Gangrene - Causes, symptoms and treatment. MF.

Gangrene is one of the forms of necrosis of tissues in a living organism that develops when their blood supply or innervation is impaired, with direct traumatic effects on them or with certain metabolic disorders.

Gangrene can develop in all tissues and organs of the human body: skin, subcutaneous tissue, lung, intestines, muscles, gall bladder can be affected. The most common in medical practice is gangrene of the end parts of the legs, as well as the abdominal cavity organs( vermiform appendix, gallbladder, intestinal tract, etc.).

In the historical retrospect of gangrene, resulting from a violation of the blood supply to the limb, was known to mankind already in antiquity;in the medical literature the description of gangrene is found already in the writings of the ancient doctors of Hippocrates and Celsus.

The causes of gangrene

The most common cause of gangrene is oxygen starvation of tissues as a result of acute circulatory disturbances in them, which can develop as a result of thrombosis or embolism( blockage of large arteries by circulating blood in the bloodstream( for example, detached from the vessel wall)or surgical ligation of the artery, prolonged compression of blood vessels with a tourniquet or a tight plaster bandage, when the abdominal cavity is infringed with hernias,e intestine, in some vascular diseases( arteriosclerosis obliterans, occlusive disease, Raynaud's disease).

The development of gangrene can be caused by the action of the body's enzymes, which occurs in pancreatitis and peptic ulcer. Gangrene can also be caused by local exposure to tissue of microbes and toxins produced by them, which is observed with anaerobic infection( gas gangrene);metabolic disorders( diabetes mellitus), exposure to high and low temperature tissues( burns and frostbites), electrocution and aggressive chemicals.

The development of gangrene can contribute to heart failure, anemia, hypovitaminosis, smoking, alcohol intake.

The most common causes of gangrene development in peacetime are thrombosis and embolism, and in military - artery damage.

Symptoms of gangrene

Manifestations of the disease depend on the features of the body part and the organ in which gangrene developed, as well as the extent of the lesion and its nature. Most often, gangrene of the limbs, which can be dry and wet.

Dry gangrene occurs, as a rule, with gradually progressing infringement of blood supply to the limb, in case of a favorable course it does not progress. In the initial stage there are intense pains in the limbs below the site of blockage of the artery. The skin of the limb becomes pale and cold, then acquires a marble-bluish hue. Disappears pulsation on the peripheral arteries of this limb, its sensitivity decreases, movements in it are disturbed. The tissues lose moisture and mummify, thicken, wrinkle and acquire a bluish-black color due to impregnation with their pigments of blood. The spread of gangrene is limited by the level of sufficient blood supply to tissues, where the border between healthy and necrotic tissues is formed( the so-called demarcation shaft).Since the decomposition of dead tissues does not occur with dry gangrene and the absorption of the products of such decomposition is insignificant, the general condition of the patients remains satisfactory, but when penetrating into the dead tissue of the infection, dry gangrene can pass into the wet one.

Dry gangrene of toes in a patient with diabetes mellitus.

Wet gangrene occurs, as a rule, in patients with increased body weight with acute infringement of the blood supply to the extremity( damage, acute thrombosis or embolism of a large artery), which leads to the rapid necrosis of tissues with a high liquid content, which do not have time to dry out and become a favorable environmentfor the development of purulent or putrefactive infection. Fineness first pale, it becomes cold, then on the skin appear purple-cyanotic spots and blisters filled with bloody contents with a fetid odor. Pulse on the peripheral arteries of this limb is not determined, there is a violation of sensitivity and active movements, fast edema progresses, there is no tendency to delimit the process. The tissues are putrefied by decomposition, turning into a fetid mass of a testy consistency of dirty gray or black.

Absorption of decay products leads to severe intoxication of the body, which causes a severe general condition of the patient. Weakness and inhibition of the patient, increased heart rate, lowering of blood pressure, increase in body temperature are noted. The complexion becomes earthy, the appetite disappears. There is a real threat of death of a patient from intoxication or sepsis.

Gangrene of the abdominal cavity ( intestine, gallbladder, appendix) has clinical manifestations of peritonitis.

Gangrene site of the small intestine( pathoanatomical drug).

Gangrene lung is manifested by significant intoxication, expectoration of putrefacted sputum with a fetid odor, sometimes with fragments of dead puerperium.

