TUGAS ILMU BEDAH

DIABETIC GANGRENE IN THE EXTREMITIES

Oleh :

Ghiffar Oka Prihardian

18700062

PROGRAM PENDIDIKAN DOKTER

FAKULTAS KEDOKTERAN
UNIVERSITAS WIJAYA KUSUMA SURABAYA
SURABAYA
2023
 PROBLEMS AND TREATMENT OF

DIABETIC GANGRENE IN THE EXTREMITIES

1. Definitions

Diabetes mellitus is a condition where the body is unable to control the blood sugar.
Normally the body has a good immune system that fights against microbes and invading
organisms that may lead to infections. The white blood cells are the main fighters in this
respect to keep the body protected. In patients with diabetes, the immune system of a person
is affected. In addition, the blood vessels are damaged due to the excessive blood sugar
running in the veins.

Gangrene is the most dreaded form of diabetic foot. There is death or decay of the
affected foot. Gangrene usually affects diabetics with high and uncontrolled blood sugar. It is
found that high blood sugar damages the nerves of the foot causing peripheral neuropathy and
also hardens the walls of the arteries leading to narrowing and obstructed blood supply. These
are main causative factors of a raised risk of gangrene in diabetic.

Extremities or also called limbs are extensions of the main body limbs (expl the legs
of an insect which is extension of the abdomen), or are also limbs of prehensileness or limbs
used for gripping/holding something. On the human body, the upper and lower extremities
are called arms and legs, the arms and legs are connected to the torso. Gangrene in the
extremities are gangrene that arises in the human limbs or the human body movement,
especially in the legs.

2. Anatomy

Gangrene is tissue damage secondary to infection, ischemia or both. It is a relatively

uncommon condition and early recognition is essential. Gangrene is associated with a high
incidence of mortality and in patiens that survive, it can have a massive impact on the quality
of life. This activity reviews the identification, evaluation and treatment of gangrene,
highlighting the role of the interprofessional team in managing patiens with this condition.

Gangrene is a clinical condition of ischemic and necrotic tissue, often circumferential

around a digit or extremity. It is identified by discolored or black tissue and associated
sloughing of natural tissue planes. The three main types of gangrene are wet gangrene, dry
gangrene and gas gangrene.

Dry gangrene is dehydrated ischemic tissue caused by progressive ischema distal to

arterial occlusion, often a progression of peripheral artery disease. Wet gangrene, which may
be dry, complicated by a secondary infection, has associated edema and erythema but no
crepitus. Gas gangrene is a specific type of necrotizing infection with edema, crepitus and gas
on radiographs. Necrotizing soft tissue infections overlap with the infectious causes of
gangrene and involve necrotic skin lesions that may extend into subcutaneous, fascial and
muscle cpmpartments. The associated tissue loss in gangrene can significantly decrease life
quality due to associated pain, limited mobility and increased risk of hospitalization. These
condition can also progress to substantial morbidity and mortality, with the risk of multiple
surgeries and death with the disease progression.

3. Pathophysiology

The process of developing diabetic foot gangrene starts with edema of the soft tissues
of the foot, formation of fissures between the toes or in dry areas of the feet or callus
formation. The affected tissue initially turns bluish in color and feels cool to the touch. Then
the tissue will die, blacken and smell bad. Pain at the time of injury will not be felt by
patients whose sensitivity has disappeared and the injuries that occur can be thermal injuries,
chemical injuries or traumatic injuries. The first signs of gangrene are pus and redness

Diabetic foot ulcers are caused by three factors which are often called the triad,
namely: ischemia, neuropathy and infection. Uncontrolled blood glucose levels will cause
complications chronic peripheral neuropathy includes sensory, motoric and autonomic
neuropathy.

4. Klasifikasi/Classification of gangrene as below:

a. Grade 0 – no lesions, skin intact.

b. Grade I – superficial ulcer limited to the skin.

c. Grade II – deep ulcer penetrates the tendon and bone.

d. Grade III – deep abscess, with or without osteomyelitis.

e. Grade IV – gangrene of toes or distal parts of feet with or cellulitis.

f. Grade V – gangrene of the whole foot or part of the leg.

Classification of gangrene based condition divided into 2 as below:

* Dry gangrene

There will be initial symptoms in the form of pain in the concerned, the area
becomes pale, bluish and has gradually the area is black. Not palpable pulse (not
always). When touched feels dry and cold. Gangrene is well defined. The pain/pain
gradually decreases and finally disappears, this dry gangrene can be separated from
intact tissue.

* Wet gangrene

Will be found with signs such as swelling in the lesion area, occurs
discoloration from dark red to green which finally blackish, cold, wet, soft, there is
necrotic tissue that smells bad, but can be without smell at all.

