Gangrene

Source: Wikipedia, the free encyclopedia.
For other uses, see Gangrene (disambiguation).
Gangrene
Other namesGangrenous necrosis
Raynaud's syndrome[3][4]
Diagnostic methodBased on symptom, With medical imaging used to identify the underlying cause.
TreatmentDepends on underlying cause[5]
PrognosisVariable
FrequencyUnknown[2]

Gangrene is a type of tissue death caused by a lack of blood supply.[4] Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness.[1] The feet and hands are most commonly affected.[1] If the gangrene is caused by an infectious agent, it may present with a fever or sepsis.[1]

Risk factors include

wet gangrene, gas gangrene, internal gangrene, and necrotizing fasciitis.[3] The diagnosis of gangrene is based on symptoms and supported by tests such as medical imaging.[6]

Treatment may involve surgery to remove the dead tissue,

hyperbaric oxygen therapy may be useful.[5] How commonly the condition occurs is unknown.[2]

Signs and symptoms

Four drawn illustrations on a page, including (top left) a foot with black toes, (top right) a limb with holes in the skin showing yellowed matter beneath, (centre right) the end of a foot with blackened stubs where the toes once were, and (bottom) a foot that is wrinkled and dark, with prominent veins and purple toes.
An illustration showing four different stages of gangrene, including one (Fig. 4 top right) caused by an obstacle to the return of the venous blood due to heart disease.

Symptoms may include a change in skin color to red or black, numbness, pain, skin breakdown, and coolness.[1] The feet and hands are most commonly involved.[1]

Causes

Gangrene is caused by a critically insufficient blood supply (e.g.,

peripheral vascular disease) or infection.[3][7][8] It is associated with diabetes[9] and long-term tobacco smoking.[4][3]

Dry gangrene

Dry gangrene is a form of

acute limb ischemia. As a result, people with atherosclerosis, high cholesterol, diabetes and smokers commonly have dry gangrene.[12] The limited oxygen in the ischemic limb limits putrefaction and bacteria fail to survive. The affected part is dry, shrunken, and dark reddish-black. The line of separation usually brings about complete separation, with eventual falling off of the gangrenous tissue if it is not removed surgically, a process called autoamputation.[12]

Dry gangrene is the result of chronic

ischemic wounds rather than gangrene are present, the process can be treated by revascularization (via vascular bypass or angioplasty).[13] However, once gangrene has developed, the affected tissues are not salvageable.[14] Because dry gangrene is not accompanied by infection, it is not as emergent as gas gangrene or wet gangrene, both of which have a risk of sepsis. Over time, dry gangrene may develop into wet gangrene if an infection develops in the dead tissues.[15]

Diabetes mellitus is a risk factor for peripheral vascular disease, thus for dry gangrene, but also a risk factor for wet gangrene, particularly in patients with poorly controlled blood sugar levels, as elevated serum glucose creates a favorable environment for bacterial infection.[16]

Wet gangrene

Wet gangrene of the foot.

Wet, or infected, gangrene is characterized by thriving bacteria and has a poor

Bacillus fusiformis, for example), which cause tissue to swell and emit a foul odor. Wet gangrene usually develops rapidly due to blockage of venous (mainly) or arterial blood flow.[12] The affected part is saturated with stagnant blood, which promotes the rapid growth of bacteria. The toxic products formed by bacteria are absorbed, causing systemic manifestation of sepsis and finally death. The affected part is edematous, soft, putrid, rotten, and dark.[citation needed
]

Because of the high mortality associated with infected gangrene (about 80% without treatment and 20% with treatment), an emergency salvage amputation, such as a

below- or above-knee amputation.[17]

Gas gangrene

Main article: Gas gangrene

Gas gangrene is a bacterial infection that produces gas within tissues. It can be caused by Clostridium, most commonly alpha toxin-producing C. perfringens, or various nonclostridial species.[8][18] Infection spreads rapidly as the gases produced by the bacteria expand and infiltrate healthy tissue in the vicinity. Because of its ability to quickly spread to surrounding tissues, gas gangrene should be treated as a medical emergency.

Gas gangrene is caused by bacterial exotoxin-producing clostridial species, which are mostly found in soil, and other anaerobes such as Bacteroides and anaerobic streptococci. These environmental bacteria may enter the muscle through a wound and subsequently proliferate in necrotic tissue and secrete powerful toxins that destroy nearby tissue, generating gas at the same time. A gas composition of 5.9% hydrogen, 3.4% carbon dioxide, 74.5% nitrogen, and 16.1% oxygen was reported in one clinical case.[19]

Gas gangrene can cause necrosis, gas production, and sepsis. Progression to

toxemia and shock is often very rapid.[20]

Other types

Treatment

Treatment varies based on the severity and type of gangrene.[12]

Lifestyle

Exercises such as walking and massage therapy may be tried.[12]

Medication

Medications may include pain management, medications that promote circulation in the

antibiotics are often a critical component of its treatment. The life-threatening nature of gangrene requires treatment with intravenous antibiotics in an inpatient setting.[12] Antibiotics alone are not effective because they may not penetrate infected tissues sufficiently.[25]

Surgery

Surgical removal of all dead tissue, however, is the mainstay of treatment for gangrene. Often, gangrene is associated with underlying infection, thus the gangrenous tissue must be debrided to hinder the spread of the associated infection. The extent of surgical debridement needed depends on the extent of the gangrene and may be limited to the removal of a finger, toe, or ear, but in severe cases may involve a limb amputation.[12]

Dead tissue alone does not require debridement, and in some cases, such as dry gangrene, the affected part falls off (autoamputates), making surgical removal unnecessary. Waiting for autoamputation, however, may cause health complications as well as decreased quality of life.[12]

