Gangrene

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] Certain types may present
with a fever or sepsis.[1]
 Gangrene
Other names Gangrenous necrosis

Dry gangrene affecting the toes as a result of

peripheral artery disease

Specialty Infectious disease,

surgery

Symptoms Change in skin color to

red or black,
numbness, pain, skin
breakdown, coolness[1]
Complications Sepsis, amputation[1][2]

Types Dry, wet, gas, internal,

necrotizing fasciitis[3]
 necrotizing fasciitis[3]

Risk factors Diabetes, peripheral

arterial disease,
smoking, major
trauma, alcoholism,
HIV/AIDS, frostbite,
Raynaud's
syndrome[3][4]
Treatment Surgery, antibiotics[5]

Frequency Unknown[2]

Risk factors include diabetes, peripheral

arterial disease, smoking, major trauma,
alcoholism, HIV/AIDS, frostbite, and
Raynaud's syndrome.[3][4] It can be
classified as dry gangrene, 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, antibiotics to treat any
infection, and efforts to address the
underlying cause.[5] Surgical efforts may
include debridement, amputation, or the
use of maggot therapy.[5] Efforts to treat
the underlying cause may include bypass
surgery or angioplasty.[5] In certain
cases, hyperbaric oxygen therapy may be
useful.[5] How commonly the condition
occurs is unknown.[2]

Signs and symptoms

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 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.[10] Dry gangrene is often due to
peripheral artery disease, but can be due
to acute limb ischemia. As a result,
people with arteriosclerosis, high
cholesterol, diabetes and smokers
commonly have dry gangrene.[11] 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.[11]

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).[12] However, once gangrene
has developed, the affected tissues are
not salvageable.[13] 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.[14]

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.[15]

Wet gangrene

Wet gangrene of the foot

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 bad smell. Wet gangrene
usually develops rapidly due to blockage
of venous (mainly) or arterial blood
flow.[11] 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.[16] Such
an amputation can be converted to a
formal amputation, such as a below- or
above-knee amputation.[16]

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][17]
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, 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.[18]

Gas gangrene can cause necrosis, gas

production, and sepsis. Progression to
toxemia and shock is often very rapid.

Other types
Necrotizing fasciitis, also known as
hemolytic streptococcal gangrene, is
an infection that spreads deep into the
body along tissue planes. It is
characterized by infection with
S.pyogenes, a gram-positive cocci
bacteria.[19]
Noma is a gangrene of the face.
Fournier gangrene is a type of
necrotizing fasciitis that usually
affects the genitals and groin.[20]
Venous limb gangrene may be caused
by heparin-induced thrombocytopenia
and thrombosis.[21]
Severe mesenteric ischemia may result
in gangrene of the small intestine.
 Severe ischemic colitis may result in
gangrene of the large intestine.

Treatment
Treatment varies based on the severity
and type of gangrene.[11]

Lifestyle

Exercises such as walking and massage

therapy may be tried.[11]

Medication

Medications may include pain

management, medications that promote
circulation in the circulatory system and
antibiotics. Since gangrene is associated
with periodic pain caused by too little
blood flow, pain management is
important so patients can continue doing
exercises that promote circulation. Pain
management medications can include
opioids and opioid-like analgestics. Since
gangrene is a result of ischemia,
circulatory system management is
important. These medications can
include antiplatelet drug, anticoagulant,
and fibrinolytics. As infection is often
associated with gangrene, antibiotics are
often a critical component of its
treatment. The life-threatening nature of
gangrene requires treatment with
intravenous antibiotics in an inpatient
setting.[11] Antibiotics alone are not
effective because they may not penetrate
infected tissues sufficiently.[22]

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. [11]

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 decrease
quality of life.[11]

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 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.[23]

Angioplasty should be considered if

severe blockage in lower leg vessels
(tibial and peroneal artery) leads to
gangrene.[24]

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.[25]

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,[26] 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.[27]

French King Louis XIV died of gangrene

in his leg on 1 September 1715, four days
prior to his 77th birthday.[28]

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%."[29] 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[30] were issued to Union surgeons
to encourage the use of his methods.[31]

Etymology
The etymology of gangrene derives from
the Latin word gangraena and from the
Greek gangraina (γάγγραινα), which
means "putrefaction of tissues".[32] 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.

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32. Liddell & Scott's Lexicon, Oxford
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External links
Classification D
ICD-10: R02 , I70.2 ,
E10.2 , I73.9 •
ICD-9-CM: 040.0 ,
785.4 •
MeSH: D005734 •
DiseasesDB: 19273

External resources MedlinePlus:

007218 •
eMedicine:
article/217943
article/782709
article/214992
article/438994
article/2028899
article/2051157 •
Patient UK: Gangrene
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