5. Epidemiology
 Ischemic or dry gangrene occurs as tissue loss most commonly seen with progressive
peripheral artery disease (PAD). Critical limb ischemia/chronic limb-threatening ischemia
(CLI/CLTI) is the most advanced stage of peripheral artery disease, with an incidence of 1%
of the United States population over 50 years old and up to twice that over 70 years old.
Lower extremity peripheral artery disease itself affects more than 200 milion people
worldwide and up to 10% of people with PAD have CLI/CLTI. Over five years, between 5-
10% of patients with asymptomatic PAD or minimal symptoms with intermittent
claudication, may progress to CLI/CLTI.

Gas gangrene typically occurs after trauma, with anaerobic bacteria’s introduction
into a previously protected tissue space. Gas gangrene has been identified after traffic
accidents, crush injuries, gunshot, wounds and postoperative complications relatedto
infection. Non-traumatic gas gangrene has also been documented from hematogenous spread
and multiple case studies have demonstrated an association with a metastatic gut malignancy.
Similarly, other necrotizing soft tissue infections typically have a defined entry point due to
trauma or postoperative surgical site complications. Gas gangrene is relatively rare, with
approximately 1000 cases per year in the United States; 50% are attributed to traumatic
injures, 30% to postoperative complications and 20% as a spontaneous infection.

6. Faktor risiko/ Risk factors

* People with diabetes are more at risk of developing gangrene. High blood
sugar levels can cause nerve damage which can cause numbness.

* Loss of sensation in vulnerable body parts, such as the fingers and soles of
your feet, can make it easier to get cuts or injuries that you are not aware of.

* High blood sugar levels or hyperglycemia can also affect the work of the
circulatory system, including limiting blood flow to your feet, as result, less oxygen,
nutrients and infection-fighting cells are produced get to the feet. Even leg injuries
take longer to heal healed. If not treated immediately, the wound on the foot can get
worse, the condition is known as diabetic foot.

7. Etiology

Dry or ischemic gangrene is most commonly secondary to atherosclerosis and

progressive occlusion of the peripheral arterial blood supply to distal tissue. The risk factors
of peripheral atherosclerosis overlap with the risk factors for coronary artery disease:
diabetes, smoking, hypertension and hyperlipidemia. Conditions that increase blood demand,
such as localized infection and trauma, may worsen limb ischemia. Dry gangrene is often
aseptic as bacteria fail to survive in the dry and mummified tissue.

Less common causes of ischemic gangrene are vascular occlusions from pathology.
Thromboembolic disease may rarely result in the cessation of arterial flow if thrombosis is
transferred downstream and areterial thromboses may developed in situ in a hypercoagulable
state. Trauma to the limb or vascular system may result in ischemia and gangrene. Vasculitis,
adventitial cystic disease, popliteal entrapment and buerger disease may also contribute to
gangrene development. These condition may also result in acute limb ischemia, which can
progress to gangreneif severe. Acute limb ischemia is defined by a sudden decrease in limb
perfusion, diagnosed within two weeks of symptom on set. The symptoms of acute limb
ischemia are classically identified by the 6 ps mnemonic: paresthesia, pain, pallor,
pulselessness, poikilothermia and paralysis.

Ischemic limb gangrene may also occur in limbs with intact peripheral pulses due to
thromboses in the microcirculation. Venous limb gangrene is one possible cause where micro
thrombosis happens in the same limb as an acute large-vein thrombosis, typically in a
hypercoagulable state, symmetric peripheral gangrene is another condition where multiple
limbs may develop symmetric gangrene despite adequate perfusion, for example purpura
fulminans in patients with septicemia secondary to Neisseria meningitidis.

Wet gangrene occurs when tissue compromised by poor venous or arterial blood flow
becomes infected. This is most commonly seen in areas prone to edema on lower extremities
like feet, though it also can be seen in genitourinary and oral tissues. Diabetic patients are
more suspectible to these infections due to poor wound healing and hyperglycemia.

Gas gangrene is historically caused by infection with clostridium perfringes and other
clostridium species/C. septidium, resulting in clostridial myonecrosis. This organism can
cause rapid development of localized tissue necrosis and systemic signs of illness in part due
to its production of exotoxins and is characterized by the presence of gas in subcutaneous
tissue. Additional bacterial infections may also result in gas production and the rapid spread
of infection, including Escherichia coli, bacteroides, staphylococcus epidermidis and
streptococcal infection. Type I necrotizing fasciitis, characterized by friable superficial fascia,
dishwater-gray exudate and an absence of pus, is another bacterial infection caused by a
polymicrobial mix of aerobic and anaerobic organisms that may also cause gas in tissue.

