{"id":2232,"date":"2013-04-08T07:53:53","date_gmt":"2013-04-08T07:53:53","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2232"},"modified":"2013-06-11T12:14:23","modified_gmt":"2013-06-11T12:14:23","slug":"7-zanetliva-a-vasospasticka-onemocneni","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2232","title":{"rendered":"7 Z\u00e1n\u011btliv\u00e1 a vasospastick\u00e1 onemocn\u011bn\u00ed"},"content":{"rendered":"<h6>ENDANGIITIS OBLITERANS (BUERGER\u016eV SY, WINIWATER-BUERGEROVA NEMOC, AO-TROMBANGIITIS OBLITERANS)<\/h6>\n<p style=\"text-align: justify;\">Onemocn\u011bn\u00ed je p\u0159\u00ed\u010dinou 3\u20135% poruch arteri\u00e1ln\u00edho prokrven\u00ed doln\u00edch kon\u010detin. Je pova\u017eov\u00e1no za problematick\u00e9 jak v diagnostice, tak i v terapii.<\/p>\n<p style=\"text-align: justify;\">Jedn\u00e1 se o z\u00e1n\u011btliv\u00e9 a obliteruj\u00edc\u00ed c\u00e9vn\u00ed onemocn\u011bn\u00ed s multilok\u00e1ln\u00edm v\u00fdskytem, kter\u00e9 postihuje nejprve c\u00e9vn\u00ed intimu v r\u016fzn\u00fdch segmentech arteri\u00ed mal\u00e9ho a st\u0159edn\u00edho kalibru. Posti\u017eeny jsou sou\u010dasn\u011b tak\u00e9 povrchov\u00e9 \u017e\u00edly. P\u0159i dal\u0161\u00ed progresi se onemocn\u011bn\u00ed \u0161\u00ed\u0159\u00ed i na arterie velk\u00e9ho kalibru a lze hovo\u0159it o panangiitid\u011b.<\/p>\n<p style=\"text-align: justify;\">Etiologie onemocn\u011bn\u00ed nen\u00ed jasn\u00e1, je v\u0161ak z\u0159ejm\u00fd z\u00e1sadn\u00ed vliv inhalace nikotinu (ev. kysli\u010dn\u00edku uhelnat\u00e9ho). \u00dazk\u00fd patogenetick\u00fd vztah ke kou\u0159en\u00ed je prokazateln\u00fd \u2013 pokud nemocn\u00fd p\u0159estane kou\u0159it, dojde k remisi onemocn\u011bn\u00ed, p\u0159i op\u011btovn\u00e9m kou\u0159en\u00ed onemocn\u011bn\u00ed recidivuje. P\u0159edm\u011btem studi\u00ed je po\u0161kozen\u00ed st\u011bny karboxyhemoglobinem nebo alergie na n\u011bkter\u00e9 slo\u017eky tab\u00e1kov\u00e9ho kou\u0159e.<\/p>\n<p style=\"text-align: justify;\">Zm\u011bny c\u00e9vn\u00ed intimy lze jen obt\u00ed\u017en\u011b definovat jako jednozna\u010dn\u011b z\u00e1n\u011btliv\u00e9, typick\u00fd je plynul\u00fd p\u0159echod z\u00e1n\u011btliv\u00fdch zm\u011bn do zm\u011bn aterosklerotick\u00fdch s parci\u00e1ln\u00edmi nebo \u00fapln\u00fdmi trombotick\u00fdmi uz\u00e1v\u011bry.<\/p>\n<p style=\"text-align: justify;\">Pod\u00edl endangiitis obliterans na c\u00e9vn\u00edch uz\u00e1v\u011brech se li\u0161\u00ed mezi rasov\u00fdmi skupinami. V Evrop\u011b se\u00a0vyskytuje\u00a0asi u 0,5\u20135% populace, v Koreji a Japonsku u 16\u201366% a v n\u011bkter\u00fdch skupin\u00e1ch \u017eidovsk\u00e9 populace (ashkenazi) a\u017e v 80%.<\/p>\n<p style=\"text-align: justify;\">Serologick\u00e1 a histochemick\u00e1 vy\u0161et\u0159en\u00ed prokazuj\u00ed imunopatologick\u00e9 n\u00e1lezy (protil\u00e1tky proti elastinu, kolagenu I a III, ukl\u00e1d\u00e1n\u00ed imunoglobulin\u016f do c\u00e9vn\u00ed st\u011bny). Jsou prokazateln\u00e9 tak\u00e9 genetick\u00e9 vlivy na vznik onemocn\u011bn\u00ed \u2013 nap\u0159. zv\u00fd\u0161en\u00fd v\u00fdskyt n\u011bkter\u00fdch HLA antigen\u016f.