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Dry and wet gangrene of the toes in diabetes mellitus
Last reviewed: 26.11.2021
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One of the serious problems associated with chronic hyperglycemia (high blood sugar) is gangrene in diabetes, which occurs in patients with this metabolic disease due to poor blood supply to tissues and deterioration of their trophism.
Epidemiology
According to WHO statistics, the average prevalence of diabetes in the world has reached 6.3% (in North America - twice as high) and continues to increase. [1], [2]
Every year, trophic ulcers and tissue necrosis caused by diabetes appear in 2-5% of patients, and the risk of these complications of chronic hyperglycemia is estimated at 15-20%.
Approximately one in three patients eventually develop diabetic foot syndrome, and the result of not treating it is foot gangrene in diabetes. In almost 85% of cases, it ends in amputation of the limb, and in 5.5% of cases - death. [3]
According to surgeons, today 60-70% of all lower limb amputations are associated with diabetes.
Causes diabetic gangrene
Experts note such underlying causes leading to tissue death - gangrene - in patients with diabetes, such as:
- vascular damage - diabetic angiopathy of the lower extremities, that is, impaired peripheral blood circulation with limited blood flow to the distal extremities and local tissue ischemia. This negatively affects the wound healing process, slowing down the natural regeneration of damaged cells, reducing the rate of re-epithelialization and restoration of anatomical integrity, even with the smallest wounds; [4]
- diabetic neuropathy - damage to sensitive nerve fibers, as a result of which the transmission of nerve impulses is impaired and sensitivity and / or sensation of pain is lost. Thus, there are prerequisites for the inconspicuous injury (cuts, abrasions, scratches, etc.) and the progression of developing inflammation. [5]
The presence of chronic lesions of blood vessels and nerve fibers is caused by gangrene of the lower extremities in diabetes, and most often it is gangrene of the foot or gangrene of the fingers (feet or hands).
In addition, hyperglycemia negatively affects local immunity, reducing the response of immunocompetent cells to infections and their protective functions. [6]
Risk factors
The undoubted risk factors for the development of gangrene in patients with diabetes include:
- mechanical damage (trauma) to the skin and soft tissues;
- trophic ulcers with diabetes mellitus on the legs ;
- ulceration of the skin and subcutaneous tissue accompanied by infection, alteration of the connective tissue articular structures and bone tissue on the foot, called diabetic foot , upon reaching the pathological process of 4-5 stages of development.
There was information that the drugs Canagliflozin and Dapagliflozin, which lower blood sugar levels (by blocking protein compounds that transport glucose into the blood), increase the likelihood of developing gangrene of the anogenital region - Fournier's gangrene . Symptoms can include fatigue and fever, as well as swelling and redness of the skin in the genital area. According to experts, this type of gangrene is rare and can occur in diabetics with insufficient fluid intake and functional kidney failure due to a urinary tract infection.[7]
Pathogenesis
Gangrene is tissue necrosis due to the cessation of their blood supply, in many cases - with infection of the zone of violation of the integrity of the skin with inflammation-causing bacteria, in particular, Staphylococcus aureus (Staphylococcus aureus), Streptococcus pyogenes (β-hemolytic streptococcus), Pseudomonas aeruginosa coli), Proteus mirabilis (Proteus), etc.
The pathogenesis of tissue necrosis caused by them is discussed in detail in the material - Gangrene .
Explaining the mechanism of gangrene development in diabetes, doctors emphasize that in this endocrine disease - with its characteristic metabolic disorders - the expression of pro-inflammatory cytokines is increased, but the main phases of the normal healing process are slowed down. And this leads to non-healing trophic ulcers in diabetes , which are often infected with complications in the form of abscesses and gangrene.
Symptoms diabetic gangrene
How does gangrene start in diabetes? This directly depends on its type, since gangrene can be dry, wet and anaerobic (gas).