8. Pathophysiology

In ischemic gangrene, reduced arterial perfusion leads to arteriole dilation as

compensation, resulting in distal edema and endothelial damage. This can trigger a cycle of
micro thrombosis resulting in worsening tissue damage. Due to the ischemic environment,
localized celluler dysregulation limits the ability to have adequate wound healing and set the
tissue up for continued damage and infection.

In gas gangrene, bacteria such as C.perfringens and group A streptococcus can

produce multiple exotoxins, resulting in local tissue destruction and subsequent systemic
infection. Alpha-toxin, C-lecithinase, can result in extensive tissue necrosis and promote
systemic hemolysis.

9. Gejala klinis / Clinical symptoms

Here are some other signs and symptoms that might indicate you have diabetic
gangrene of this condition:
 * Red sores, pain or swelling

* Swelling filled with pus or smells bad

* The part of the body where there is an injury feels cold

* Wounds that repeatedly appear on the same body part

* Skin color changes, ranging from green-black, red, blue or copper.

10. Diagnosis of diabetic gangrene

If you suspect that you have diabetic gangrene, doctor will diagnose through a
physical examination and some of the following tests:

 Laboratory analysis of tissue or tissue samples. Tissue samples from body

parts will be examined by the doctor under a microscope to see dead cells.

 Blood test. The doctor will measure the white blood cell count. Cell rate high
white blood cells can indicate an infection gangrene.

 Medical imaging. Several types or medical imaging tests are useful for
diagnosing the spread of diabetic gangrene in internal tissues, such as x-rays, MRI or
CT scans.

11. Differential Diagnosis

Gangrene is typically fairly unique with visible necrotic tissue. The differential
diagnosis of limb pain can include:

* Diabetic neuropathy

* Complex regional pain syndrome

* Nerve root compression

Other potential causes of local ischemia not listed above are:

* Frostbite

* Ergotism – localized vasospasm with thrombosis

* Compartment syndrome

* Calciphylaxis – a rare condition seen in renal failure patients.

The differential diagnosis for gas gangrene include:

* Group A streptococcal infections

* Septic shock
 * Toxic shock syndrome

* Abdominal abscess

* Vibrio infections

12. Complications

While most limb salvage treatment is focused on limiting amputations, especially

major amputations (above the ankle, requiring a prosthetic for ambulation), amputation may
also be optimal for some patients to allow for participation in rehabilitation with a prosthesis.
However, retrospective studies have demonstrated that only 65% of patients with below-the-
knee amputation and 29% of above-the-knee amputation amputees were ambulatory at one
year. Observational studies of patients two years after below-the-knee amputation
demonstrated that 15% had a contralateral amputation, 15% progressed to an above-the-knee
amputation and 30% were dead.

13. Treatment or Management

Treatment og gangrene as below:

o Antibiotics, by giving antibiotics if there is a bacterial infection. Generally,

giving antibiotic drugs through by infus so they can go straight in to the bloodstream.

o Vascular surgery, by recommend vascular surgery procedures to patients

diabetic gangrene is a circulatory disorder. The treatment for gangrene is surgery to
reconstruct the damaged blood vessels and improve internal blood flow body tissue.

o Hyperbaric oxygen chamber, in hyperbaric oxygen therapy, the patient will

enter a room filled with pure oxygen gas. This treatment method provides more
oxygen to the damaged tissue. This can inhibit the growth of bacteria and recovery.

o Debridement, in case of serious gangrenous wounds, paramedic will remove

dead tissue or body parts which is also called debridement. This done by doctor to
clean the wound, prevent the spread of gangrene and allow the healthy tissue around it
to heal.

o Amputation, for more serious cases, amputation of organs, including fingers or

toes, doctor may do to save patient’s life.

Treatment of ischemic gangrene is focused on restoring blood flow to help reduce rest
pain and heal ischemic wounds. Once ulcers have progressed to dry gangrene, it is unlikely
that the tissue will recover completely, but tissue loss can be minimized by medical and
surgical management. Medical treatment of ischemic gangrene includes the use of antiplatelet
therapy with Aspirin or clopidogrel and treatment of hypertension with beta-blockers and
angiotensin-converting enzyme inhibitors. Hyperlipidemia should be treated with a statin as
appropriate and patients with diabetes should achieve adequate glucose control, ideally to a
hemoglobin A1C less than 7%. Smoking cessation is vital for reducing the risk of disease
progression.

Surgical treatment of limb ischemia is focused on revascularization to improve pain

and prevent limb loss. In the setting of acute ischemia, catheter-based intravascular
thrombolysis can be used. Otherwise, revascularization can be pursued with endovascular
intervention with balloon angioplasty (with or without stent) and surgical therapy can baypass
a stenotic area or directly remove a blockage. The decision to pursue bypass or endovascular
treatment is dependent on the lesion and the patient’s comorbidities and early involvement in
a multi-disciplinary vascular team, if available, is recommended.