<\/p>\n<p style=\"text-align: justify;\">Onemocn\u011bn\u00ed postihuje mu\u017eskou populaci. Prvn\u00ed projevy onemocn\u011bn\u00ed b\u00fdvaj\u00ed ve v\u011bku pod 40 let. Prakticky v\u0161ichni nemocn\u00ed jsou ku\u0159\u00e1ci. Vliv kou\u0159en\u00ed prokazuje tak\u00e9 zv\u00fd\u0161en\u00fd pod\u00edl \u017een posti\u017een\u00fdch endangiitis obliterans ve st\u0159edn\u00ed Evrop\u011b. Z pom\u011bru 99:1 do\u0161lo ke zm\u011bn\u011b na 4:1.<\/p>\n<p style=\"text-align: justify;\">Onemocn\u011bn\u00ed m\u016f\u017ee m\u00edt pr\u016fb\u011bh chronick\u00fd, subakutn\u00ed, akutn\u00ed nebo fulminantn\u00ed. Chronick\u00e1 nebo subakutn\u00ed forma je typick\u00e1 spont\u00e1nn\u00edmi n\u011bm\u00fdmi intervaly. P\u0159i akutn\u00edm pr\u016fb\u011bhu vznikaj\u00ed i p\u0159i intenzivn\u00ed terapii perifern\u00ed nekr\u00f3zy. Fulminantn\u00ed pr\u016fb\u011bh je spojen s \u010dast\u00fdmi amputacemi. P\u0159i hodnocen\u00ed v\u0161ech forem onemocn\u011bn\u00ed lze p\u0159edpokl\u00e1dat b\u011bhem 5 let pot\u0159ebu amputac\u00ed ve 20\u201330%, p\u0159i\u010dem\u017e celkov\u00e1 d\u00e9lka \u017eivota nemocn\u00fdch je stejn\u00e1 jako u ostatn\u00ed populace.<\/p>\n<p style=\"text-align: justify;\">Za typick\u00e9 pot\u00ed\u017ee se pova\u017euj\u00ed pocit chladu kon\u010detin (60%), parestezie (40%), cyan\u00f3za (40%) klaudikace plant\u00e1rn\u00ed nebo l\u00fdtkov\u00e9 (70%) a klidov\u00e9 bolesti (50%). \u010casto se sou\u010dasn\u011b vyskytuj\u00ed povrchov\u00e9 flebitidy (40%) a trofick\u00e9 defekty (nekr\u00f3zy) periferie kon\u010detin (50%) (fotogalerie 7a). Krom\u011b povrchov\u00fdch tromboflebitid se sou\u010dasn\u011b vyskytuje u 40% nemocn\u00fdch Raynaudova nemoc. Pom\u011brn\u011b \u010dasto postihuje endangiitis obliterans c\u00e9vn\u00ed svazek horn\u00edch kon\u010detin (foto 7c), je tak\u00e9 pops\u00e1no posti\u017een\u00ed mozkov\u00fdch a koron\u00e1rn\u00edch arteri\u00ed nebo arteri\u00ed za\u017e\u00edvac\u00edho traktu.<\/p>\n<p style=\"text-align: justify;\">V diagnostice neexistuje laboratorn\u00ed test, kter\u00fd by prok\u00e1zal endangiitis obliterans. Na rozd\u00edl od ostatn\u00edch vaskulitid nejsou v akutn\u00ed f\u00e1zi onemocn\u011bn\u00ed zv\u00fd\u0161eny hodnoty CRP nebo sedimentace. Doporu\u010den\u00e1 laboratorn\u00ed vy\u0161et\u0159en\u00ed vylu\u010duj\u00ed ostatn\u00ed mo\u017en\u00e9 p\u0159\u00ed\u010diny vaskulitidy. Diagn\u00f3zu endangiitis obliterans lze prok\u00e1zat jen histologick\u00fdm vy\u0161et\u0159en\u00edm. V prvn\u00ed f\u00e1zi je diagn\u00f3za postavena na anamn\u00e9ze a na klinick\u00e9m n\u00e1lezu, n\u00e1sleduje UZ vy\u0161et\u0159en\u00ed a arteri\u00e1ln\u00ed angiografie. P\u0159\u00edm\u00e1 arteriografie dok\u00e1\u017ee nejl\u00e9pe zobrazit segment\u00e1rn\u00ed zm\u011bny na \u0159e\u010di\u0161ti poplite\u00e1ln\u00ed arterie nebo na b\u00e9rcov\u00fdch tepn\u00e1ch a tepn\u00e1ch nohy. Na horn\u00ed kon\u010detin\u011b b\u00fdvaj\u00ed nej\u010dast\u011bji posti\u017eeny digit\u00e1ln\u00ed arterie a uln\u00e1rn\u00ed \u010d\u00e1st palm\u00e1rn\u00edho oblouku s dist\u00e1ln\u00ed \u010d\u00e1st\u00ed uln\u00e1rn\u00ed arterie.<\/p>\n<p style=\"text-align: justify;\">Typick\u00fdm obrazem endangiitis obliterans je obraz\u201ev\u00fdvrtkov\u00fdch\u201c kolater\u00e1l. Odstupuj\u00ed ze zdrav\u00fdch \u00fasek\u016f tepen a obt\u00e1\u010dej\u00ed se pod\u00e9l uzav\u0159en\u00fdch arteri\u00e1ln\u00edch segment\u016f a kon\u010d\u00ed v s\u00edti drobn\u00fdch arteri\u00ed.