crs buerger hafiz & yasir
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CRS Buerger Hafiz & YasirTRANSCRIPT
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CASE REPORT SESSIONBUERGER’S DISEASE
Oleh:Hafizh Budhiman Mahmud
Yasir Hady
Preseptor:dr. Krishna Pradananta, Sp.B, FInaCS
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Identitas Pasien
• Nama : Tn.W• Jenis Kelamin : Laki-laki• Umur : 45 tahun• Agama : Islam• Alamat : Sapan• Pekerjaan : Supir• Tanggal masuk poli : Rabu, 7 Oktober 2015• Tanggal Pemeriksaan : Rabu, 7 Oktober 2015
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Anamnesis
Keluhan Utama:• Ujung jari tengah kaki kiri membusuk
RIWAYAT PENYAKIT SEKARANG : (Auto anamnesa)Pasien datang ke poliklinik bedah RSUD Al-Ihsan
dengan keluhan ujung jari tengah kaki kiri yang membusuk sejak 4 bulan SMRS. Pasien merasakan keluhan awalnya berupa bintik hitam pada ujung jari kemudian meluas dan mengenai seluruh bagian jari yang bersangkutan.
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Anamnesis
Keluhan disertai dengan rasa nyeri pada jari yang membusuk dan jari terasa dingin. Pasien merasakan nyeri pada jari kaki makin lama bertambah nyeri terutama bila dingin atau malam hari, nyeri dirasakan pada daerah ujung jari yang membusuk. Keluhan yang sama terjadi juga pada jari jempol tangan kanan. Tidak ada riwayat terluka pada jari yang terkena.
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Anamnesis
Pasien mengaku pernah mengalami hal serupa 3 tahun yang lalu di jari telunjuk tangan kanan dan jari manis tangan kiri dan kemudian dilakukan operasi amputasi pada kedua jari tersebut. Pasien mengatakan memiliki kebiasaan mengkonsumsi rokok 1 bungkus per hari sejak usia 15 tahun. Setelah dilakukan amputasi, pasien kemudian meneruskan kebiasaan merokoknya kembali setelah sempat berhenti merokok selama 6 bulan sebelum amputasi. Pasien mengatakan untuk keluhan sekarang sudah berobat ke puskesmas dan diberi obat tetapi tidak tahu nama obatnya, dan keluhan tidak membaik.
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Anamnesis
RIWAYAT PENYAKIT DAHULU :• Pasien tidak memiliki riwayat penyakit kencing
manis, darah tinggi, penyakit jantung, alergi, ataupun asma.
Riwayat Penyakit Keluarga : • Pasien mengatakan tidak ada riwayat penyakit
seperti ini pada keluarga.
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Pemeriksaan Fisik
TANDA VITAL • Kesadaran : Compos mentis• Keadaan Umum : Tampak sakit ringan• Tekanan darah : 130/80 mmHg• Nadi : 70x/menit• Respirasi : 20x/menit• Suhu : 36,3oC
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Pemeriksaan Fisik
STATUS GENERALIS• Kepala : Normocephal• Mata : Konjunctiva tidak anemis, sklera tidak ikterik,
madarosis (-)• Leher : Teraba pembesaran KGB pada leher kiri• Thorax : Bentuk & gerakan simetris• Paru-paru : Simetris, vocal fremitus normal, bunyi nafas
vesikuler kanan = kiri, Wheezing -/-, Rhonki -/-• Jantung: BJ S1 S2 reguler murni. Murmur dan Gallop tidak
ada• Abdomen: Supel, datar, BU (+) 8x/menit, nyeri tekan (-)
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Pemeriksaan Fisik
• Extremitas atas : Akral dingin, terdapat nyeri pada digiti 1 manus dextra, arteri radialis dextra & sinistra teraba lemah, ditemukan digiti 2 dextra teramputasi pada bagian distal phalang, dan digiti 4 sinistra teramputasi seluruhnya.• Extremitas bawah : Akral dingin, terdapat nyeri digiti 3 pedis sinistra, arteri dorsalis pedis dextra & sinistra teraba lemah.
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Status Lokalisa/r digiti 3 pedis sinistra terdapat lesi dengan jaringan nekrotik seluas 5 cm melingkupi seluruh bagian digiti 3, warna hitam keputihan, darah (-), pus (-), teraba dingin, nyeri tekan (+)
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Status Lokalisa/r digiti 1 manus dextra terdapat lesi dengan jaringan nekrotik seluas 4 cm melingkupi seluruh bagian digiti 1, warna hitam, darah (-), pus (-), teraba dingin, nyeri tekan (+)
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ResumePasien laki-laki usia 45 tahun datang dengan keluhan ujung
jari tengah kaki kiri yang membusuk sejak 4 bulan SMRS. Keluhan disertai dengan rasa nyeri & dingin pada jari yang membusuk. Pasien merasakan nyeri pada jari kaki makin lama bertambah nyeri terutama bila dingin atau malam hari. Keluhan yang sama terjadi juga pada jari jempol tangan kanan. Pasien mengatakan memiliki kebiasaan mengkonsumsi rokok 1 bungkus per hari sejak usia 15 tahun.
