gangrene

Definition

Gangrene is the term used to describe the decay or death of an organ or tissue caused by a lack of blood supply. It is a complication resulting from infectious or inflammatory processes, injury, or degenerative changes associated with chronic diseases, such as diabetes mellitus.

Description

Gangrene may be caused by a variety of chronic diseases and post-traumatic, post-surgical, and spontaneous causes. There are three major types of gangrene: dry, moist, and gas (a type of moist gangrene).

Dry gangrene is a condition that results when one or more arteries become obstructed. In this type of gangrene, the tissue slowly dies, due to receiving little or no blood supply, but does not become infected. The affected area becomes cold and black, begins to dry out and wither, and eventually drops off over a period of weeks or months. Dry gangrene is most common in persons with advanced blockages of the arteries (arteriosclerosis) resulting from diabetes.

Moist gangrene may occur in the toes, feet, or legs after a crushing injury or as a result of some other factor that causes blood flow to the area to suddenly stop. When blood flow ceases, bacteria begin to invade the muscle and thrive, multiplying quickly without interference from the body's immune system.

Gas gangrene, also called myonecrosis, is a type of moist gangrene that is commonly caused by bacterial infection with Clostridium welchii, Cl. perfringes, Cl. septicum, Cl. novyi, Cl. histolyticum, Cl. sporogenes,or other species that are capable of thriving under conditions where there is little oxygen (anaerobic). Once present in tissue, these bacteria produce gasses and poisonous toxins as they grow. Normally inhabiting the gastrointestinal, respiratory, and female genital tract, they often infect thigh amputationwounds, especially in those individuals who have lost control of their bowel functions (incontinence). Gangrene, incontinence, and debility often are combined in patients with diabetes, and it is in the amputation stump of diabetic patients that gas gangrene is often found to occur.

Other causative organisms for moist gangrene include various bacterial strains, including Streptococcus and Staphylococcus. A serious, but rare form of infection with Group A Streptococcus can impede blood flow and, if untreated, can progress to synergistic gangrene, more commonly called necrotizing fasciitis, or infection of the skin and tissues directly beneath the skin.

Chronic diseases, such as diabetes mellitus, arteriosclerosis, or diseases affecting the blood vessels, such as Buerger's disease or Raynaud's disease, can cause gangrene. Post-traumatic causes of gangrene include compound fractures, burns, and injections given under the skin or in a muscle. Gangrene may occur following surgery, particularly in individuals with diabetes mellitus or other long-term (chronic) disease. In addition, gas gangrene can be also be a complication of dry gangrene or occur spontaneously in association with an underlying cancer.

In the United States, approximately 50% of moist gangrene cases are the result of a severe traumatic injury,

and 40% occur following surgery. Car and industrial accidents, crush injuries, and gunshot wounds are the most common traumatic causes. Because of prompt surgical management of wounds with the removal of dead tissue, the incidence of gangrene from trauma has significantly diminished. Surgeries involving the bile ducts or intestine are the most frequent procedures causing gangrene. Approximately two-thirds of cases affect the extremities, and the remaining one-third involve the abdominal wall.

— Kathleen D. Wright, RN

[Medieval Latin cancrēna, from Latin gangraena, gangrēna, from Greek gangraina.]

For more information on gangrene, visit Britannica.com.

A form of tissue death, or necrosis, usually occurring in an extremity and due to insufficient blood supply.

If no bacterial contamination is present, the part becomes dry, greenish-yellow, and finally turns brown or black. This is known as mummification. A sharp inflammatory border marks the edge of the adjacent viable tissue. This dry gangrene is seen most often in small portions of the extremities, such as the fingers and toes. Senile gangrene is the form caused by deterioration of blood supply in the elderly, usually as the result of progressive arteriosclerosis. Similar types are often present in diabetes, Reynaud's disease, and Buerger's disease (thromboangiitis obliterans). See also Arteriosclerosis; Diabetes.

When bacterial infection intervenes, putrefaction ensues, thus producing the moist or wet type of gangrene. Moist gangrene may occur anywhere in the body that the blood supply is blocked and bacterial contamination occurs.