After the gangrene is treated with debridement and antibiotics, the underlying cause can be treated. In the case of gangrene due to

critical limb ischemia, revascularization can be performed to treat the underlying peripheral underlateral artery disease.[citation needed
]

Ischemic disease of the legs is the most common reason for amputations. In about a quarter of these cases, the other side requires amputation in the next three years.[26]

Angioplasty should be considered if severe blockage in lower leg vessels (

peroneal artery) leads to gangrene.[27]

Other

Hyperbaric oxygen therapy treatment is used to treat gas gangrene. It increases pressure and oxygen content to allow blood to carry more oxygen to inhibit anaerobic organism growth and reproduction.[28]

stem-cell therapies have successfully altered gangrene and ulcer prognosis.[citation needed
]

History

Confederate Army
Private Milton E. Wallen lies in bed with a gangrenous amputated arm

As early as 1028, flies and maggots were commonly used to treat chronic wounds or ulcers to prevent or arrest necrotic spread,[29] as some species of maggots consume only dead flesh, leaving nearby living tissue unaffected. This practice largely died out after the introduction of antibiotics to the range of treatments for wounds. In recent times, however, maggot therapy has regained some credibility and is sometimes employed with great efficacy in cases of chronic tissue necrosis.[30][31][32]

The French Baroque composer Jean-Baptiste Lully contracted gangrene in January 1687 when, while conducting a performance of his Te Deum, he stabbed his own toe with his pointed staff (which was used as a baton). The disease spread to his leg, but the composer refused to have his toe amputated, which eventually led to his death in March of that year.[33]

French King

Louis XIV died of gangrene in his leg on 1 September 1715, four days prior to his 77th birthday.[34]

Leyden University, from 1795 on Director of the Medical Bureau of the Batavian Republic, and inspector-general of the French Imperial Military Health-Service in 1811, became a leading expert in the fight against hospital-gangrene and its prevention. He wrote a treatise on gangrene in 1814 in which he meticulously analyzed and explained the causes of this dreadful disease, which he was convinced was contagious. He completed his entry with a thorough evaluation of all possible and well experienced sanitary regulations. His work was very well received and was instrumental in convincing most later authors that gangrene was a contagious disease.[35][36]

John M. Trombold wrote: "Middleton Goldsmith, a surgeon in the Union Army during the American Civil War, meticulously studied hospital gangrene and developed a revolutionary treatment regimen. The cumulative Civil War hospital gangrene mortality was 45%. Goldsmith's method, which he applied to over 330 cases, yielded a mortality under 3%."[37] Goldsmith advocated the use of debridement and topical and injected bromide solutions on infected wounds to reduce the incidence and virulence of "poisoned miasma". Copies of his book[38] were issued to Union surgeons to encourage the use of his methods.[39]

Etymology

The etymology of gangrene derives from the Latin word gangraena and from the Greek gangraina (γάγγραινα), which means "putrefaction of tissues".[40]

References

  1. ^ a b c d e f g "Gangrene Symptoms". NHS. 13 October 2015. Retrieved 12 December 2017.
  2. ^ a b c "Gangrene". patient.info. 12 March 2014. Retrieved 12 December 2017.
  3. ^ a b c d e f "Gangrene Causes". NHS. 13 October 2015. Retrieved 12 December 2017.
  4. ^ a b c d "Gangrene". NHS. 13 October 2015. Retrieved 12 December 2017.
  5. ^ a b c d e "Gangrene Treatment". NHS. Retrieved 12 December 2017.
  6. ^ "Gangrene Diagnosis". NHS. 13 October 2015. Retrieved 12 December 2017.
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  20. ^ "Gas Gangrene". The Lecturio Medical Concept Library. Retrieved 22 July 2021.
  21. ^ "For Clinicians: Type II Necrotizing Fasciitis | CDC". www.cdc.gov. 2019-02-21. Retrieved 2019-08-05.
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  26. ^ Amputations of the Lower Extremity at eMedicine
  27. ^ "Angioplasty and stent placement – peripheral arteries". Retrieved July 24, 2013.
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  30. ^ "Product Classification: Maggots, Medical". fda.gov. US: Food and Drug Administration.
  31. ^ "FDA CDRH 510(k) summary" (PDF).
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  33. ^ "Music Trivia – The Death of Lully". The Musician's Lounge. Utah Symphony Orchestra. August 2010. Retrieved March 7, 2017.
  34. ^ Laurenson, John (21 November 2015). "The strange death of Louis XIV". The Spectator. Retrieved 12 March 2017.
  35. ^ Teun van Heiningen, "Sebald Justinus Brugmans' strijd tegen de hospitaalversterving", Leiden University, URN:NBN:NL:UI:10-1-112565
  36. ^ Brugmans, Sebald Justinus (May 24, 1814). "Verhandeling ter beantwoording der vrage: Kan de gesteldheid en zamenstelling van den dampkring, welke onmiddelijk tot de Hospitaal-versterving (Gangraena NosocomialisZ) aanleiding geeft, door Natuur- of Scheikundige middelen worden ontdekt?". J. van der Heij – via Google Books.
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  38. ^ A report on hospital gangrene, erysipelas and pyaemia. 1863
  39. ^ Watson, Dr. Scott. "Hospital Gangrene During The Civil War – Civil War Medicine". Retrieved 2014-04-15.
  40. ^ Liddell & Scott's Lexicon, Oxford University Press, 1963 edition

External links

  • Media related to Gangrene at Wikimedia Commons
Look up gangrene or festering in Wiktionary, the free dictionary.
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