GANGRENE

IT IS THE MACROSCOPIC DEATH OF TISSUE WITH SUPERADDED PUTREFACTION. GANGRENE IS OF TWO TYPES: 1) DRY GANGRENE 2)WET GANGRENE

DRY GANGRENE


THE PART IS GRADUALLY DEPRIVED OF ITS ARTERIAL BLOOD SUPPLY. THERE IS CHARACTERISTIC COLOUR CHANGE. THERE IS A DEFINITE BRIGHT RED LINE OF SEPARATION APPEARS BETWEEN THE LIVING AND DEAD TISSUE. EXAMPLES :SENILE GANGRENE,BUERGERS DISEASE.

MOIST GANGRENE


IT IS CHARACTERISED BY MOIST AND EDEMATOUS LIMB,WITH COLOUR CHANGES WHICH VARY AMONG DARK RED,GREEN,PURPLE AND BLACK OWING TO SULPHATED HYDROGEN PRODUCED BY THE PUTREFACTIVE BACTERIA ACTING UPON THE LIBERATED HEMOGLOBIN DUE TO HEMOLYSIS AND WITH HORRIBLE ODOUR,WHICH IS PARTLY DUE TO NITROGENOUS PRODUCT INDOLE AND SKATOL AND PARTLY DUE TO SULPHURATED HYDROGEN BUTYRIC ACID AND LACTIC ACID.

CHARACTERISTICS


 

WHEN THE VEIN IS OBSTRUCTED ,NO BLOOD CAN LEAVE THE PART.NO FRESH BLOOD CAN ENTER,SO LIQUIFACTION AND BACTERIAL INFECTION OCCUR TO CAUSE MOIST GANGRENE. THE PART IS COLD,PULSELESS,SWOLLEN AND EDEMATOUS. CHARACTERISED BY HORRIBLE ODOUR. EXAMPLES:VENOUS THROMBOSIS,BED SORE AND GAS GANGRENE

CAUSES


 

 

 

ARTERIAL OCCLUSION:Atherosclerosis,embolism,buergers disease,raynauds disease.syphilitic gangrene(endarteritis obliterans) obliterans) VENOUS OBSTRUCTION:DVT NERVOUS DISEASE:syringiomyelia,tabes dorsalis,peripheral neuritis and leprosy. TRAUMATIC GANGRENE INFECTIVE GANGRENE:carbuncle,fourniers and gas gangrene. DIABETIC GANGRENE PHYSICAL GANGRENE:burns,frostbite,corrosive. GANGRENE:burns,frostbite,corrosive.

INVESTIGATIONS


BLOOD : Hb , TC, DC, RBS, B.Urea. B.Urea. S.creatinine,Electrolytes,Lipid prophile RADIOLOGY:X RAY of the part. Duplex scan.

TREATMENT


GENERAL TREATMENT:this includes nutritious diet ,control of diabetes,relief of pain and care of heart. LOCAL TREATMENT:part should be kept dry,release of pus and dressing. SURGICAL TREATMENT:AMPUTATION, DIRECT ARTERIAL SURGERY AND SYMPATHECTOMY.

GAS GANGRENE

DEFINITION


This is a rapid spreading infective gangrene of the muscles characterised by collection of gas in the muscle and subcutaneous tissue.

Also called clostridial myonecrosis

AETIOLOGY AND PREDISPOSING FACTORS



Anaerobic Clostridial organisms of which Clostridium perfringens (Cl.Welchii) is the main organism Others are
Cl.oedematiens Cl.septicum, Cl.histolyticum, Cl.bifermentans.

Exotoxins of these organisms produce the disease

Clostridium perfringens

Exotoxins produced


Alpha toxins (lecithinase) is a hemolytic and also splits lecithin to phosphocholine and diglyceride. Collagenase is a proteinase and breaks down collagen, the connective tissue element of the muscle Hyaluronidase breaks down hyaluronic acid Theca toxins is hemolytic, lethal and necrotic LeucocidinLeucocidin-kills leucocytes

.