<\/p>\n<p style=\"text-align: justify;\">Nej\u010dast\u011bj\u0161\u00ed krit\u00e9ria pro vysloven\u00ed diagn\u00f3zy endangiitis obliterans jsou:<\/p>\n<ul>\n<li>nikotinismus,<\/li>\n<li>v\u011bk pod 45 let,<\/li>\n<li>infrapoplite\u00e1ln\u00ed arteri\u00e1ln\u00ed uz\u00e1v\u011bry (klaudikace, klidov\u00e9 bolesti, trofick\u00e9 l\u00e9ze),<\/li>\n<li>sou\u010dasn\u00e9 posti\u017een\u00ed horn\u00edch kon\u010detin nebo flebitis\u00a0migrans,<\/li>\n<li>vylou\u010den\u00ed autoimunn\u00edch onemocn\u011bn\u00ed, diabetu\u00a0a trombofiln\u00edch stav\u016f,<\/li>\n<li>vylou\u010den\u00ed ev. zdroje embolizac\u00ed.<\/li>\n<\/ul>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\n<h6>Fotogalerie 7a:<br \/>\nM. Buerger<\/h6>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_246.png\"><img decoding=\"async\" style=\"font-size: 8px; font-weight: bold;\" title=\"NMR ag, p\u00e1nevn\u00ed \u0159e\u010di\u0161t\u011b bez patologick\u00e9ho n\u00e1lezu\" alt=\"NMR ag, p\u00e1nevn\u00ed \u0159e\u010di\u0161t\u011b bez patologick\u00e9ho n\u00e1lezu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_246.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">NMR ag, p\u00e1nevn\u00ed \u0159e\u010di\u0161t\u011b bez patologick\u00e9ho n\u00e1lezu<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_248.png\"><img decoding=\"async\" title=\"NMR ag, p\u00e1nevn\u00ed \u0159e\u010di\u0161t\u011b stehen bez patologick\u00e9ho n\u00e1lezu\" alt=\"NMR ag, p\u00e1nevn\u00ed \u0159e\u010di\u0161t\u011b stehen bez patologick\u00e9ho n\u00e1lezu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_248.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">NMR ag, p\u00e1nevn\u00ed \u0159e\u010di\u0161t\u011b stehen bez patologick\u00e9ho n\u00e1lezu<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_247.png\"><img decoding=\"async\" title=\"NMR ag, zm\u011bn\u011bn\u00e9 b\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b\" alt=\"NMR ag, zm\u011bn\u011bn\u00e9 b\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_247.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">NMR ag, zm\u011bn\u011bn\u00e9 b\u00e9rcov\u00e9 \u0159e\u010di\u0161t\u011b<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_249.png\"><img decoding=\"async\" title=\"Ischemie periferie kon\u010detin\" alt=\"Ischemie periferie kon\u010detin\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_249.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Ischemie periferie kon\u010detin<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_250.png\"><img decoding=\"async\" title=\"Vlhk\u00e1 gangr\u00e9na palce\" alt=\"Vlhk\u00e1 gangr\u00e9na palce\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_250.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Vlhk\u00e1 gangr\u00e9na palce<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\n<h6>\u00a0Fotogalerie 7c:<br \/>\nM. Buerger<\/h6>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_253.png\"><img decoding=\"async\" title=\"Ischemie prst\u016f\" alt=\"Ischemie prst\u016f\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_253.