Gangrene

From Wikipedia, the free encyclopedia

Gangrene

Dry gangrene affecting the toes as a result of

peripheral artery disease.
Classification and external resources
Specialty Infectious disease, general surgery
ICD-10 R02, I70.2, E10.2, I73.9
ICD-9-CM 040.0, 785.4
DiseasesDB 19273
MedlinePlus 007218
article/217943 article/782709
eMedicine article/214992 article/438994
article/2028899 article/2051157
Patient UK Gangrene
MeSH
D005734
[edit on Wikidata]
Gangrene (or gangrenous necrosis) is a type of necrosis caused by a critically insufficient
blood supply.[1][2] This potentially life-threatening condition may occur after an injury or
infection, or in people suffering from any chronic health problem affecting blood circulation.[2]
The primary cause of gangrene is reduced blood supply to the affected tissues, which results in
cell death.[3] Diabetes and long-term smoking increase the risk of suffering from gangrene.[2][3]
Gangrene is a non-communicable disease. It does not spread from person to person. There are
different types of gangrene with different symptoms, such as dry gangrene, wet gangrene, gas
gangrene, internal gangrene and necrotizing fasciitis.[1][2] Treatment depends on the underlying
cause, and can include resection, debridement (or, in severe cases, amputation) of the affected
body parts, antibiotics, revascularization (via a vascular bypass or angioplasty), or hyperbaric

oxygen therapy.[4] It can rarely include medical therapy to stop vascular spasm or the production
of cold-induced vascular obstruction by cold-precipitated cryoglobulins.

Contents

1 Etymology

2 Causes

3 Types
o 3.1 Dry
o 3.2 Wet
o 3.3 Gas
o 3.4 Other

4 Treatment

5 History

6 See also

7 References

8 External links

Etymology
The etymology of gangrene derives from the Latin word gangraena and from the Greek
gangraina (), which means "putrefaction of tissues". It has no etymological connection
with the word green, despite the affected areas turning black and/or green and/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.

Causes
Gangrene is caused by a critically insufficient blood supply (e.g., peripheral vascular disease) or
infection.[3][5][6] It is associated with diabetes[7] and long-term tobacco smoking. This condition
most commonly occurs in the lower extremities (legs and feet).

Types
Dry
Dry gangrene is a form of coagulative necrosis that develops in ischemic tissue, where the blood
supply is inadequate to keep tissue viable. 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 reddishblack. 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 there are ischemic wounds rather than gangrene, the process can be treated by
revascularization (via vascular bypass or angioplasty).[medical citation needed] However, once gangrene
has developed, the affected tissues are not salvageable.[medical citation needed]
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.[8]

Wet
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 cause
tissue to swell and emit a fetid smell. Wet gangrene usually develops rapidly due to blockage of
venous (mainly) and/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.[9] Such an amputation can be converted to a formal amputation, such as a below or
above knee amputation.[9]

Gas
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 Clostridium perfringens, or various nonclostridial species.[6][10] 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. These toxins 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.[11]
Gas gangrene can cause necrosis, gas production, and sepsis. Progression to toxemia and shock
is often very rapid.

Other

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.[12]

Venous limb gangrene may be caused by heparin-induced thrombocytopenia and

thrombosis (HITT).[13]

Severe mesenteric ischemia may result in gangrene of the small intestine.

Severe ischemic colitis may result in gangrene of the large intestine.

Treatment
The method of treatment is generally determined by the location of affected tissue and extent of
tissue loss. The best treatment for gangrene is revascularization (i.e., restoration of blood flow)
of the afflicted organ, which can reverse some of the effects of necrosis and allow healing. Other
treatments include antibiotic therapy, wound care, debridement and surgical amputation.
Most amputations are performed for ischemic disease of the lower extremity. Of dysvascular
amputations, 1528% of patients undergo contralateral limb amputations within 3 years. Of
elderly persons who undergo amputations, 50% survive the first 3 years.[14]
In the United States, 30,00040,000 amputations are performed annually. There were an
estimated 1.6 million individuals living with the loss of a limb in 2005; these estimates are
expected to more than double to 3.6 million such individuals by the year 2050.[15] Antibiotics
alone are not effective because they may not penetrate infected tissues sufficiently.[16] 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.[17] 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.
Angioplasty should be considered if severe blockage in lower leg vessels (tibial and peroneal
artery) leads to gangrene.[18]

History

American Civil War soldier lies in bed with a gangrenous amputated arm
As early as 1028 fly maggots were commonly[citation needed] 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[citation needed] 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.
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."[19]
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.[20]

See also

Frank Adamo, a prison camp physician during World War II who developed a unique
treatment for the disease

Allan Pinkerton, one of the co-founders of the Pinkerton Detective Agency, who
succumbed to gangrene of the tongue after slipping on the sidewalk.

References

1.

Porth, Carol (2007). Essentials of pathophysiology. Lippincott Williams &

Wilkins. p. 41. ISBN 978-0-7817-7087-3. Retrieved 2010-06-15.

2.

"Gangrene Introduction". NHS Health AZ. NHS. Retrieved 2010-06-15.

3.

"Gangrene Causes". NHS Health AZ. National Health Service (England).

Retrieved 2010-06-15.

4.

"Gangrene Treatment". NHS Health AZ. National Health Service (England).

Retrieved 2010-06-15.

5.

Gardner, AW; Afaq, A (NovemberDecember 2008). "Management of lower

extremity peripheral arterial disease". Journal of cardiopulmonary rehabilitation and
prevention 28 (6): 349357. doi:10.1097/HCR.0b013e31818c3b96. PMC 2743684.
PMID 19008688.

6.

Yang, Z.; Hu, J.; Qu, Y.; Sun, F.; Leng, X.; Li, H.; Zhan, S. (2013). "Interventions
for treating gas gangrene (Protocol)". Cochrane Database of Systematic Reviews (6):
Article number: CD010577. doi:10.1002/14651858.CD010577.

7.

Korzon-Burakowska, A; Dziemidok, P (December 2011). "Diabetic foot-the need

for comprehensive multidisciplinary approach.". Annals of agricultural and
environmental medicine 18 (2): 314317. PMID 22216805.

8.

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): 46672. doi:10.1111/j.1742481x.2012.01006.x. PMID 22694053.

9.

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.

10.

Sakurai, J.; Nagahama, M.; Oda, M. (November 2004). "Clostridium perfringens

alpha-toxin: characterization and mode of action". Journal of Biochemistry 136 (5):
569574. doi:10.1093/jb/mvh161. PMID 15632295.