Gas gangrene is a localized, but rapidly spreading, necrotizing wound infection, characterized by extensive edema with gas production and discoloration of the tissue, and often accompanied by a putrefactive odor. The disease commonly arises following septic abortion or dirt contamination of deep wounds. The microbial flora of the gangrenous wound usually comprises one or more species of toxigenic anaerobic bacteria mixed with nontoxigenic anaerobic species, aerobic species, or both.

Gangrene does not necessarily follow the presence of bacteria in a wound, as initiation of the disease depends on the virulence of the organisms and other factors relating to the resistance of the host. The virulence of the gangrene-producing organisms depends on the toxins produced and the same species may produce several immunologically different toxins. See also Toxin; Virulence.

The rapidly spreading nature of the disease precludes extensive laboratory diagnostic aids because therapeutic measures, possibly including amputation, usually must be instituted before laboratory results are available. The effectiveness of antibiotic therapy seems to depend on the species involved in the infection and the elapsed time between injury and treatment. Hyperbaric oxygen therapy is beneficial for individuals who are diagnosed early.

The death of tissue en masse, usually the result of loss of blood supply, bacterial invasion, and subsequent putrefaction. For example, gangrene of the pulp is total death and necrosis of the pulp.

Definition

Gangrene is a term used to describe the decay or death of an organ, tissue, or bone caused by a lack of oxygen and nutrients. It is a complication resulting from tissue injuries (such as frostbite), the obstruction of blood flow, or the processes of chronic diseases such as diabetes mellitus. Externally, the hands and feet are the areas most often affected by gangrene; internally, it is most likely to affect the gallbladder and the intestines. Gangrene is referred to as wet, or moist, if a bacterial infection is involved. In dry gangrene, there is no infection.

Description

Gangrene is often characterized by pain followed by numbness. The infection may first go unnoticed, especially in the elderly or those individuals with a loss of sensation. The area affected by gangrene may be cold and pale, especially early in the disease. Blisters may be apparent and the patient may experience an increased heart rate and profuse sweating. As the tissue dies, the skin begins to darken. The dead tissue gradually separates and falls away from the healthy tissue.

Dry gangrene is often seen in advanced cases of diabetes and arteriosclerosis. The tissue doesn't become infected, rather it dries out and shrivels over a period of weeks or months. Wet gangrene progresses much more rapidly. The affected area becomes swollen and gives off a foul smelling discharge. Death may occur within a matter of hours or days. Fever, rapid heart rate, rapid breathing, altered mental state, loss of appetite, diarrhea, vomiting, and vascular collapse may occur as the infection progresses.

Causes & Symptoms

The primary cause of gangrene is often an injury to the blood vessels, causing either an interruption of blood flow, the introduction of a bacterial infection, or both. Such injuries may include burns, infected bedsores, boils, frostbite, compound fractures, deep cuts, or gunshot wounds. Gangrene can also develop due to the poor circulation and obstructions in the blood vessels associated with abnormal blood clots, torsion of organs, and diseases such as diabetes, heart disease, and Raynaud's disease. Gangrene of the internal organs may be attributed to a ruptured appendix, internal wounds, or the complications of surgery.

The bloodstream is the body's main transport system. When blood flow is diminished, the flow of the oxygen and nutrients needed to keep tissues healthy is greatly decreased. The white blood cells needed to fight infection are not readily available. In such an environment, invading bacteria thrive and multiply quickly. Streptococcus spp. and Staphylococcus spp. are the most common agents of external skin infection.

Gas gangrene, also called progressive or clostridial myonecrosis, is a type of moist gangrene most commonly caused by an infection of Clostridium perfringens, or other species that are capable of thriving under conditions where there is little oxygen. These bacteria produce gases and poisonous toxins as they grow in the tissues. Gas gangrene causes the death of tissue, the destruction of red blood cells, and the damaging of the walls of the blood vessels and parts of the kidneys. Early symptoms include sweating, fear, and anxiety. Gas gangrene is a life-threatening condition and should receive prompt medical attention.

Diagnosis

A diagnosis of gangrene will be based on a combination of patient history, a physical examination, blood test results, and other laboratory findings. A physician will look for a history of recent trauma, surgery, cancer, or chronic disease. Blood tests will be used to determine whether infection is present and to determine how much the infection has spread. A sample of drainage from a wound or obtained through surgery may be tested to identify the bacteria causing the infection and to aid in determining treatment. In the case of gas gangrene, the gas produced by the bacteria may be detected beneath the skin by pressing into the swollen areas. The crackling sounds of gas bubbles may also be heard in the affected area and the surrounding tissues.

