GANGRENE
Definition :-
Gangrene is the death of a portion of the body with putrefaction.
Types :-
There are 2 types of gangrene –
1. Dry gangrene 2. Moist gangrene
1. Dry Gangrene :-
The characteristic features are –
i. The part is gradually deprived of its arterial blood supply.
ii. There is characteristic colour changes – first greenish and
finally black due to haemolysis of the red blood corpusles.
iii. There is mainly arterial occlusion, but the venous outflow
remains unimpaired.
iv. Occlusion of the artery is by acute or chronic process.
v. There is definite bright red line of separation appears b/w the
living and dead tissue.
vi. The condition which produce dry gangrene are senile gangrene,
diabetec gangrene, buerger’s disease, raynaud’s disease, sudden
vascular occlusion.
2. Moist Gangrene :-
i. When the vein is obstructed, so that no blood can leave the part.
No fresh blood can enter, so liquefaction and bacterial infection
occur to cause moist gangrene.
ii. The part is cold, pulseless, swollen and oedematous. The colour
also changes. The skin becomes raised into blebs which contain
foul smelling fluid.
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iii. It is characterised by horrible odour.
iv. There is little attempt at formation of a line of demarcation.
v. Constitutional symptoms are always grave, which are almost
absent in gry gangrene.
vi. The condition which produce moist gangrene are acute
inflammation, long-standing venous thrombosis, bed sores and
gas gangrene.
Cause of Gangrene :-
A. Arterial occlusion
B. Venous obstruction
C. Nervous disease
D. Traumatic gangrene
E. Infective gangrene
F. Diabetic gangrene
G. Physical gangrene
Special Investigation :-
A. General investigation –
1. Blood examination
2. Plain X-ray
3. E.C.G.
B. Local investigation –
1. Doppler ultrasound
2. Duplex imaging
3. Plethysmography
4. B-scan ultrasound
5. Treadmill
6. Determination of ankle pressure
7. Isotope technique
8. Electromagnetic flow meter
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Treatment :-
a) General treatment –
This includes nutritious diet, control pf diabetes, relief of pain and
care of the heart.
b) Local trearment –
Care of the affected part-
i. The part should be kept dry. Keep dry gangrene as dry as
possible and try to convert moist gangrene into dry gangrene.
ii. The part may be kept elevated, which will reduce pain.
iii. The part should not be heated.
iv. The part should be protected particularly the local pressure
areas.
v. The gangrenous part should be carefully observed and toileted.
c) Surgical treatment –
1. Sympathectomy
2. Amputation
i) Limb-saving aspect
ii) Life-saving aspect
3. Direct arterial surgery
DIABETEC GANGRENE
The diabetics possess distinct problems, which make their limbs
more liable to gangrene formation.
Causes :-
1. Sugar laden tissues of the diabetics lower their resistance to
infection.
2. Formation of atheroma in the arteries of the diabetic patients.
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3. Diabetic neuropathy.
Clinical features :-
Pain and ulceration of foot
There may be loss of sensation
Peripheral pulse may be absent
Change of colour and temperature where gangrene is impending
There may be abscess formation
Meggitt’s classification of diabetic foot :-
Grade 0 – foot pain only
Grade 1- superficial ulcer of foot
Grade 2 – deep ulcer of foot
Grade 3 – ulcer with bone involvement
Grade 4 - forefoot gangrene
Grade 5 – whole foot gangrene
Special Investigation :-
Blood sugar and urine ketone bodies estimation
Blood creatinine estimation
Pus should be sent for culture and sensitivity
Doppler study to know arterial patency
Angiogram to know any arterial blockage
X-ray if osteomyelitis is suspected
Treatment :-
Diabetes should be controlled by drugs and insulin
Vasodilators, dipyridamole, pentoxiphylline, low dose aspirin etc.
Care of foot – avoid injury, keep it clean and dry particularly toe
webs
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Micro cellular rubber (MCR) foot wear may be used
When there is infection, antibiotics should be prescribed
Problems of Diabetic Foot :-
Callosities followed by ulceration
Abscess and cellulitis of foot
Diabetic wet gangrene
Osteomyelitis
Arthritis of joints
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