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Ischemie prst\u016f<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_254.png\"><img decoding=\"async\" title=\"Ischemie rukou, stav po amputaci obou doln\u00edch kon\u010detin\" alt=\"Ischemie rukou, stav po amputaci obou doln\u00edch kon\u010detin\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_254.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Ischemie rukou, stav po amputaci obou doln\u00edch kon\u010detin<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 160px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_252.png\"><img decoding=\"async\" title=\"Arteriografi e p\u0159edlokt\u00ed\" alt=\"Arteriografi e p\u0159edlokt\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_252.png\" width=\"150\" \/><\/a><p class=\"wp-caption-text\">Arteriografi e p\u0159edlokt\u00ed<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Z hlediska diferenci\u00e1ln\u00ed diagnostiky je t\u0159eba vylou\u010dit jin\u00e9 vaskulitidy (imunologick\u00e9) a aterosklerotick\u00e9 zm\u011bny. Vz\u00e1cn\u011b p\u0159ich\u00e1z\u00ed v \u00favahu cystick\u00e1 degenerace adventitie. Konzervativn\u00ed terapie endangiitis obliterans spo\u010d\u00edv\u00e1 v z\u00e1kazu kou\u0159en\u00ed, prevenci prochladnut\u00ed a sanaci fok\u00e1ln\u00edch zm\u011bn. Medikament\u00f3zn\u00ed terapie se skl\u00e1d\u00e1 z prostaglandin\u016f, antikoagulanci\u00ed a antiagreganci\u00ed. Endovaskul\u00e1rn\u00ed l\u00e9\u010dba, syst\u00e9mov\u00e1 nebo kat\u00e9trov\u00e1 fibrinol\u00fdza nejsou v\u016fbec vhodn\u00e9. Odstran\u011bn\u00edm fibrinogenu doch\u00e1z\u00ed k aktivaci z\u00e1n\u011btliv\u00e9ho procesu.<\/p>\n<p style=\"text-align: justify;\">Z opera\u010dn\u00edch mo\u017enost\u00ed p\u0159ich\u00e1z\u00ed v \u00favahu lumb\u00e1ln\u00ed a torak\u00e1ln\u00ed sympatektomie. P\u0159ed v\u00fdkonem je nutn\u00e1 angiografie. P\u0159i posti\u017een\u00ed doln\u00edch kon\u010detin je indikac\u00ed stadium III nebo IV dle Fontaina. V\u00fdsledek chirurgick\u00e9 l\u00e9\u010dby lze odhadnout transkut\u00e1nn\u00edm m\u011b\u0159en\u00edm oxygenace periferie po obst\u0159iku ggl. stellatum u horn\u00edch kon\u010detin nebo po zaveden\u00ed peridur\u00e1ln\u00edho kat\u00e9tru u doln\u00edch kon\u010detin. Otev\u0159en\u00e1 chirurgick\u00e1 hrudn\u00ed nebo bedern\u00ed sympatektomie se dnes prakticky neprov\u00e1d\u00ed, mo\u017enost\u00ed je hrudn\u00ed sympatektomie miniinvazivn\u011b (torakoskopicky), ale p\u0159ev\u00e1\u017en\u011b je indikov\u00e1na perkut\u00e1nn\u00ed sympatikol\u00fdza alkoholem. P\u0159i sledov\u00e1n\u00ed nemocn\u00fdch, kter\u00fdm byla provedena chirurgick\u00e1 sympatektomie, bylo prok\u00e1z\u00e1no, \u017ee jej\u00ed efekt je dlouhodob\u011bj\u0161\u00ed ne\u017e u sympatikol\u00fdzy. P\u0159\u00ed\u010dinou je z\u0159ejm\u011b mo\u017enost regenerace sympatick\u00fdch vl\u00e1ken. Sympatikol\u00fdzu v\u0161ak lze bez v\u011bt\u0161\u00edho rizika opakovat.<\/p>\n<p style=\"text-align: justify;\">Poopera\u010dn\u00ed nebo postinterven\u010dn\u00ed p\u00e9\u010de vy\u017eaduje v intervalech 3 m\u011bs\u00edc\u016f kontroly oxygenace periferie standardizovan\u00fdm postupem na pracovi\u0161ti, kter\u00e9 sympatektomii nebo sympatikol\u00fdzu provedlo.