Diabetic gangrene – a necrosis of a part of the body at diabetes. Usually disteel departments of the lower extremities suffer. The main symptoms are pains, black (black-blue, dark-purple) color of an extremity, lack of sensitivity and blood supply in the struck zone. At a damp necrosis suppuration, nausea, a fever, a hyperthermia is observed. The diagnosis is exposed on the basis of the anamnesis and data of external survey, for assessment of a condition of fabrics and vessels appoint MRT, UZDG, a X-ray analysis, carry out definition of a lodyzhechno-humeral index, neurologic inspection. Depending on prevalence and a type of a necrosis carry out conservative actions, a nekrektomiya or amputation of an extremity.
Gangrene – a local necrosis of a part of a body of a live organism. Is the reason of an invalidization. In case of a damp necrosis becomes the organism intoxication reason products of disintegration of fabrics. Diabetic gangrene – a severe form of a syndrome of diabetic foot. In risk group of development of this pathology there are about 35-40% of patients with diabetes, the epidemiological indicator makes 3,5-8,5%. At SD of 1 type the probability of developing of gangrene sharply increases in 7-10 years after a disease debut, at diabetes 2 types the risk of this complication exists since the beginning of a disease. Patients with SD of the second type have gangrene 10 times more often than persons with 1 type of diabetes. 8-12% of patients with the confirmed diagnosis need amputation of an extremity.
Reasons of diabetic gangrene
Key etiologichesky factor is the heavy course of diabetes. Violation of metabolism of glucose becomes the cause of the vascular, neurologic and bone and articulate changes leading to development of gangrene. Carry to primary and minor reasons of a diabetic necrosis of extremities:
- SD decompensation. The long hyperglycemia is the cornerstone of vascular and neurologic frustration. Gangrene is formed against the background of insufficiency of a blood-groove, a hypoxia of fabrics, decrease in sensitivity.
- Deformations of foot. Limited mobility of joints, uneven distribution of load of foot, an overload of its certain sites lead traffic of fabrics to violation. There are attritions, cracks and ulcers in the field of which in the subsequent sites of a necrosis are formed.
- Immunodeficiency. Decrease in adaptable and protective mechanisms of an organism is noted. Patients become more vulnerable to casual injuries of skin, infection of wounds.
- Associated diseases. Gangrene is more often diagnosed for patients with pathologies of a cardiovascular and urinary system. In risk group carry elderly people with a heavy nephropathy, heart and venous failure, excess weight.
- Socio-economic factors. Often complications of SD are caused by a low komplayentnost of patients – discrepancy of their behavior to recommendations and appointments of the doctor-endocrinologist. Other factors – inaccessibility of medical care and an asocial way of life.
Carry peripheral neuropathy, an angiopatiya and deformation of feet with formation of sites of high pressure to mechanisms of development of gangrene. A pathogenetic basis of gangrene are disorders of blood circulation. The hyperglycemia provokes structurally functional changes of large and small vessels. The membrane of capillaries is thickened, stratified, broken a selective filtration and exchange diffusion of liquids. Nutrients and oxygen do not arrive in the necessary quantity, in fabrics metabolism products collect.
Formation of atherosclerotic plaques leads to narrowing or blocking of a gleam of arteries of large and small caliber. On this background destructive changes are formed, necrotic processes are started. At violation of food and supply with oxygen of a cage perish. If this process happens gradually, development of dry gangrene is probable – fabrics are dehydrated, mummified. Death of cages in the course of rotting becomes the cause of damp gangrene. Decomposition of fabrics happens under the influence of bacteria, the congestion of pus and gases is observed.
Symptoms of diabetic gangrene
Dry gangrene arises at slowly formed blood circulation violation. Struck there is a limited area of fabrics, distribution of a necrosis is uncharacteristic. At a stage of ischemia severe pain lower than the level of obstruction of a vessel is felt. Integuments turn pale, become marble-bluish. Temperature of the affected leg is reduced, deterioration in sensitivity is noted, prickings, an itch, burning are possible. In the healthy fabrics adjoining on the necrosis center inflammatory process with expressed polnokroviy develops. The line of demarcation – a border area of an acute inflammation is as a result formed.
Because of hypostasis in a zone of demarcation it is long the pain syndrome remains. Other types of sensitivity in underlying departments are completely lost. Affected area black, dark blue or black-brown. The necrosis extends from the periphery to area with normal blood circulation, then process stops. Necrotic fabrics through demarcation are softened and replaced with granulyatsionny fabric, the hem is gradually formed. Sometimes there is a spontaneous rejection of the died-off part (spontaneous amputation). The died fabrics dry, but do not break up therefore patients feel well, symptoms of intoxication are absent.
The pobledneniye of integuments, formation of spots and vials of sanious liquid become the first displays of damp gangrene. The struck area cold to the touch, sensitivity is absent or is significantly lowered, veins are expanded. Hypostasis quickly progresses, the border between the struck and healthy sites is not defined, the necrosis extends in the proximal direction. The fabrics which underwent rotting have a pasty consistence and a fetid smell. Color – from gray to dark-black. At a palpation the characteristic sound reminding a crunch or whistle is heard. Symptoms of the general intoxication accrue: high temperature of a body, slackness, block, headache, nausea, vomiting.
