GANGRENEOJI, VALERIE K.

#1415MD4

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INTRODUCTION TYPES DISEASES ASSOCIATED WITH GANGRENE RISK FACTORS CLINICAL PRESENTATION TREATMENT PROGNOSIS PREVENTION REFERENCES

OVERVIEW

GANGRENE IS A CONDITION THAT OCCURS WHEN BODY TISSUE DIES.

IT IS CAUSED BY A LOSS OF BLOOD SUPPLY DUE TO AN UNDERLYING ILLNESS, INJURY, AND/OR INFECTION

LACK OF BLOOD SUPPLY IS CAUSED BY THREE MAJOR MECHANISMS: INFECTION, VASCULAR OR TRAUMA.

WHAT IS GANGRENE?

INFECTIOUS GANGRENE: BACTERIAL MULTIPLICATION AND PRODUCTION OF EXOTOXINS

REQUIRE LOW OXYGEN TENSION. THE PRECISE ROLE OF EXOTOXINS IS NOT ENTIRELY CLEAR, ALTHOUGH IT APPEARS THAT ALPHA-TOXIN IS THE MOST IMPORTANT. ALPHA-TOXIN IS A METALLOENZYME THAT CAUSES CELL DESTRUCTION BY HYDROLYSIS OF COMPONENTS OF THE CELL MEMBRANE. BY THIS MECHANISM, IT CAN CAUSE LYSIS OF ERYTHROCYTES, LEUKOCYTES, PLATELETS, FIBROBLASTS, AND MUSCLE CELLS. IT IS ALSO THOUGHT THAT THIS ENZYME HAS C-PROTEIN ACTIVITY.

INFECTION STARTS WITH TISSUE CONTAMINATION OF POST-TRAUMATIC OR POST-OPERATIVE WOUNDS BY CLOSTRIDIUM SPORES. LOCAL WOUND CONDITIONS ARE MORE IMPORTANT THAN THE LEVEL OF CLOSTRIDIAL CONTAMINATION IN DETERMINING THE PROGRESSION OF THE CONDITION.

PATHOPHYSIOLOGY

NECROTIC TISSUE PROVIDES THE NECESSARY ENVIRONMENT FOR SPORE GERMINATION; THE PRESENCE OF TISSUE ENZYMES AND A LOW OXIDATION/REDUCTI

ON POTENTIAL HAVE KEY ROLES IN THIS STEP. SPREADING LOCAL NECROSIS OF MUSCLE AND SUBCUTANEOUS FAT, AND THROMBOSIS OF BLOOD VESSELS, CREATE AN ENVIRONMENT IDEAL FOR CONTINUED BACTERIAL MULTIPLICATION.

TISSUE OEDEMA MAY FURTHER COMPROMISE BLOOD SUPPLY. FERMENTATION OF GLUCOSE IS PROBABLY THE MAIN MECHANISM OF GAS PRODUCTION.

ISCHAEMIC GANGRENE: ATHEROSCLEROSIS UNDERLIES MOST PERIPHERAL ARTERIAL

DISEASE. NARROWED BLOOD VESSELS CANNOT SUPPLY SUFFICIENT BLOOD FLOW TO LEG MUSCLES AND MAY CAUSE CLAUDICATION.

ATHEROMATOUS PLAQUES CONTAIN A NECROTIC CORE WITHIN THE ARTERIAL INTIMA, CONSISTING OF FOAM CELLS, CELLULAR DEBRIS, AND LIPIDS (MAINLY CHOLESTEROL), COVERED OVER BY A PROTECTIVE CAP.

SHEAR FORCES OF THE CIRCULATING BLOOD OR SPONTANEOUS RUPTURE CAN DISRUPT THIS PROTECTIVE CAP, CAUSING EMBOLISATION OF THE CHOLESTEROL CRYSTALS AND INDUCING THROMBOGENESIS, FURTHER REDUCING BLOOD FLOW.