Primary amputation (amputation before an attempt at revascularization) is recommended if

there is significant necrosis of the weight-bearing portion of the foot, refractory pain,
sepsis/uncontrolled infection, paresis of the extremity or limited life expectancy. Often,
above-ankle amputation is recommended if there is extensive foot necrosis. Autoamputation
is also a possibility, the spontaneous separation of the unviable tissue from the viable tissue;
however, a case series of patients with diabetes-related dry gangrene found that only 1 of 12
developed autoamputation – all others required surgical amputation. If more than two digital
ray amputations are required to treat necrosis, it is recommended to consider transmetatarsal
amputation of the forefoot instead to preserve function-multiple toe amputattions can
adversely affect pressure distributions and result in worsening pressure injuries.

Treatment with hyperbaric oxygen therapy has been proposed as a method to increase
oxygen tension in ischemic tissue. There has not been a demonstrated benefit with critical
limb ischemia (CLI). Other potential experimental treatments include the use of growth
factors and stem cell therapy to promote angiogenesis; however, there is a lack of clinical
data. This treatment is currenly limitedto clinical trials.

If an infection is suspected as wet gangrene, either based on systemic signs of

infection, localized erythema/drainage or plantar foot pain, urgent surgical drainage and
debridement (possibly with minor amputation) are indicated. Antibiotic treatment should be
started for all patients with suspected chronic limb-threatening ischemia (CLTI) and
additional deep foot infection or wet gangrene. The appropriate dressing should be used to
retain moisture without adding maceration. Empiric antibiotic choice should depend on
patient risk factors and local susceptibility rates; gram-positive coverage is usually indicated,
with broadened coverage in diabetic petients to include potential MRSA or gram-negative
coverage.

Gas gangrene, with associated exotoxin, can be very aggressive with a high mortality
rate when treatment is delayed. Therefore surgical exploration and debridement are
recommended as soon as possible to gauge the extent of infection and obtain speciments for
culture/gram stain. The initial surgical site often will need to be re-evaluated and debrided
multiple times. Surgery within 24 hours of admission is associated with increased survival.
Fasciotomies will also help to decompress fascial compartments and promote blood flow.
Gangrene of the trunk cannot be amputated, so aggressive debridement is required.
 Antibiotic treatment of gas gangrene and necrotizing soft tissue infections should be
tailored to the causative organism as soon as possible; however, in the immediate initial
evaluation, broad-spectrum treatment with coverage for gram-positive, gram-negative and
anaerobic bacteria should be used. If group A streptococci or clostridium are identified, the
recommended treatment is penicillin with clindamycin for 10 to 14 days; clindamycin is
especially recommended to reduce toxin production monotherapy with clindamycin is not
recommended due to increased inducible resistance rates. Patients with necrotizing infections
are often systemically ill and should be managed based on sepsis guidelines for fluid
resuscitation and treatment of associated organ damage.

14. Prognosis

Within one year of the diagnosis of critical limb ischemia/chronic limb-threatening

ischemia (CLI/CLTI), up to 40 to 50% of patient with diabetes will have an amputation, and
20 to 25% will die. Additional observational studies observed an amputation rate of 19% at
six months and 23% at 12 monts in nondiabetic patients with rest pain and ischemic
ulcers/gangrene. The most common indication for amputation was an untreatable infection.
Patients should be followed for at least two years after revascularization procedures to
evaluate for any recurrence of CLTI.

Gas gangrene has a significant fatality rate: up to 25% of trauma patients with gas
gangrene die, with an increase to 100% if treatment is delayed or inadequate. Poor prognosis
is associated with increased age and multiple underlying comorbidities and a location on the
trunk.

15. Kesimpulan/Conclusion

Diabetic gangrene is tissue death by obstruction of the blood vessels that provide
nutrition to the tissues which usually occurs in the lower extremities or also known as the
diabetic foot. The main mechanisms of diabetic gangrene in people with diabetes mellitus are
angiopathy and neuropathy. Diabetic foot clinical picture is classified into two namely,
neuropathy foot and ischemic foot. Based on the type of gangrene, it is divided into wet
gangrene and dry gangrene. Management of diabetic gangrene consists of medical, non-
medical and surgical.

Patients should be educated on the proper foot and wound protection to promote
healing and prevent a recurrence. This includes education on appropriate shoes and insoles,
as well as early identification of signs of inflammation. Patients should get medical attention
immediately if they develop any symptoms of tenderness, redness, disproportionate pain or
fever. Educate intravenous drug users about potential fatal complications of gas gangrene due
to the injection of contaminated heroin or other chemicals.