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Owrzodzenia goleni w przebiegu anemii sierpowatej

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Anemia sierpowata, czyli wrodzona choroba układu krążenia, która jest spowodowana nieprawidłową budową hemoglobiny, objawia się między innymi występowaniem wrzodów w obrębie kończyn dolnych. Jakie są przyczyny ich powstawania, jak wygląda terapia i w jaki sposób można im zapobiegać?

Patogeneza wrzodów goleni

Patogeneza przewlekłych owrzodzeń kończyn dolnych w przebiegu anemii sierpowatej jest złożona. Wśród przyczyn rozwoju tego powikłania można wymienić mechaniczną niedrożność żylną spowodowaną przez zagęszczenie krwinek sierpowatych, zwiększoną podatność na infekcje bakteryjne, zakrzepicę, zmniejszoną zdolność do transportu tlenu przez komórki krwi oraz zmniejszoną biodostępność tlenku azotu, która prowadzi do upośledzenia funkcji śródbłonka.

Badania wykazują jednak, że niewydolność żylna nie jest główną przyczyną owrzodzeń w przebiegu anemii sierpowatokrwinkowej. Jako bezpośredni czynnik wpływający na powstawanie wrzodów wskazuje się przetoki tętniczo-żylne, które wpływają na zmniejszenie podaży tlenu do tkanek.

Wrzody rozwijają się na obszarach o zmniejszonej zawartości tłuszczu podskórnego, gdzie skóra jest cienka, a dopływ krwi zmniejszony. Najczęściej wrzody rozwijają się w pierwszej kolejności w pobliżu kostek. Mniej powszechnie zmiany występują w obszarze piszczelowym, na grzbietach stóp oraz w okolicy ścięgna Achillesa.

Objawy kliniczne wrzodów goleni

Wrzody goleni w przebiegu anemii sierpowatej charakteryzują się powolnym rozwojem i wykazują trudności w leczeniu i gojeniu. Towarzyszący im ból może mieć znaczne nasilenie. Dolegliwości bólowe są opisywane jako rozdzierające, przenikliwe, ostre i kłujące. Zwalczanie tych dolegliwości u większości pacjentów wymaga stosowania doustnie lub pozajelitowo opioidowych środków przeciwbólowych.

Podatność na wrzody goleni w przebiegu anemii sierpowatej wzrasta wraz z wiekiem pacjenta.

Leczenie i profilaktyka wrzodów goleni

Terapia wrzodów goleni w anemii sierpowatej przebiega zgodnie ze schematami leczenia owrzodzeń o innej patogenezie. Leczenie skupione jest na kontrolowaniu infekcji, regularnym opracowywaniu ran oraz stosowaniu opatrunków kompresyjnych. Wskazuje się także na skuteczność stosowania płytkowych czynników wzrostu (ang. platelet-derived growth factor, PDGF) oraz przeszczepów skóry z hodowanych laboratoryjnie komórek.

Badania wskazują, że jednym z częstych czynników rozwoju wrzodów goleni w anemii sierpowatej są miejscowe urazy w obrębie kończyn dolnych. Z tego powodu profilaktyka powinna obejmować noszenie przez pacjenta ochronnej odzieży i obuwia (zwłaszcza w czasie pracy, kiedy ryzyko urazów jest zwiększone). Także przedstawiciele kadry medycznej powinni w miarę możliwości unikać wykonywania wkłuć żylnych i innych zabiegów w obrębie kończyn dolnych u pacjentów z występującą anemią sierpowatą.

Praktyka kliniczna wskazuje na znaczny związek pomiędzy występowaniem owrzodzeń goleni a niewydolnością żylną. Z tego powodu należy rozważyć wdrożenie rehabilitacji oraz zalecić pacjentowi ograniczanie długotrwałego przebywania w pozycji stojącej oraz odciążanie kończyn dolnych.

Źródło:

C.P. Minniti i in., „Leg Ulcers in Sickle Cell Disease”, „American Journal of Hematology” 2010, 85 (10): 831-833.

Przeczytaj także: Mięsak Kaposiego – czynniki ryzyka, rodzaje, objawy

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