Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. Certain types may present with a fever or sepsis.
|Dry gangrene affecting the toes as a result of peripheral artery disease|
|Specialty||Infectious disease, general surgery|
|Symptoms||Change in skin color to red or black, numbness, pain, skin breakdown, coolness|
|Types||Dry, wet, gas, internal, necrotizing fasciitis|
|Risk factors||Diabetes, peripheral arterial disease, smoking, major trauma, alcoholism, HIV/AIDS, frostbite, Raynaud's syndrome|
Risk factors include diabetes, peripheral arterial disease, smoking, major trauma, alcoholism, HIV/AIDS, frostbite, and Raynaud's syndrome. It can be classified as dry gangrene, wet gangrene, gas gangrene, internal gangrene, and necrotizing fasciitis. The diagnosis of gangrene is based on symptoms and supported by tests such as medical imaging.
Treatment may involve surgery to remove the dead tissue, antibiotics to treat any infection, and efforts to address the underlying cause. Surgical efforts may include debridement, amputation, or the use of maggot therapy. Efforts to treat the underlying cause may include bypass surgery or angioplasty. In certain cases hyperbaric oxygen therapy may be useful. It is unknown how commonly the condition occurs.
Signs and symptomsEdit
Dry gangrene is a form of coagulative necrosis that develops in ischemic tissue, where the blood supply is inadequate to keep tissue viable. It is not a disease itself, but a symptom of other diseases. Dry gangrene is often due to peripheral artery disease, but can be due to acute limb ischemia. 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.
Dry gangrene is the end result of chronic ischemia without infection. If ischemia is detected early, when ischemic wounds rather than gangrene are present, the process can be treated by revascularization (via vascular bypass or angioplasty). However, once gangrene has developed, the affected tissues are not salvageable. 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.
Diabetes mellitus is a risk-factor for peripheral vascular disease and thus for dry gangrene, but also a risk factor for wet gangrene, particularly in patients with poorly controlled blood-sugars, as elevated serum glucose creates a favorable environment for bacterial infection.
Wet, or infected, gangrene is characterized by thriving bacteria and has a poor prognosis (compared to dry gangrene) due to sepsis resulting from the free communication between infected fluid and circulatory fluid. In wet gangrene, the tissue is infected by saprogenic microorganisms (Clostridium perfringens or Bacillus fusiformis, for example), which causes tissue to swell and emit a fetid smell. Wet gangrene usually develops rapidly due to blockage of venous (mainly) or arterial blood flow. 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.
Because of the high mortality associated with infected gangrene, an emergency salvage amputation, such as a guillotine amputation, is often needed to limit systemic effects of the infection. Such an amputation can be converted to a formal amputation, such as a below or above knee amputation.
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. Infection spreads rapidly as the gases produced by 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, which 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.
- Necrotizing fasciitis is an infection that spreads deep into the body along tissue planes.
- Noma is a gangrene of the face.
- Fournier gangrene is a type of necrotizing fasciitis that usually affects the genitals and groin.
- Venous limb gangrene may be caused by heparin-induced thrombocytopenia and thrombosis (HITT).
- Severe mesenteric ischemia may result in gangrene of the small intestine.
- Severe ischemic colitis may result in gangrene of the large intestine.
Surgical removal of all dead tissue is the mainstay of treatment for gangrene. Often, gangrene is associated with underlying infection, and 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.
Dead tissue alone does not require debridement, and in some cases, such as dry gangrene, the affected part falls off (auto-amputates), making surgical removal unnecessary.
As there is often infection associated with gangrene, antibiotics are often a critical component of the treatment of gangrene. The life-threatening nature of gangrene requires treatment with intravenous antibiotics in an inpatient setting.
After the gangrene is treated with debridement and antibiotics, the underlying cause of gangrene can be treated. In the case of gangrene due to critical limb ischemia, revascularization can be performed to treat the underlying peripheral artery disease.
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.