X-ray studies and other imaging techniques, such as computed tomography (CT) scans or magnetic resonance imaging (MRI), may be helpful in making a diagnosis by showing evidence of gas accumulation or muscle tissue death. These techniques, however, are not sufficient alone to provide an accurate diagnosis of gangrene. Precise diagnosis often requires surgical exploration of the wound.

Treatment

Chelation therapy is a treatment that uses an intravenous solution containing the drug ethylenediamine tetra-acetic acid (EDTA), among other substances. In the bloodstream, EDTA binds and removes toxins and plaque formation on arterial walls. It promotes circulation throughout the body, and is reportedly, although not proven, able to reverse the processes leading to gangrene. Early intervention is necessary, however.

Other alternative and complementary treatments are used to treat gangrene. Herbal remedies such as goldenseal can be applied topically. Biofeedback and hypnosis can increase blood flow. Diabetics will receive herbal and traditional Chinese medicine remedies and nutritional supplements to help prevent gangrene.

Allopathic Treatment

Pain medications and large amounts of intravenous antibiotics are given. Prompt surgical removal of infected and destroyed tissue is required for healing to take place. Gas gangrene is often treated with the antitoxin for clostridium as well. In a number of cases, amputation may have to be used to keep the infection under control.

In hyperbaric oxygen (HBO) therapy the patient is placed in a pressurized chamber and receives 100% pure oxygen to breathe. This has been shown useful in inhibiting the production of toxins in gas gangrene and for getting oxygen quickly to tissues, especially following a crushing injury that might lead to gangrene. HBO therapy must be carried out early in the process and used before any surgical removal. The therapy, though useful, does have adverse side effects. It requires skilled technicians and may not be widely available.

Expected Results

The outcomes for gangrene are generally favorable if the infection is recognized and treated early in the progression of the disease. Left untreated, gas gangrene will result in a decrease in blood pressure, kidney failure, and coma. Overall, about 20% of those infected with gas gangrene die from the disease, and another 20% require an amputation. Gangrene is most dangerous to the elderly, those who are immuno-compromised, and those who have internal infections and chronic conditions such as diabetes. Individuals suffering from dry gangrene often have multiple health problems that complicate recovery and may prove fatal.

Prevention

Infections and injuries should be thoroughly cleaned and monitored; medical attention should be pursued if symptoms worsen or remain unresolved. Gastrointestinal wounds should be surgically explored, drained, and repaired. Use of antibiotic therapy prior to and directly following surgery has been shown to reduce the rates of infection.

Patients with diabetes or severe arteriosclerosis should take particular care of their hands and feet to avoid the decreased circulation and unchecked infection that may lead to gangrene. Any injury or infection, however slight, should be cared for promptly. There should be a focus on proper foot care, including keeping the feet clean, dry, and warm, wearing well-fitting shoes and not going barefoot. It is important to avoid smoking, since tobacco use constricts the blood vessels of the hands and feet, decreasing circulation.

Resources

Books

Bunch, Bryan, ed. The Family Encyclopedia of Diseases: a Complete and Concise Guide to Illnesses and Symptoms. New York: Scientific Publishing, Inc., 1999.

The Burton Goldberg Group Alternative Medicine: The Definitive Guide. Tiburon, CA: Future Medicine Publishing, 1993.

Other

drkoop.comhttp://www.drkoop.com/conditions/foot_care/library/gangrene.asp.

drkoop.comhttp://www.drkoop.com/conditions/ency/article/000620.htm.

The Merck Manualhttp://www.merck.com/pubs/mmanual/section21/chapter292/292a.htm.

[Article by: Patience Paradox]

Local death of body tissue due to a deficient blood supply. The dead tissue may decay through putrefaction by bacteria. Gangrene can be caused by disease, injury (such as a physical blow to a bone), frostbite, or burns.

The death and decay of body tissue owing to insufficient supply of blood.

Pertaining to, marked by, or of the nature of gangrene.

