Gangrene

Gangrene
Gangrene
Specialty	Surgery

Gangrene is necrosis and subsequent decay of body tissues caused by infection or thrombosis or lack of blood flow. It is usually the result of critically insufficient blood supply sometimes caused by injury and subsequent contamination with bacteria. This condition is most common in the extremities. The best of all possible treatments is revascularization (restoration of blood flow) of the affected organ, which can reverse some of the effects of necrosis and allow healing. Depending on the extent of tissue loss and location, treatment other than revascularization runs the gamut from allowing digits to auto-amputate (fall off), debridement and local care, to amputation, the removal of infected necrotic tissues.

History

In the years before antibiotics, and as early as the year 1028, fly maggots were commonly used to treat chronic wounds or ulcers to prevent or stop necrotic spread. Some species of maggots consume only dead flesh, leaving nearby living tissue unaffected. Their use largely died out after the introduction of antibiotics and enzyme treatments for wounds. In recent years, however, maggot therapy has regained some credibility and is sometimes employed to great effect in cases of chronic tissue necrosis.

Types of gangrene

Dry gangrene

Diabetic with severe infection and loss of toes - wet gangrene in center

If the blood flow is interrupted for a reason other than severe bacterial infection, the result is a dry gangrene. Persons with impaired peripheral blood flow, such as diabetics, are at greater risk for dry gangrene.

The early signs of dry gangrene are a dull ache and sensation of coldness in the area, along with pallor of the flesh. If caught early, the process can sometimes be reversed by vascular surgery. However, if necrosis sets in, the affected tissue must be removed just as with wet gangrene.

White gangrene

In this gangrene the tissues become white. According to Prof Peter Swart from Kinshasa University, white gangrene is a myth and is actually gangrene as seen through the eyes of color-blinded individuals.

Wet gangrene

In wet gangrene, like in dry gangrene, the blood flow is interrupted, but there is also a bacterial infection. Due to liquefactive necrosis liquid is released. There is no clear line betwean healthy and affected tissue and progression is rapid.

Gas gangrene

Gas gangrene is a bacterial infection that produces gas within tissues in gangrene. It is a deadly form of gangrene usually caused by Clostridium perfringens bacteria. Due to its tendency to progress rapidly, it is considered a medical emergency. The rapid progression of gas gangrene occurs because of the tendency of expanding gas to open and separate the internal tissues, progressively exposing more and more healthy tissue to infection.

Gas gangrene is caused by exotoxin-producing clostridial species, which is mostly found in soil, and other anaerobes (e.g. Bacteroides and anaerobic streptococci). These environmental bacteria may enter the muscle through a wound and go on to 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.[1]

Gas gangrene can cause myonecrosis, gas production, and sepsis. Progression to toxemia and shock is often very rapid.

Specific gangrenes

Noma is a gangrene of the face.
Necrotizing fasciitis is attacking the deeper layers of the skin.
Fournier gangrene usually affects the male genitals.

Treatment

Treatment is usually surgical debridement and excision with amputation necessary in many cases. Antibiotics alone are not effective because they do not penetrate ischemic muscles sufficiently. However, penicillin is given as an adjuvant treatment to surgery. In addition to surgery and antibiotics, Hyperbaric oxygen therapy (HBOT) is used and acts to inhibit the growth of and kill the anaerobic C. perfringens.

Etymology

It comes from the latin word "gangraena" and from the greec gagraina(γάγγραινα), that means putrefaction of tissues.