In 2005, an estimated 1.6 million individuals in the United States were living with the loss of a limb caused by either trauma, cancer or vascular disease; these estimates are expected to more than double to 3.6 million such individuals by 2050. Antibiotics alone are not effective because they may not penetrate infected tissues sufficiently. Hyperbaric oxygen therapy (HBOT) treatment is used to treat gas gangrene. HBOT increases pressure and oxygen content to allow blood to carry more oxygen to inhibit anaerobic organism growth and reproduction. A regenerative medicine therapy was developed by Dr. Peter DeMarco to treat diabetic gangrene to avoid amputations. Growth factors, hormones, and skin grafts have also been used to accelerate healing for gangrene and other chronic wounds.
As early as 1028, flies and maggots were commonly used to treat chronic wounds or ulcers to prevent or arrest necrotic spread, as some species of maggots consume only dead flesh, leaving nearby living tissue unaffected. This practice largely died out after the introduction of antibiotics, acetonitrile and enzyme 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.
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.
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 percent. Goldsmith's method, which he applied to over 330 cases, yielded a mortality under 3 percent." 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 were issued to Union surgeons to encourage the use of his methods.
The etymology of gangrene derives from the Latin word gangraena and from the Greek gangraina (γάγγραινα), which means "putrefaction of tissues". It has no etymological connection with the word green, despite the affected areas turning black, green, or yellowish brown. It is coincidence that, in Lowland Scots, the words "gang green" (go green) can be said to be an eggcorn for gangrene, as it describes the symptoms of the affliction.
- "Gangrene Symptoms". NHS. 13 October 2015. Retrieved 12 December 2017.
- "Gangrene". patient.info. 12 Mar 2014. Retrieved 12 December 2017.
- "Gangrene Causes". NHS. 13 October 2015. Retrieved 12 December 2017.
- "Gangrene". NHS. 13 October 2015. Retrieved 12 December 2017.
- "Gangrene Treatment". NHS. Retrieved 12 December 2017.
- "Gangrene Diagnosis". NHS. 13 October 2015. Retrieved 12 December 2017.
- Gardner, AW; Afaq, A (November–December 2008). "Management of lower extremity peripheral arterial disease". Journal of cardiopulmonary rehabilitation and prevention. 28 (6): 349–357. doi:10.1097/HCR.0b013e31818c3b96. PMC . PMID 19008688.
- Yang, Z; Hu, J; Qu, Y; Sun, F; Leng, X; Li, H; Zhan, S (3 December 2015). "Interventions for treating gas gangrene". The Cochrane Database of Systematic Reviews (12): CD010577. doi:10.1002/14651858.CD010577.pub2. PMID 26631369.
- Korzon-Burakowska, A; Dziemidok, P (December 2011). "Diabetic foot-the need for comprehensive multidisciplinary approach". Annals of Agricultural and Environmental Medicine. 18 (2): 314–317. PMID 22216805.
- Smith, Tyler (2015). Gangrene Management: Today and Tomorrow. Hayle Medical. ISBN 1632412233.
- Aiello A, Anichini R, Brocco E, Caravaggi C, Chiavetta A, Cioni R, Da Ros R, De Feo ME, Ferraresi R, Florio F, Gargiulo M, Galzerano G, Gandini R, Giurato L, Graziani L, Mancini L, Manzi M, Modugno P, Setacci C, Uccioli L (2014). "Treatment of peripheral arterial disease in diabetes: a consensus of the Italian Societies of Diabetes (SID, AMD), Radiology (SIRM) and Vascular Endovascular Surgery (SICVE)". Nutr Metab Cardiovasc Dis. 24 (4): 355–69. doi:10.1016/j.numecd.2013.12.007. PMID 24486336.