Most often, the toes are affected by dry gangrene in diabetes - without the participation of bacteria, caused by tissue ischemia and developing in the form of their coagulation necrosis. Its first signs: numbness, tingling and a decrease in local skin temperature (the affected area of the limb becomes cold and pale due to the outflow of blood). Then there are severe pains in the depths of the affected area, which turns into a brown-green ulcer with rapidly blackening skin along the edge. [8], [9]
The symptoms that manifests itself with a bacterial infection associated with wet gangrene of the legs in diabetes, in fact, demonstrate all the characteristic signs of colliquation (melting) necrosis developing in the tissues - with swelling and redness of the skin, bleeding and pain (with subsequent loss of sensitivity), as well as rapid loosening fabrics that become the most unusual color (from grayish-green to purple-red) with a putrid odor. The body temperature rises. At one of the stages of tissue necrosis, a scab forms on the surface, under which pus can accumulate, and when the crust cracks, it spills out. [10]
When tissues are damaged by anaerobic infection , primarily with clostridia (Clostridium septicum, Clostridium perfringens, etc.), gas gangrene develops in diabetes, and at the initial stage the patient begins to feel heaviness, swelling and bursting pain in the affected limb. All the details about its features and symptoms in the publication - Gas gangrene .
How the gangrene of the lower extremities proceeds and is treated in diabetes, see the publication - Gangrene of the leg .
Complications and consequences
Complications of dry gangrene are its infection and transformation into wet gangrene, as well as spontaneous amputation of the affected part of the limb (due to the rejection of dead tissue).
The most serious consequences of wet and gas gangrene are general intoxication of the body and sepsis .
Diagnostics diabetic gangrene
Diagnosis begins with an examination of the lesion and the patient's history.
Analyzes are required: general and biochemical blood test; on the level of glucose in the blood; bacteriological inoculation of purulent exudate; antibiotic susceptibility test .
To assess the viability of tissues and the possibility of restoring the vessels of the limb, instrumental diagnostics are used: X-ray and ultrasound of soft tissues in the affected area, ultrasonic duplex scanning of blood vessels, ultrasound Doppler and sphygmomanometry, radioisotope scintigraphy. [11]
Differential diagnosis
Differential diagnosis of diabetic gangrene includes abscess, inflammation with phlebothrombosis or embolism of the arteries of the lower extremities, pyoderma, as well as necrosis with erysipelas or streptococcal muscle tissue.
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Treatment diabetic gangrene
Diabetic gangrene can be treated if it is detected early. The main drugs that are used for gangrene are broad-spectrum antibiotics , that is, they can act on most bacteria that can cause tissue inflammation with subsequent necrosis. Amoxiclav, Ampiillin + Clindamycin, Carbenicillin, Amikacin, cephalosporins ( Cefazolin , Ceftriaxone , etc.), Metronidazole or Vancomycin are injected . [12]
To treat the affected area and dressings, a solution of Dioxidin is used, an antibiotic ointment (Baneocin, Levosin, Levomekol ).
If the gangrene is gas and is accompanied by intoxication, antitoxic anti-gangrenous serum is injected intramuscularly.
Physiotherapeutic treatment is possible with hyperbaric oxygenation , which - by improving the supply of oxygen to damaged cells - stimulates healing and tissue regeneration.
Experts consider herbal treatment ineffective in the case of gangrene, and only in the mildest forms allow it as an aid, for example, in the form of washing and irrigating the damaged areas with decoctions of St. John's wort, calendula, arnica, plantain, chamomile, thyme or rosemary.
In almost all cases, surgical treatment is required. First of all, sanitation is carried out - removal of the affected tissue, after which a reconstructive operation is possible, during which the affected area of the limb is closed using a skin graft. [13]
With dry gangrene, they resort to vascular surgery: they restore blood flow in the affected area, that is, revascularization is performed - by stenting or transplanting a part of a healthy vessel. [14]
When the progressive gangrene in diabetes has reached a late stage, a decision is made on the need to amputate the affected part of the limb.
Prevention
To avoid gangrene, it is necessary to control blood sugar levels with an appropriate diet and adequate treatment of diabetes and all its complications, read more:
According to endocrinologists, it is important that every patient with diabetes is aware of the nature of the disease and its possible consequences. [15]
With a diabetic foot, experts advise the following preventive measures: the feet should be kept clean and the nails should be trimmed regularly; wear comfortable shoes (which do not rub or press on anywhere), examine your feet every day (to check for the presence / absence of any damage or discoloration of the skin).
Forecast
Patients with dry gangrene (not associated with a bacterial infection) have a high chance of a successful outcome.
And the prognosis of wet and gas gangrene in diabetes is not very favorable due to the threat of sepsis. With gangrene of the foot in diabetic patients, mortality ranges from 6-35%.