Cold toes, pale or purplish red
Introduction
Introduction The toes are cold and cold, and the pale or purple color is the clinical manifestation of occlusive thromboangiitis. Thrombosis angiitis obliterans (tao) is a kind of difference from arteriosclerosis, segmental distribution. The vascular inflammation, the lesion mainly involves the small and medium arteries and veins in the distal segment of the extremities. The pathologically mainly characterized by invasive thrombus of inflammatory cells, and less involvement of the vessel wall. Long-lasting vasospasm affects the blood supply of the nourishing blood vessels in the wall, which can cause ischemic damage to the wall, leading to inflammatory reactions and thrombosis, which form the basis of the occurrence and development of this disease.
Cause
Cause
The etiology of thromboangiitis obliterans is still not fully understood and is generally believed to be caused by a combination of factors. mainly includes:
Smoking
Refers to active and passive smokers, nicotine can cause blood vessels to contract. According to statistics, 80% to 95% of patients have a history of smoking. Quitting smoking can improve the condition, and then relapse after smoking. Smoking is closely related to this disease, but it is not the only cause of illness. Because women smokers, the incidence is not high, and a small number of patients never smoke.
2. Cold and infection
Cold damage can cause blood vessels to contract, so the incidence in the north is significantly higher than in the south. Because many patients have skin fungal infections, some scholars believe that it affects the human immune response, can increase the fibrinogen content in the blood, prone to thrombosis. However, some susceptible people are often exposed to cold environment due to work relationship, and although there are fungal infections, the incidence is not high, so it is not possible to confirm the main cause of cold and infection as the disease, but may be a Causes of aggravation of vasospasm.
3. Sex hormones
Most of the patients are male, and they are all young and young, which may be related to prostate dysfunction and vasomotor dysfunction.
4. Vascular dysregulation
The autonomic nervous system's dysregulation of endogenous or exogenous stimuli can cause the blood vessels to be paralyzed, which can lead to thickening of the wall and thrombosis.
5. Trauma
A small number of patients have a history of physical injury, such as crushing, strenuous exercise, long-distance walking, etc., the incidence may be related to vascular injury. However, some minor trauma is not enough to cause limb vascular injury, and sometimes mild trauma to one limb and vasculitis in other limbs. These conditions are difficult to explain with direct trauma violence. Some people think that after trauma, nerve receptors are stimulated, which causes central nervous system dysfunction, which gradually loses the regulation of peripheral blood vessels, causing vasospasm and long-term paralysis leading to thrombosis.
6. Immunology
Clinical studies have shown that patients with vasculitis have specific cellular and humoral immunity against human arterial antigens, and anti-arterial antibodies are present in serum. Various immunoglobulins (igm, igg, iga) and c3 complexes are found in the patient's blood vessels. Antinuclear antibodies are found in the serum, no anti-mitochondrial antibodies, human leukocyte antigen abnormalities and the presence of these autoantibodies suggest that the disease may be itself Immune disease. In recent years, it has been reported in the literature that the patient's arterial antigen is used as a complement-binding test, and the positive rate is 44.3%. The positive rate is higher in the acute active period.
In short, from a clinical point of view, any person who can make the peripheral blood vessels persistently paralyzed is likely to be a causative factor, and the cause may be comprehensive.
Examine
an examination
Related inspection
Limb blood flow skin color
Symptom
(1) cold and paresthesia: cold limbs and coldness are common early symptoms. The body surface temperature of the affected part is reduced, especially at the toe (finger) end. Due to the ischemic influence of the nerve endings, the affected limbs (toes, fingers) may have sensation abnormalities such as sputum, acupuncture, numbness or burning.
(2) Pain: It is also an early symptom, which originates from arterial spasm. It is caused by stimulation of nerve receptors in the blood vessel wall and surrounding tissues, and the pain is generally not severe.
(3) Intermittent claudication: is a special manifestation of ischemic pain caused by occlusion of endarteritis and thrombosis. That is, when the patient walks for a long distance, the calf or the foot muscles are painful or painful. If you continue walking, the pain is aggravated and you have to stop. After a short break, the pain is relieved quickly, and the pain reappears after walking. The symptoms are intermittent claudication. As the disease progresses, the walking distance is gradually shortened, and the time for stopping the rest increases.
(4) Resting pain: The condition continues to develop, the arterial ischemia is more serious, the pain is severe and sustained, and even if the limb is at rest, the pain is still more than that, which is called resting pain. Especially at night, when the limbs are raised, the pain is aggravated. After the drooping, the pain can be slightly relieved. The patient sat down on the knees day and night and stayed up all night. Sometimes the affected limb is drooping at the bedside to relieve the pain. If it is complicated, the pain is more severe.