- Gerhard-Herman, MD; Gornik, HL; Barrett, C; Barshes, NR; Corriere, MA; Drachman, DE; Fleisher, LA; Fowkes, FG; Hamburg, NM; Kinlay, S; Lookstein, R; Misra, S; Mureebe, L; Olin, JW; Patel, RA; Regensteiner, JG; Schanzer, A; Shishehbor, MH; Stewart, KJ; Treat-Jacobson, D; Walsh, ME (2017). "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Circulation. 135 (12): e726–e779. doi:10.1161/CIR.0000000000000471. PMC . PMID 27840333.
- Nather, Aziz (2013). The diabetic foot. ISBN 9789814417006.
- Vayvada, H; Demirdover, C; Menderes, A; Karaca, C (August 2013). "Necrotising fasciitis in the central part of the body: diagnosis, management and review of the literature". International wound journal. 10 (4): 466–72. doi:10.1111/j.1742-481x.2012.01006.x. PMID 22694053.
- Tisi, PV; Than, MM (8 April 2014). "Type of incision for below knee amputation". The Cochrane Database of Systematic Reviews. 4: CD003749. doi:10.1002/14651858.CD003749.pub3. PMID 24715679.
- Sakurai, J.; Nagahama, M.; Oda, M. (November 2004). "Clostridium perfringens alpha-toxin: characterization and mode of action". Journal of Biochemistry. 136 (5): 569–574. doi:10.1093/jb/mvh161. PMID 15632295.
- Chi CH, Chen KW, Huang JJ, Chuang YC, Wu MH (December 1995). "Gas composition in Clostridium septicum gas gangrene". Journal of the Formosan Medical Association. 94 (12): 757–9. PMID 8541740.
- Levenson, RB; Singh, AK; Novelline, RA (March–April 2008). "Fournier gangrene: role of imaging". Radiographics. 28 (2): 519–528. doi:10.1148/rg.282075048. PMID 18349455.
- Warkentin, TE (August 2010). "Agents for the treatment of heparin-induced thrombocytopenia". Hematology/Oncology clinics of North America. 24 (4): 755–775. doi:10.1016/j.hoc.2010.05.009. PMID 20659659.
- Amputations of the Lower Extremity at eMedicine
- Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R (March 2008). "Estimating the prevalence of limb loss in the United States: 2005 to 2050". Arch Phys Med Rehabil. 89 (3): 422–9. doi:10.1016/j.apmr.2007.11.005. PMID 18295618.
- Lipsky BA (December 1999). "Evidence-based antibiotic therapy of diabetic foot infections". FEMS Immunol. Med. Microbiol. 26 (3–4): 267–76. doi:10.1016/s0928-8244(99)00143-1. PMID 10575138.
- Liu R, Li L, Yang M, Boden G, Yang G (2013). "Systematic review of the effectiveness of hyperbaric oxygenation therapy in the management of chronic diabetic foot ulcers". Mayo Clin. Proc. 88 (2): 166–75. doi:10.1016/j.mayocp.2012.10.021. PMID 23374620.
- "Angioplasty and stent placement – peripheral arteries". Retrieved July 24, 2013.
- Shi E. and Shofler D., Maggot debridement therapy: a systematic review, British Journal of Community Nursing, 19:Sup12, S6-S13, 2014. PMID 25478859, doi:10.12968/bjcn.2014.19.Sup12.S6. Accessed 2016-11-07.
- "Music Trivia – The Death of Lully". The Musician's Lounge. Utah Symphony Orchestra. August 2010. Retrieved March 7, 2017.
- Laurenson, John (21 November 2015). "The strange death of Louis XIV". The Spectator. Retrieved 12 March 2017.
- Trombold JM (2011). "Gangrene therapy and antisepsis before lister: the civil war contributions of Middleton Goldsmith of Louisville". Am Surg. 77: 1138–43. PMID 21944621.
- A report on hospital gangrene, erysipelas and pyaemia. 1863
- Watson, Dr. Scott. "Hospital Gangrene During The Civil War – Civil War Medicine". Retrieved 2014-04-15.
- Liddell & Scott's Lexicon, Oxford University Press, 1963 edition
- Media related to Gangrene at Wikimedia Commons