum and diseased blood vessels of patients. Smoler et al found in 20 cases of thromboangiitis obliterans. There were collagen antibodies in the case, but no collagen antibody was found in the control group. Bollinger et al. and Berlit found elastin antibodies in thromboangiitis obliterans. Gulati et al. believe that smoking and other factors can change the vascular antigenicity and produce itself. Anti-arterial antibodies, the resulting immune complex deposited on the patient's blood vessels leads to vascular inflammatory responses and thrombosis.
Prevention
Thromboangiitis obliterans prevention
In the cold season, you should pay attention to your body's warmth, especially your limbs, diet, daily life, and sexual intercourse. Eat less or not sticky foods, such as glutinous rice noodles, rice cakes, sesame sugar, etc., do not smoke, do not drink, feel comfortable, full. Passion, full of energy to live, study, work, find patients with initial symptoms should go to the hospital for diagnosis, and actively treat, early detection, early treatment.
Complication
Complications of thromboangiitis obliterans Complication
In addition to the above-mentioned pathological changes in blood vessels, there are still ischemic pathological changes of nerves, muscles, bones and other tissues. If there is a local infection, fever, chills, irritability and other systemic toxic symptoms may occur, and the tissue of the extremities is more ischemic. Severe, ulcers or gangrene, mostly dry gangrene, if secondary infection, it is wet gangrene. The symptoms of systemic poisoning caused by the toxins or other toxins produced by bacteria entering the blood circulation are called toxemia;
Toxemia: refers to the symptoms of systemic poisoning caused by the toxins or other toxins produced by bacteria entering the blood circulation.
Dry gangrene: Dry gangrene has nothing to do with bacterial infection. If the blood flow to a certain tissue is blocked or reduced, dry gangrene will occur. When the muscle is necrotic, it will be extremely painful. Once the muscle dies, it will become It is numb and slowly turns black. There is a visible line between the necrotic tissue and the living tissue.
Wet gangrene: Infectious "wet" gangrene, a toxin produced by bacteria called Clostridium that multiplies on necrotic muscles, killing muscles and upper skin in an area.
In order to prevent gangrene, sometimes doctors must inevitably remove part of the limb, which will be one of the serious complications of this disease.
Symptom
Thrombotic occlusive inflammatory symptoms Common symptoms Dry skin, skin, cold, muscles, muscles, shrinking, leg ulcers, acute lower limbs, ischemia, purpura, limbs, local skin... Lower limb skin, nutritional changes, limbs, numbness, lower limbs, standing up...
Its clinical features are ischemia, pain, intermittent claudication, affected arterial pulsation weakened or disappeared, accompanied by migratory thrombotic superficial phlebitis, severe cases may have acral ulcer or necrosis, occur in male blue In the prime of life, women are rare, mostly in the cold season, and the course of disease is prolonged. The lesions often start from the lower limbs of the lower extremities, and then gradually develop to the feet and calves. It is rare for those who occur in the upper limbs alone, involving the brain, heart, kidney and other parts. Rare.
1. More common in male smokers aged 20 to 40 years old, most of them are affected by lower limbs.
2. When the onset is cold, the body is cold, numb, sore, and then intermittent claudication, and finally developed into resting pain, especially at night.
3. The skin of the extremities is purple or pale, the skin temperature is lowered, the skin is dry, the calf muscles are atrophy, the toes or feet are ulcerated and dry and gangrene, and may be accompanied by migratory superficial phlebitis, dorsal artery and/or posterior The arterial pulsation weakened or disappeared, and the limb position test was positive, that is, the limb end was pale when the limb was raised, and the flushing or purpura was drooping.
4. Increased immunoglobulin, anti-arterial antibody positive, help diagnosis, limb segmental manometry, arterial waveform analysis, transcutaneous oxygen partial pressure measurement, skin temperature measurement, limb infrared thermal image examination, help to determine occlusion The location and extent of the lesion, angiography showed a segmental distribution of the lesion, the affected segment was narrow or occluded.
Examine
Examination of thromboangiitis obliterans
First, the limb elevation test (Buerger's test) The patient is lying flat, the limb is raised 45 °, after 3 minutes, observe the skin color change of the foot; then let the patient sit up, the lower limbs hang down at the bed, observe the skin color changes, if After raising, the skin of the toes and soles is pale or yellowish. When the skin of the feet is flushed or plaque-like purpura occurs after sag, it is called a positive result.
Second, auxiliary inspection
According to the medical history and physical examination, the diagnosis of thromboangiitis obliterans can be diagnosed. The following auxiliary examinations can help to further define the location, extent, nature, extent and establishment of collateral circulation.