CRITICAL TISSUE ISCHAEMIA IS CHARACTERISED CLINICALLY BY REST PAIN, CHRONIC WOUNDS, OR TISSUE NECROSIS (TYPICALLY FOUND ON THE TOES). HYPERCOAGULABLE STATES CAN GIVE RISE TO LARGE THROMBI, WHICH CAN OCCLUDE PROMINENT BLOOD VESSELS AND CAUSE EXTENSIVE GANGRENE.

SYMPATHOMIMETICS SUCH AS COCAINE CAN CAUSE SEVERE VASOSPASM SUFFICIENT TO PRODUCE GANGRENE. 

DRY WET GAS NECROTIZING FASCILITIS INTERNAL NOMA FOURNIER’S GANGRENE MELENEY’S SYNERGESTIC GANGRENE

TYPES

RESULTS FROM DIMINISHED BLOOD SUPPLY DUE TO VASCULAR PROBLEMS SUCH AS PERIPHERAL ARTERIAL DISEASE (ESPECIALLY WITH CARDIAC RISK FACTORS PRESENT, SUCH AS SMOKING AND DIABETES MELLITUS).

OTHER CAUSES CAN BE ASSOCIATED WITH VASCULITIS. FOR INSTANCE, AUTOIMMUNE CONDITIONS SUCH AS RAYNAUD’S PHENOMENON OR SCLERODERMA.

THE AREA APPEARS COLD, DRY AND BLACK, AND WOULD EVENTUALLY SLOUGH OFF.

DRY GANGRENE

USUALLY FOLLOWS INFECTION IN THE TISSUES, WITH ORGANISMS INCLUDING STREPTOCOCCI AND STAPHYLOCOCCI.

THE SWELLING RESULTING FROM THE INFECTION AND CONSEQUENT INFLAMMATION LEADS TO BLOCKAGE OF THE BLOOD VESSELS SUPPLYING THE AREA IN QUESTION.

MAY LEAD TO LIFE-THREATENING COMPLICATIONS (SUCH AS SEPTIC SHOCK) IF NOT IMMEDIATELY TREATED.

TERMED 'WET‘ DUE TO ASSOCIATION WITH RELEASE OF DISCHARGE.

WET GANGRENE

GAS GANGRENE IS A PARTICULAR SUBTYPE OF WET GANGRENE, USUALLY RESULTING FROM CLOSTRIDIUM TOXINS

COMMON CAUSE OF DEATH DURING WARS CLASSIFIED INTO TRAUMATIC, NON-

TRAUMATIC AND RECURRENT GAS GANGRENE

GAS GANGRENE

OCCURS DUE TO BLOCKED FLOW TO INTERNAL ORGANS, USUALLY THE APPENDIX OR COLON.

INTERNAL

RARE TYPE OF GANGRENE AFFECTS THE GENETALIA

FOUNRNIER’S GANGRENE

AKA CANCRUM ORIS, GANGRENOUS STOMATITIS

DESTRUCTIVE PROCESS OF ORO-FACIAL TISSUE

NOMA

ALSO RARE USUALLY POST-OP MAINLY CAUSED BY S. AUREUS AND

STREPTOCOCCUS ORGANISMS THE MAJOR SYMPTOM IS THE FORMATION

OF PAINFUL LESIONS IN THE SECOND WEEK AFTER A MAJOR SURGERY OR MINOR TRAUMA.

MELENEY’S SYNERGISTIC GANGRENE

PHLEGMASIA CERULEA DOLENS IS A RARE CONDITION, IN WHICH THERE IS TOTAL OR NEAR-TOTAL OBSTRUCTION OF VENOUS DRAINAGE FROM A LIMB. PAIN, OEDEMA, CYANOSIS, AND ISCHAEMIA FROM REDUCED BLOOD FLOW ENSUE, AND UNLESS THE OBSTRUCTION IS RELIEVED THE CONDITION CAN PROGRESS TO A FORM OF GANGRENE KNOWN AS VENOUS GANGRENE.