Predisposing factors
 

 

Trauma, laceration and crush injuries, Diabetes Mellitus, old age, poor circulation, Mellitus, haemorrhage and blood clot help infection by supplying calcium, Malignancies of blood cell line, poor nutrition, decrease in number of neutrophils and chemotherapy are some of the predisposing risks and causes of gangrene

Pathology


Affects the whole of the involved muscle Foul smelling necrosis of the muscle which becomes from dull red to green and ultimately black in appearance Earliest change is a rapid spreading edema of the subcutaneous tissue and muscle with accumulation of gas Collagen fibres- swollen, fragmented and then fibresbroken down

*Blood vessels are damaged

*Muscle loses striations and nuclei degenerated *Loses contractility and its healthy colour *become soft and friable *Green to black colour due to action of sulphurated hydrogen on iron liberated from break down of muscle hemoglobin

TYPES


Clostridial cellulitis Single muscle type Group type Massive type Fulminating type

C/F
GENERALGENERALPt anxious , anaemic Rapid pulse Fall in BP Mentally normal

LOCAL
*

Complains of pain in the affected limb

*Gradual swelling and gross edema of the part *Profuse discharge of brownish and foul smelling fluid *Skin discoloured-khaki to greenish discoloured*Crepitus + due to gas in muscle and subcutaneous tissue. *If muscle visible colour becomes green to black

INVESTIGATIONS


Direct microscopic examination -stained with Grams stain. Staphylococci and Streptococci seen. The causative organism seen as thick rectangular bacilli. CultureCultureNagler reaction- Serologically controlled toxogenic strains of reactionCl.Welchii are rapidly detected by direct plate culture of the exudate by nagler reaction method. This test is based on the fact that lecithinase of Cl.Welchii splits soluble lipoprotein complex of the human serum with the formation of an insoluble precipitate of lipoids and protien, producing an opacity in the culture medium. X ray- gas shadow within muscle ray-

CULTURE

Treatment
ProphylaxisProphylaxis1. Wound excision or debridement 2. High dose of benzyl penicillin-20lacs 4th penicillinhourly.metronidazole 500mg 8th hourly. 3. While performing wound excision tourniquet should be avoided 4. If wound is in tension better to leave wound open than primary sutures under tension 5. Passive immunization -IM injection of anti gas gangrene serum of polyvalent antitoxin of 22,500 I.U containing 9000 Cl.Welchii,4500I.U Cl.septicum,9000I.U Cl.oedematiens. Cl.oedematiens. 6. Active immunization-not popular immunization-

Treatment of established casecaseSurgerySurgery multiple longitudinal incisions for decompression and drainage  Aggressive surgical debridement of all devitalised tissue  Massive type or if early diagnosis was not made then amputation

Supportive treatment


  

High dose of penicillin administered as soon as diagnosis confirmed Blood transfusion started soon after operation is contemplated to combat shock n anemia Anti gas gangrene serum given Hyper baric oxygenation. Electrolyte management.

Fourniers Gangrene

Definition
Fournier(1832-1914): Fulminant gangrene of the penis and scrotum Sudden onset in an hitherto healthy young man Rapid progression to gangrene Absence of a definite cause
Dorlands Illustrated Medical Dictionary 29th edition:

An acute gangrenous type of necrotizing fasciitis of the scrotum, penis, or perineum involving Gram-Positive organisms, enteric bacilli, or anaerobes.

Anatomy

Risk factors
Male : Female = 10 : 1 Immunocompromised Alcoholism Diabetes mellitus Cancer, HIV Hygiene problems Low social economic status Indwelling catheters Post-surgical

Etiology

Dermatological Anorectal Urological Intra-abdominal

Pathophysiology
Synergistic necrotizing fasciitis Thrombosis of small subcutaneous vessels Development of gangrene

Infection

Common pathogens: Streptococci, Staphylococci, Enterococci, Corynebacteria E.coli, Klebsiella, Proteus Bacterioides, Clostridia

Clinical Presentation
Bronze or Violaceous discoloration of the skin Thin brown watery discharge Ulceration, Bullous vesicles, Subcutaneous gas

Treatment
ABCs Central venous access Fluid resuscitation Empirical broad spectrum antibiotics  Penicillins with -lactamase inhibitor, Carbapenems  Penicillins + 3rd cephalosporins + aminoglycosides + clindamycin or metronidazole Early emergent surgical debridement Hyperbaric Oxygen therapy Electrolyte and Metabolic control Blood product if indicated

Morbidity and Complacations

Morbidity: Duration of hospital stay: 2-278 days

Complications: Great tissue loss lead to sacrifice the testes. Penile gangrene may result in total loss of penis. DKA may appear in the course.

Mortality and Prognosis

Mortality rate: 16% (3-45) Cause of Death: Severe sepsis, Coagulopathy, ARF, DKA, MOF Factor associated with mortality: Age > 60 y/o Unstable hemodynamic status Anorectal source Renal or Hepatic dysfunction Delay treatment Patients with more than 5% BSA involvement

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