Keadaan umum tampak sakit ringan, kesadaran kompos mentis, tanda vital dalam batas normal. Status lokalis ditemukan a/r digiti 3 pedis sinistra terdapat lesi dengan jaringan nekrotik seluas 5 cm melingkupi seluruh bagian digiti 3, warna hitam, darah (-), pus (-), teraba dingin, nyeri tekan (+). a/r digiti 1 manus dextra terdapat lesi dengan jaringan nekrotik seluas 4 cm melingkupi seluruh bagian digiti 1, warna hitam, darah (-), pus (-), teraba dingin, nyeri tekan (+)
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Diagnosis Banding
• Buerger’s Disease a/r digiti 3 pedis sinistra & digiti 1 manus dextra
• Morbus Hansen• Gangrene pedis ec. Diabetes Mellitus
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Diagnosis Kerja
• Buerger’s Disease a/r digiti 3 pedis sinistra & digiti 1 manus dextra
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Usulan Pemeriksaan
• Darah rutin• Glukosa darah• Angiography extremitas superior dextra &
sinistra dan inferior dextra & sinistra
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Tatalaksana
Edukasi: berhenti merokokMedikamentosa: • Analgetik: asam mefenamat 3x500 mg• Vasodilator: amlodipin 1x10 mg• Pro rujuk dokter spesialis bedah• Pro Amputasi digiti 3 pedis sinistra dan digiti 1
manus dextra
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Prognosis
• Qua ad Vitam : ad bonam• Qua ad fungsionam : ad malam• Quo ad sanationam : dubia ad malam
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Tinjauan Pustaka
Buerger’s Disease
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Pendahuluan
• Penyakit Buerger (Tromboangitis Obliterans) penyakit progresif inflamasi nonatherosclerotic segmental yang paling sering mempengaruhi arteri kecil/sedang, pembuluh darah, dan saraf pada ekstremitas atas dan bawah.
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Epidemiologi
• Banyak terjadi di Korea, Jepang, Indonesia, India, dan negara lain di Asia Selatan, Asia Tenggara, dan Asia Timur.
• 0.5-5.6% Eropa Barat, 45-63% India, 16-66% Korea & Jepang, 80% Israel.
• Hampir 100% perokok usia dewasa muda• Usia 20—50 tahun• Perempuan – pola merokok
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Etiologi
• Belum diketahui secara pasti• Penggunaan/paparan tembakau
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Morfologi
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Morfologi
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Copyright © American Heart Association, Inc. All rights reserved.
Patofisiologi
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Gambaran Klinis
• Klaudikasio intermiten• Nyeri saat istirahat, << jika tergantung• Perubahan warna kulit memucat ringan,
campuran pucat-sianosis-kemerahan. Bersifat unilateral.
• Pulsasi arteri rendah/menghilang• Tromboflebitis migrans superfisialis• Perjalanan penyakit bertahap bertambah berat
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Diagnosis (Shionoya, 1998)
• Smoking history• Onset before the age of 50 years• infrapopliteal arterial occlusions• Either arm involvement or phlebitis migrans• Absence of atherosclerotic risk factors other
than smoking
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Diagnosis (Olin, 2000)
• Age under 45 years• Current or recent history of tobacco use• The presence of distal-extremity ischemia indicated by
claudication, pain at rest, ischemic ulcers or gangrenes and documented by non-invasive vascular testing
• Exclusion of autoimmune diseases, hypercoagulable states and DM
• Exclusion of a proximal source of emboli by echocardiography or arteriography
• Consistent arteriographic findings in the clinically involved and non-involved limbs
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Pemeriksaan Penunjang
• Laborarorium– Pemeriksaan darah lengkap– Tes fungsi hati– kreatinin,– Gula darah puasa– Rheumatoid factor– Screening hypercoagulability
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Angiography
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Figure 1: 44-year old male patient with sudden onset of pain in left leg and ulcer on the toe, diagnosed with Buerger's disease. Baseline digital substraction angiography of (a and b) the popliteal region and (c) leg demonstrates abrubt thromboembolic occlusion of the popliteal artery (large white arrow in a). Typical corkscrew collateral arteries (small white arrows in b and c) and occlusion of the run-off vessels in concordance with Buerger's disease before intervention.
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Figure 2: 44-year-old male patient with sudden onset of pain in left leg and ulcer on the toe, diagnosed with Buerger's disease. Digital substraction angiography of (a-d) the popliteal region and (e and f) leg during mechanical thrombectomy of the distal popliteal artery with Rotarex and reconstruction of flow to the foot. (a) Complete occlusion of the popliteal artery above the knee joint involving the trifurcation and all three lower limb artery origins (white arrows). (b) 6F Rotarex catheter (large white arrow) over the 0.018-inch wire (small white arrow). (c) Partial removal of the thrombus (open black arrows) and recanalization of the popliteal artery (black arrow) after retrograde re-entry to the true lumen following dorsalis pedis access (not shown). (d) Using the rotarex catheter, the clot was destroyed and removed totally. Patent anterior tibial artery is visible (white arrows). (e and f) Flow was reconstructed to the foot via anterior tibial artery (white arrows).
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Terapi
• Berhenti merokok!!!• Debridement konservatif • Amputasi konservatif• Simpatektomi lumbalis
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TERIMA KASIH