DM 1& 2 RAYNAUD’S PHENOMENON PERIPHERAL VASCULAR DISEASE FROSTBITE BURNS STREPTOCOCCAL INFECTIONS CARCINOID TUMOUR AND SYNDROME SMOKING HEMORRHOIDS STAPHYLOCOCCUS INFECTION

ASSOCIATED DISEASES

DIABETES MELLITUS ATHEROSCLEROSIS PERIPHERAL ARTERIAL DISEASES RAYNAUD’S PHENOMENON SMOKING

RISK FACTORS

GENERAL SYMPTOMS INCLUE: INITIAL REDNESS AND SWELLING  EITHER A LOSS OF SENSATION OR SEVERE PAIN IN THE

AFFECTED AREA SORES OR BLISTERS THAT BLEED OR RELEASE A DIRTY-

LOOKING OR FOUL-SMELLING DISCHARGE THE SKIN BECOMING COLD AND PALE

SYMPTOMS MAY ALSO BE FROM THE UNDERLYING CAUSE:

FEVER LOSS OF APPETITE TACHYCARDIA AND TACHYPNEA DIZZINESS SHIVERING

CLINICAL PRESENTATION

A DIAGNOSIS OF GANGRENE IS BASED ON A COMBINATION OF PHYSICAL EXAMINATION, MEDICAL HISTORY AND TESTS WHICH INCLUDE:

BLOOD TESTS FLUID/TISSUE CULTURE BLOOD CULTURES IMAGING TESTS SURGICAL EXAMINATION

DIAGNOSIS

ANTIBIOTICS MAGGOT THERAPY OXYGEN THERAPY SURGICAL DEBRIDEMENT (AMPUTATION)

TREATMENT

SEQUENTIAL PROGRESS OF SPONTANEOUS GANGRENE IN A DIABETIC PATIENT MANAGED WITH HBOT

PROGNOSIS DEPENDS ON THE PRESENCE OF OTHER MORBIDITY, THE AREA OF THE BODY AFFECTED AND THE EXTENT OF GANGRENE.

ONE QUARTER OF PATIENTS WILL DEVELOP SEPTIC SHOCK WHICH HAS A HIGH FATALITY RATE.

EARLY RECOGNITION AND INSTITUTION OF TREATMENT ARE ASSOCIATED WITH A RELATIVELY GOOD OUTCOME.

PROGNOSIS

ADOPT HEALTHY LIFESTYLE PROTECT THE FEET AVOID SMOKING AVOID ALCHOHOL TREAT UNDERLYING CONDITION

PREVENTION

http://www.webmd.com/skin-problems-and-treatments/guide/gangrene-causes-symptoms-treatments?page=2

http://www.news-medical.net/health/Types-of-gangrene.aspx http://

bestpractice.bmj.com/best-practice/monograph/1015/basics/pathophysiology.html

http://www.patient.co.uk/doctor/gangrene http://www.medicinenet.com/gangrene/related-conditions/index.htm https://www.google.com/search?

q=gangrene&espv=2&biw=1366&bih=667&source=lnms&tbm=isch&sa=X&ei=X8XGVMjvLOeHsQTRqYKICw&ved=0CAYQ_AUoAQ#tbm=isch&q=dry+gangrene+vs+wet+gangrene&revid=728461983&imgdii=_&imgrc=xgyA7-Eia-DNIM%253A%3B_d4pWFgcbwDimM%3Bhttp%253A%252F%252Fimage.slidesharecdn.com%252Fdiabeticfootgangrene-110429231526-phpapp02%252F95%252Fdiabetic-foot-gangrene-8-728.jpg%253Fcb%253D1304137051%3Bhttp%253A%252F%252Fwww.slideshare.net%252Fgroup7usmkk%252Fdiabetic-foot-gangrene%3B728%3B546

REFERENCES

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