• g. cellulitis — gangrenous necrosis of the skin of the thorax and thighs of chickens of 1 to 4 months of age caused by Clostridium septicum and other clostridia. Most affected birds die and the mortality rate in a flock may be as high as 60%. Called also necrotic dermatitis, gangrenous dermatitis.
• g. coryza — see malignant catarrhal fever.
• g. dermatitis — see gangrenous cellulitis.
• g. ergotism — see rye ergot1.

For the American football team nicknamed "Gang Green", see New York Jets.

This article needs additional citations for verification. Please help improve this article by adding reliable references. Unsourced material may be challenged and removed. (February 2008)

Gangrene
Classification and external resources
ICD-10	R02.
ICD-9	040.0
DiseasesDB	19273
MeSH	D005734

Gangrene is a complication of necrosis or cell death characterized by the decay of body tissues, which become black (and/or green) and malodorous. It is caused by infection or ischemia, such as from thrombosis. It is usually the result of critically insufficient blood supply^[1] (e.g., peripheral vascular disease) and is often associated with trauma, diabetes and long-term smoking^{[citation needed]}. This condition is most common in the lower extremities. The best treatment for gangrene is revascularization of the affected organ, which can reverse some of the effects of necrosis and allow healing. Other treatments include debridement and surgical amputation. The method of treatment is generally determined depending on location of affected tissue and extent of tissue loss.

Contents 1 Etymology 2 Types of gangrene 2.1 Dry gangrene 2.2 Wet gangrene 2.3 Gas gangrene 3 Specific gangrenes 4 Treatment 5 See also 6 References

Etymology

The etymology of gangrene derives from the Latin word "gangraena" and from the Greek gangraina (γάγγραινα), which means "putrefaction of tissues". It has no etymological connection with the word green, despite the affected area turning black and/or green. Coincidentally, in Lowland Scots the words "gang green" (going green) can be said to be an eggcorn for gangrene as it describes the symptoms of the affliction.

Types of gangrene

Dry gangrene

Diabetic ulceration with central "dry" gangrene and toward the edges wet gangrene with some ascending cellulitis

Dry gangrene begins at the distal part of the limb due to ischemia and often occurs in the toes and feet of elderly patients due to arteriosclerosis. Dry gangrene spreads slowly until it reaches the point where the blood supply is inadequate to keep tissue viable. Macroscopically, the affected part is dry, shrunken and dark in colour, resembling mummified flesh. The dark coloration is due to liberation of hemoglobin from hemolyzed red blood cells which is acted upon by hydrogen sulfide (H₂S) produced by the bacteria, resulting in formation of black iron sulfide that remains in the tissues.^[2] The line of separation usually brings about complete separation with eventual falling off of the gangrenous tissue if it is not removed surgically.

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

The early signs of dry gangrene are a dull ache and sensation of coldness in the affected 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.

Wet gangrene

Foot shown with severe infection – wet gangrene in center

Wet gangrene occurs in naturally moist tissue and organs such as the mouth, bowel, lungs, cervix, and vulva. Bedsores occurring on body parts such as the sacrum, buttocks and heels—although not necessarily moist areas—are also categorized as wet gangrene infections. In wet gangrene, the tissue is infected by saprogenic microorganisms (Bac.perfringes, fusiformis, putrificans, etc.), which cause tissue to swell and emit a fetid smell. Wet gangrene usually develops rapidly due to blockage of venous 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 septicemia and finally death. Macroscopically, the affected part is edematous, soft, putrid, rotten and dark. The darkness in wet gangrene occurs due to the same mechanism as in dry gangrene.

Gas gangrene

Main article: Gas gangrene

Gas gangrene is a bacterial infection that produces gas within tissues. It is a deadly form of gangrene usually caused by Clostridium perfringens bacteria. 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 a bacterial exotoxin-producing clostridial species, which are mostly found in soil and other anaerobes (e.g. 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.^[3]

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

Specific gangrenes

• Noma is a gangrene of the face.
• Necrotizing fasciitis affects the deeper layers of the skin.
• Fournier gangrene usually affects the male genitals.
• Meleney gangrene
• Gas gangrene
• Dermatitis gangrenosa

Treatment

As early as 1028, when antibiotics had not yet been discovered, fly maggots were 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. Recently, however, maggot therapy has regained some credibility and is sometimes employed with great efficacy in cases of chronic tissue necrosis.