<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\n<h6>Fotogalerie 7b:<\/h6>\n<h6>M. Raynaud \u2013 isch\u00e9mie ruky<\/h6>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<h6><\/h6>\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_257.png\"><img decoding=\"async\" title=\"Ischemie prst\u016f a ruky p\u0159i Raynaudov\u011b chorob\u011b\" alt=\"Ischemie prst\u016f a ruky p\u0159i Raynaudov\u011b chorob\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_257.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Ischemie prst\u016f a ruky p\u0159i Raynaudov\u011b chorob\u011b<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_256.png\"><img decoding=\"async\" title=\"Dtto, gangrena prst\u016f dorsa ruky\" alt=\"Dtto, gangrena prst\u016f dorsa ruky\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_256.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Dtto, gangrena prst\u016f dorsa ruky<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_258.png\"><img decoding=\"async\" title=\"Dtto, gangr\u00e9na prst\u016f\" alt=\"Dtto, gangr\u00e9na prst\u016f\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/04\/Image_258.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Dtto, gangr\u00e9na prst\u016f<\/p><\/div><\/td>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>RAYNAUD\u016eV SYNDROM\u00a0(OKLUZIVN\u00cd A VASOSPASTICK\u00c9\u00a0ONEMOCN\u011aN\u00cd HORN\u00cd KON\u010cETINY)<\/h6>\n<p style=\"text-align: justify;\">Raynaud\u016fv syndrom je klinick\u00fd stav, kter\u00fd je charakterizov\u00e1n ob\u010dasn\u00fdmi z\u00e1chvaty vasospasm\u016f, kter\u00e9 vedou k uz\u00e1v\u011bru mal\u00fdch arteri\u00ed a arteriol dist\u00e1ln\u00edch \u00fasek\u016f ruky. Vasospasmus je vyvol\u00e1n chladem nebo emocion\u00e1ln\u00edm stresem. Nej\u010dast\u011bji jsou posti\u017eeny prsty ruky a ruka. Velmi vz\u00e1cn\u011b mohou b\u00fdt posti\u017eeny prsty nohy a noha. Typick\u00fdm obrazem vasospasmu je bledost periferie ruky a prst\u016f s n\u00e1slednou cyan\u00f3zou a zarudnut\u00edm, kdy\u017e se kon\u010detina dostane do tepl\u00e9ho prost\u0159ed\u00ed. Barevn\u00e9 zm\u011bny jsou spojeny s poruchou citu. Z\u00e1chvat m\u016f\u017ee odezn\u00edt i spont\u00e1nn\u011b, tedy bez vlivu tepl\u00e9ho prost\u0159ed\u00ed. Spasmus trv\u00e1 v\u011bt\u0161inou 30 a\u017e 60 minut, ale m\u016f\u017ee p\u0159etrv\u00e1vat del\u0161\u00ed dobu i za stavu, \u017ee nemocn\u00fd je v tepl\u00e9m prost\u0159ed\u00ed. Typick\u00fd trojbarevn\u00fd projev nemus\u00ed b\u00fdt u v\u0161ech nemocn\u00fdch vyj\u00e1d\u0159en, v\u011bt\u0161inou chyb\u00ed kone\u010dn\u00e9 zarudnut\u00ed.Zhodnocen\u00ed v\u00fdskytu Raynaudova syndromu v b\u011b\u017en\u00e9 populaci chyb\u00ed, je v\u0161ak z\u0159ejm\u00e9, \u017ee je jeho v\u00fdskyt v\u00e1z\u00e1n na n\u011bkter\u00e1 povol\u00e1n\u00ed. P\u0159edev\u0161\u00edm se jedn\u00e1 o pr\u00e1ci s n\u00e1stroji vyvol\u00e1vaj\u00edc\u00edmi vibrace (a\u017e u 50% pracovn\u00edk\u016f) nebo v oborech, kde se st\u0159\u00eddav\u011b pracuje v teple a chladu (potravin\u00e1\u0159stv\u00ed).