(5) Changes in skin color: skin is pale due to arterial ischemia, accompanied by a decrease in superficial vascular tone and thinning of the skin, flushing or cyanosis may occur.
(6) Arterial pulsation weakened or disappeared: the pulsation of the dorsal or posterior tibial artery, the ulnar or radial artery, weakened or disappeared as the lesion progressed.
(7) Nutritional disorders: long-term chronic ischemia of the affected limbs, malnutrition in the tissues, manifested as dry skin, desquamation, chapped, hair loss, thickening of the toe (finger), slow deformation and growth, relaxation of the calf muscles, atrophy, The circumference is tapered. The disease progresses worse, the ischemic tissue of the extremities is severe, and eventually ulcers or gangrene are produced. Mostly dry gangrene, first appeared at the end of one or two toes or next to the toenail, and then involved the entire toe. At the beginning, the toe end is dry and black, and the necrotic tissue is detached to form a long-lasting ulcer. At this time, the pain in the extremities is more severe, the patient can not fall asleep day and night, the appetite is reduced, the weight is weak, the face is pale and even anemia. If the infection is concurrent, when it is wet and gangrene, symptoms such as hyperthermia, chills, irritability and other symptoms of toxemia appear.
(8) ambulatory thrombotic superficial phlebitis: about 1/2 of patients in the pre-onset or onset of the disease, in the calf or superficial veins of the foot, repeated migratory thrombophlebitis. The symptoms of the superficial veins are red, nodular, with mild pain. After 2 to 3 weeks of acute attack, the symptoms subsided and repeated over time. The condition was not affected by the patient for several months or years. note.
2. Physical examination
(1) Burger test: the patient was placed in a supine position, and the lower limbs were raised 45°. After 3 minutes, the skin of the positive person was pale, numbness or pain. When the patient sat up, the skin of the foot became flushed or appeared after the lower limbs drooped. Local purpura, this examination indicates that there is a serious lack of blood supply to the affected limb.
(2) Allen test: The purpose of this test is to understand the occlusion of the hand artery in patients with thromboangiitis obliterans. That is, the patient's radial artery is pressed, and the fist is repeatedly punched and fisted. If the skin color of the original finger ischemic area is restored, it is proved that the lateral branch of the ulnar artery origin is sound, and the distal artery is occluded. Similarly, this test can also detect the soundness of the collateral artery of the radial artery.
(3) nerve block test: that is, through spinal anesthesia or epidural anesthesia, block the lumbar sympathetic nerve, if the skin temperature of the affected limb is significantly increased, suggesting that the distal limb ischemia is mainly caused by arterial spasm, otherwise it may have There is arterial occlusion. However, this test is an invasive procedure and is currently rarely used clinically.
Diagnosis
Differential diagnosis
The toes are cold and cold, with a differential diagnosis of pale or purple:
Cold feet in winter: Generally speaking, patients with anemia and gastrointestinal diseases, those with nutritional deficiencies or hypothyroidism cause systemic or local blood circulation disorders, or blood circulation disorders at the extremities of the limbs can cause cold hands and feet. In particular, women during menstruation and delivery, due to physical weakness, are more likely to cause cold hands and feet. In medicine, frequent and long-term cold hands and feet can be called "coldness".
In clinical practice, the diagnosis of thromboangiitis obliterans is generally easier, but early diagnosis sometimes becomes difficult.
In 1995, the diagnostic criteria for thromboangiitis obliterans revised by the Committee on Peripheral Vascular Diseases of the Chinese Association of Integrative Medicine was:
(1) Almost all men, the age of onset is 20 to 45 years old.
(2) Chronic limb arterial ischemia, such as numbness, cold, intermittent claudication, congestion, changes in nutritional disorders, etc., often involving the lower extremities, fewer upper limbs.
(3) 40% to 60% have a history and signs of migratory thrombophlebitis.
(4) Various examinations have shown that the location of limb arterial occlusion and stenosis is mostly in the arteries and their distal arteries (often involving the small and medium arteries of the limbs).
(7) During the active period of the disease, the positive rate of IgG, IgA, IgM, anti-arterial antibodies and immune complexes in the patient's blood increased, and the T cell function index decreased.
(8) Arteriography:
1 lesions are more common in the femoral artery and its distal end;
2 Arteries are segmental occlusion and stenosis, and the arteries and proximal cardiac arteries between the occlusion segments are mostly normal;
3 The proximal end of the arterial occlusion has a "root" collateral artery;
4 Arteries have no distortion, stiffness and plaque imaging.