In modern times treatment is usually surgical debridement, and excision with amputation is necessary in many cases. (Amputation was also used on the battlefield during war in the 19th century to counter gangrene, among other things; the American Civil War was a notable occasion for such amputations.) Antibiotics alone are not effective because they do not penetrate ischemic muscles sufficiently.

See also

• Wound healing
• Liquefactive necrosis
• Bedsore

References

1. ^ gangrene at Dorland's Medical Dictionary
2. ^ chapter 3.html
3. ^ Chi CH, Chen KW, Huang JJ, Chuang YC, Wu MH (December 1995). "Gas composition in Clostridium septicum gas gangrene". J. Formos. Med. Assoc. 94 (12): 757–9. PMID 8541740. 

v • d • e Symptoms and signs: circulatory (R00-R03, 785) Cardiovascular Heart disease Tachycardia/Bradycardia · Palpitation Heart sounds: Heart murmur (Systolic, Diastolic, Continuous) · Gallop rhythm (Third heart sound, Fourth heart sound) · Pericardial friction rub · Split S2 · Heart click Cœur en sabot Cardiovascular chest pain Vascular manifestations of heart disease (pulse): Pulsus tardus et parvus · Pulsus paradoxus · doubled (Pulsus bisferiens, Dicrotic pulse, Pulsus bigeminus) · Pulsus alternans · Carotid bruit · Cannon A waves Vascular disease Bruit · necrosis (Gangrene) Myeloid/blood Shock Cardiogenic · Hypovolemic · Distributive (Septic, Neurogenic) Hyperaemia Functional • Reactive heart navs: anat/physio/dev, noncongen/congen/neoplasia, symptoms+signs/eponymous, proc vascular navs: anat/physio/dev, noncongen/systemic vasculitis/congen/neoplasia, symptoms+signs/eponymous, proc myeloid navs: cells/physio, disease of RBCs+megakaryocytes/monocytes+granulocytes/neoplasia, symptoms+signs/eponymous

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Dansk (Danish)
n. - koldbrand, gangræn
v. tr. - gøre gangrænøs
v. intr. - blive gangrænøs

Nederlands (Dutch)
gangreen (koudvuur), verderfelijkheid, aan gangreen (doen) lijden

Français (French)
n. - gangrène
v. tr. - gangrener, se gangrener
v. intr. - se gangrener

Deutsch (German)
n. - Gangrän, Faulbrand, Verderbtheit
v. - brandig machen, brandig werden

Ελληνική (Greek)
n. - (παθολ., μτφ.) γάγγραινα
v. - (παθολ., μτφ.) γαγγραινιάζω, σαπίζω, προκαλώ ή παθαίνω γάγγραινα

Italiano (Italian)
cancrena, andare in cancrena

Português (Portuguese)
n. - gangrena (f) (Med.)
v. - gangrenar

Русский (Russian)
гангрена

Español (Spanish)
n. - gangrena, cangrena
v. tr. - provocar gangrena, sufrir gangrena
v. intr. - provocar gangrena, sufrir gangrena

Svenska (Swedish)
n. - kallbrand
v. - få/utlösa kallbrand

中文（简体）(Chinese (Simplified))
坏疽, 腐败堕落的根源, 脱疽, 使生坏疽, 生坏疽, 腐败

中文（繁體）(Chinese (Traditional))
n. - 壞疽, 腐敗墮落的根源, 脫疽
v. tr. - 使生壞疽
v. intr. - 生壞疽, 腐敗

한국어 (Korean)
n. - 타락의 근원
v. tr. - 회저가 생기게 하다
v. intr. - 회저가 생기다

日本語 (Japanese)
n. - 壊疽, 腐敗の根源
v. - 壊疽を生じさせる, 壊疽になる

العربيه (Arabic)
‏(الاسم) الغنغرينا (فعل) يتغنغر‏

עברית (Hebrew)
n. - ‮נמק ומוות של רקמות חיות, גנגרנה, מק, שחיתות מוסרית‬
v. tr. - ‮נרקב כתוצאה מגנגרנה‬
v. intr. - ‮נרקב בגנגרנה‬

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