<\/p>\n<p style=\"text-align: justify;\">Projevy Raynaudova syndromu vznikaj\u00ed v r\u016fzn\u00e9m stupni u 20\u201330% populace p\u016fsob\u00edc\u00ed v chladn\u00e9m a vlhk\u00e9m prost\u0159ed\u00ed. V\u00edce jsou posti\u017eeny \u017eeny. Z dostupn\u00fdch patofyziologick\u00fdch poznatk\u016f vypl\u00fdv\u00e1, \u017ee existuj\u00ed dva mechanismy vzniku Raynaudova fenom\u00e9nu. Prvn\u00ed m\u00e1 norm\u00e1ln\u00ed n\u00e1lez na digit\u00e1ln\u00edch arteri\u00edch a vasospasmy jsou vyvol\u00e1ny abnorm\u00e1ln\u00edmi siln\u00fdmi kontrakcemi svaloviny. U druh\u00e9ho jsou prokazateln\u00e9 na palm\u00e1rn\u00edch a digit\u00e1ln\u00edch arteri\u00edch obstruk\u010dn\u00ed zm\u011bny (choroby), kter\u00e9 sni\u017euj\u00ed pr\u016ftok \u0159e\u010di\u0161t\u011bm. U t\u011bchto norm\u00e1ln\u00ed c\u00e9vn\u00ed reakce na ochlazen\u00ed (arteri\u00e1ln\u00ed kontrakce) vede k projev\u016fm ischemie.L\u00e9\u010dba je symptomatick\u00e1, kauz\u00e1ln\u00ed terapie nen\u00ed zn\u00e1ma. Nejlep\u0161\u00ed v\u00fdsledky lze o\u010dek\u00e1vat od blok\u00e1tor\u016f kalciov\u00e9ho kan\u00e1lu (nifedipin). Efekt lze o\u010dek\u00e1vat u 50% nemocn\u00fdch. Z vasoaktivn\u00edch l\u00e1tek je mo\u017en\u00e1 terapie naftidrofurylem a prostaglandiny. P\u0159ipojuje se l\u00e9\u010dba antiagrega\u010dn\u00ed. V\u00fdsledky sympatektomie jsou nejist\u00e9.U mal\u00e9 skupiny nemocn\u00fdch se vyv\u00edjej\u00ed pokro\u010dil\u00e9 ischemick\u00e9 zm\u011bny s ulceracemi a gangr\u00e9nami prst\u016f (foto 7b).Tyto pokro\u010dil\u00e9 ischemick\u00e9 zm\u011bny nemaj\u00ed nikdy p\u0159\u00ed\u010dinu jen ve vasospasmu, v\u017edy se pod\u00edl\u00ed obstrukce. Tito nemocn\u00ed mohou, ale nemus\u00ed m\u00edt Raynaud\u016fv syndrom. U v\u0161ech jsou prokazateln\u00e9 obstruktivn\u00ed procesy na palm\u00e1rn\u00edch a digit\u00e1ln\u00edch arteri\u00edch. Jejich etiologie m\u016f\u017ee b\u00fdt r\u016fzn\u00e1 \u2013 arteriitidy autoimunn\u00ed etiologie, onemocn\u011bn\u00ed pojivov\u00e9 tk\u00e1n\u011b, ateroskler\u00f3za, Buergerova choroba. L\u00e9\u010dba je chirurgick\u00e1, konzervativn\u00ed \u2013 o\u0161et\u0159en\u00ed ran, snesen\u00ed nekrotick\u00fdch tk\u00e1n\u00ed. Vasoaktivn\u00ed terapie a sympatektomie maj\u00ed mal\u00fd efekt.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>ENDANGIITIS OBLITERANS (BUERGER\u016eV SY, WINIWATER-BUERGEROVA NEMOC, AO-TROMBANGIITIS OBLITERANS) Onemocn\u011bn\u00ed je p\u0159\u00ed\u010dinou 3\u20135% poruch arteri\u00e1ln\u00edho prokrven\u00ed doln\u00edch kon\u010detin. Je pova\u017eov\u00e1no za problematick\u00e9 jak v diagnostice, tak i v terapii. Jedn\u00e1 se o z\u00e1n\u011btliv\u00e9 a obliteruj\u00edc\u00ed c\u00e9vn\u00ed onemocn\u011bn\u00ed s multilok\u00e1ln\u00edm v\u00fdskytem, kter\u00e9 postihuje nejprve c\u00e9vn\u00ed intimu v r\u016fzn\u00fdch segmentech arteri\u00ed mal\u00e9ho a st\u0159edn\u00edho kalibru. Posti\u017eeny jsou sou\u010dasn\u011b [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1868,"menu_order":35,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-2232","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2232","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2232"}],"version-history":[{"count":13,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2232\/revisions"}],"predecessor-version":[{"id":2251,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2232\/revisions\/2251"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1868"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2232"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}