When gangrene of the skin , single or multiple foci of necrosis of the skin are formed, and gangrene can be dry or moist.

Diagnosis of gangrene

Laboratory examination:

• General blood test( UAC): leukocytosis is characteristic( increase of white blood cells over 9 x 109 / L) with an increase in the content of stab neutrophil forms( over 5%).
• Biochemical blood test: with diabetic gangrene is characterized by an increase in blood glucose( hyperglycemia);with obliterating atherosclerosis there is an increase in the level of cholesterol;
• Blood test for sterility: used for gangrene complicated by sepsis.(the spread of an infectious agent from a purulent focus to the bloodstream).Allows to establish the nature of the pathogen and determine its sensitivity to antibiotics.
• Investigation of the bacterioscopic( especially under wet gangrene) bacterioscopy( microscopic examination after special coloring of the material) and bacteriological( isolation of pure culture on nutrient media) methods, also allows to determine the nature of the pathogen and determine its sensitivity to antibiotics.

Treatment of gangrene

Complex treatment of patients with gangrene includes:

1) measures to improve the general condition of the patient;
2) activities aimed at delimiting the viable tissues of the dead;
3) measures aimed at surgical removal of dead tissue.

The general measures are reduced to the elimination of intoxication, the fight against infection and optimization of the functions of the most important organs. Intravenous administration of solutions of glucose and electrolytes( saline solution, Ringer's solution), antibiotics of various groups, taking into account the sensitivity of the detected pathogens, vitamins, diuretics, if necessary, transfusion of blood components, are used.

With diabetic gangrene, the normalization of blood glucose level by correcting the dosage of insulin is very important. With ischemic and anaerobic gangrene, hyperbaric oxygenation( a pressure chamber) is used.

The nature of surgical treatment depends on which organ is affected, and the prevalence of the pathological process. With gangrene of the abdominal cavity organs, an emergency surgical intervention is indicated - laparotomy( opening of the abdominal cavity) and removal of the dead body or its part( appendectomy, gut resection, large omentum) performed in surgical hospitals.

Local treatment for gangrene of the extremity consists in ensuring rest, applying a sterile bandage, performing a Novocain blockade, prolonged regional intra-arterial administration of antibiotics, prescribing anesthetics and vasodilators and anticoagulants.

In case of dry gangrene of limbs, prevent its transition to moist: dry air baths of low temperature, treatment with alcoholic solution of tannin, ultraviolet irradiation of necrotic tissues, and the operation( amputation of part of the limb) is performed in a planned order after the formation of the demarcation line. With wet gangrene, as a rule, for vital signs, an amputation of the limb is made immediately within the viable tissues.

With gangrene of the skin, the necrotic areas are excised.

Rehabilitation of patients after limb amputation is reduced to adherence to recommendations for care of the postoperative suture, stump formation, preservation of joint mobility and training of the preserved musculature. In the case of a favorable course of the postoperative period, after 3-4 weeks after limb amputation, primary prosthesis can be performed. Modern methods of prosthetics allow people who have undergone amputation to continue their old way of life and maintain their social status.

Complications of gangrene

Gangrene is a very serious disease that can lead to serious complications, up to a lethal outcome. Gangrene of the abdominal cavity leads to the development of peritonitis - an extremely difficult condition, requiring emergency surgery for vital signs.

Gangrene lung can be complicated by sepsis, pulmonary hemorrhage, acute respiratory cardiovascular insufficiency.

Dry gangrene of the limb without adequate treatment and joining the infection can go into the wet. The course of moist gangrene may be complicated by the development of severe intoxication and sepsis, which can lead to death.

All of the above indicates the need for early contact with a doctor with the appearance of the first signs of gangrene and the inadmissibility of self-treatment.

Prevention of gangrene

Prevention of gangrene is reduced to the timely treatment of diseases that can eventually lead to its development: diseases of the cardiovascular system, surgical diseases of the abdominal cavity organs, burns and frostbites, injuries, etc. In addition, in acute conditions, accompanied by a violationblood circulation, it is necessary to restore it quickly( restoring the integrity of the vessel when it is damaged, removing the thrombus and embolus, clogging the lumen of the vessel, timely removal of the bloodtanavlivayuschego harness and m. p.).

Doctor surgeon Kletkin ME