(A) Determination of skin temperature At a certain room temperature (15 ~ 25 ° C), the limb temperature decreased by more than 2 ° C compared with the corresponding part of the contralateral side, indicating that the limb limb blood supply is insufficient.
(2) Infrared thermal image Infrared thermal imager can detect the infrared radiation radiated from the surface of the limb and convert it into a thermal image. At the same time, the temperature of each sampling point can be represented by numbers, and the infrared thermal image of the limb of thromboangiitis obliterans It can show that the ischemic part of the affected limb is dark and the abnormal "cold area" appears.
(C) segmental pressure measurement and stress test segmental pressure measurement can understand the arterial systolic pressure of each segment of the limb, thromboangiitis obliterans often manifested as lower limb blood pressure below the radial artery or radial artery, such as lesions For the lower limbs only, the / index (normal value 1) can reflect the severity of the limb ischemia. For those with normal segmental pressure measurement, stress tests such as exercise test, reactive hyperemia test, and early thromboangiography can be used. In patients with vasculitis, the pressure was significantly reduced after stress test, and the recovery time of sputum was prolonged.
(4) Pulse wave tracing The Doppler flow velocity meter and various plethysmographs can be used to trace the arterial waveforms of the limbs. The distal arterial waveform of the thrombus occlusive vasculitis often appears as a unidirectional wave. The amplitude is low and the peak is low and blunt. When the lesion is serious, the waveform of the artery is in a straight line.
(5) Arterial angiography can determine the location, extent, nature and extent of arterial occlusion, and can understand the establishment of the venous circulation of the affected limb. The typical manifestation of angiography of thromboangiitis obliterans is segmental occlusion of the small and medium arteries. Between the diseased arteries, normal arteries with smooth wall can be seen. In addition, many small collateral vessels can often be shown. Because of angiography, traumatic examination can cause arterial spasm and vascular endothelium damage, aggravating limb ischemia. It is generally not used as a routine examination method for this disease.
Diagnosis
Diagnosis and identification of thromboangiitis obliterans
diagnosis
Diagnosis can be made based on medical history, clinical manifestations, and examination.
Differential diagnosis
Thromboangiitis obliterans should be differentiated from the following diseases:
(1) Occlusive atherosclerosis with thromboangiitis obliterans and arteriosclerosis obliterans, all of which are chronic obstructive venous lesions. The two are similar in terms of symptoms, signs and course of disease, but there are obstructive arteriosclerosis. The following characteristics: 1 patients are older, mostly over 50 years old, not necessarily smoking habits; 2 often accompanied by hypertension, hyperlipidemia, coronary heart disease, arteriosclerosis or diabetes; 3 lesions of the arteries are often large, medium-sized arteries, such as Abdominal aortic bifurcation, radial artery, femoral artery or radial artery, rarely invaded the upper extremity artery; 4X line can show irregular calcification of the artery; 5 no migratory thrombophlebitis.
(2) Raynaud syndrome is a cerebral aortic spasm caused by vascular neurological dysfunction. Its main clinical manifestation is that when it is cold or emotional, the skin color of the finger (toe) suddenly turns pale. Then purple, gradually turned into flushing, and then returned to normal, a small number of patients with thromboangiitis obliterans, the early manifestations of Raynaud's syndrome, and therefore must be differentiated, the characteristics of Raynaud's syndrome are as follows: 1 mostly young Female; 2 the location of the disease is mostly fingers, and often sympathetic onset; 3 the affected limb arterial pulsation is normal, even if the disease is longer, the genus is rarely seen at the finger (toe) end.
(C) multiple arteritis is more common in young women; lesions often involve multiple aorta; active low fever, increased erythrocyte sedimentation rate; angiography shows that the main branch of the aorta is narrow or blocked.
(4) Nodular periarteritis The main invasive disease of this disease, small arteries, limbs may have ischemic symptoms similar to thromboangiitis obliterans, characterized by: 1 extensive lesions, often involving the kidney, heart, liver, stomach Intestinal and other arteries; 2 subcutaneously arranged nodules, purple spots, ischemia or necrosis; 3 often have fever, fatigue, increased erythrocyte sedimentation rate and hyperglobulinemia; 4 often need to be living tissue an examination.
(5) Diabetic gangrene Thrombotic occlusive vasculitis occurs when the gangrene of the extremity is diagnosed with diabetic gangrene. Diabetic patients have a history of thirst, hunger, polyuria, urine sugar, and blood sugar.