Despite intensive development of diagnostic techniques in endocrinology, approximately diabetic gangrene is diagnosed for 47% of patients at late stages. The most serious consequences are amputation of an extremity and death from intoxication or sepsis. Statistically, in economically developed countries 6-8 amputations of the lower extremity on 1 000 diabetic patients are carried out every year. These figures do not consider amputation of a part of foot, thus, real indicators of complications above. About 12 000 operations are annually manufactured in Russia. 1,2% of sick SD I of type, 0,7% of patients with type SD II lose foot. Amputations at the level of a shin are performed 0,4% and 0,1% of patients respectively above.
Diagnosis in the presence of the developed clinical picture does not cause difficulties. Detection of diabetic gangrene at early stages is a task for polyprofessional team of experts. Regular surveys of the endocrinologist, vascular surgeon, orthopedist are required for persons from risk group. At detection of signs of complications the full complex of researches which includes is conducted:
- Clinical poll, survey. In the anamnesis sensitivity violations, puffiness, pains, formation of ulcers are noted. At survey change of skin color from reddish to black is defined, swelled (at a kollikvatsionny necrosis) or reduction of volume of an extremity (at coagulative defeat), deformation of foot, restriction of mobility of joints. At infection from a wound pus is emitted. Different types of sensitivity are lowered or completely lost. Also akhillova reflexes are weakened knee. Lodyzhechno-plechevoy an index – less than 0,6-0,9.
- Laboratory researches. In blood the high level of glucose on an empty stomach (more than 7 mmol/l) and glikozilirovanny hemoglobin (more than 6,5%), the increased values of cholesterol, triglycerides, LPVP and LPNP comes to light. In urine – the increased concentration of glucose and ketone bodies. At a purulent inflammation bacterial crops separated on microflora are appointed.
- Tool researches. Widespread methods for assessment of safety of a blood-groove are UZDG and a X-ray contrast angiography of vessels of the lower extremities. Decrease in capillary blood circulation is characteristic, increase in regionarny vascular resistance, defeat of the vascular course, violation of passability of vessels is lower than area of occlusion. From the visualizing diagnostics methods the X-ray analysis and MRT of foot are considered as the most demanded. Signs of an osteoartropatiya, osteoporosis, an osteoliz in areas of an instep and a tarsus, giperostoza are found.
Treatment of diabetic gangrene
Treatment is performed in the conditions of a surgical hospital. Antihyperglycemic medicines replace with insulin, carry out correction of dosages for achievement of a condition of compensation of SD. Carry out the general actions directed to optimization of work of vessels and heart, elimination of intoxication, increase in activity of immune system. As a part of system therapy use the medicines improving blood circulation (vasoprotectives, proofreaders of microcirculation), the dissolving blood clots (anticoagulants of direct action) stopping spasms (spazmolitik).
For normalization HELL into the program of treatment is entered by diuretics, antagonists of calcium, APF inhibitors, beta-blockers. At receipt appoint antibiotics of a broad spectrum of activity, in the subsequent make correction of antibiotic treatment taking into account sensitivity of the activator. Carry out by the heavy patient blood transfusions, infusions of solutions for correction of exchange violations, resuscitation actions. Apply crutches and wheelchairs to unloading of the struck foot.
At dry gangrene mainly conservative maintaining is shown. Carry out the bandagings which became lifeless fabrics at emergence of signs of office delete in the conditions of dressing. Use local means for clarification of a wound surface, stimulation of an epitelization. At damp gangrene because of intoxication and danger of distribution of a necrosis treatment quick, is performed after formation of a line of demarcation. For process localization the extremity is laid over bubbles with ice, make intra arterial introductions of antibiotics.
Excision of the become lifeless fabrics is usually carried out in 1-3 days after receipt. The nekrotomiya, a nekrektomiya and amputation of an extremity is possible. The nekrotomiya purpose (a section of fabrics) is delimitation of a necrosis, reduction of intensity of pyoinflammatory process, fight against the general intoxication. To Nekrektomy (removal of impractical fabrics) carry out at small zones of a necrosis. In the subsequent appoint bandagings, after clarification of a wound according to indications apply an autodermoplastika and other techniques to defect closing. At extensive necrosis of fabrics and threat of distribution of process on overlying departments amputation is required.
In the remote period in the absence of contraindications carry out the planned interventions directed to restoration of blood circulation and prevention of repeated development of gangrene. The low-invasive operations which are not demanding the long period of rehabilitation are mainly used. The type of the procedure is defined individually. Stenting of peripheral arteries, endovascular dilatation, an arterialization of veins of an extremity is possible.
Forecast and prevention
Dry gangrene is considered predictively favorable option of pathology, extent of violation of an opornost of an extremity depends on prevalence of process. Persons with damp gangrene have a forecast less favorable both concerning preservation of functions of an extremity, and concerning life. The reason of a lethal outcome the request for medical care can become later, distribution is purulent - necrotic process on a proximal part of an extremity, sepsis, a decompensation of functions of internals against the background of the expressed intoxication. Prevention is based on correct therapy of SD. It is important to carry out strictly all appointments of the doctor, including reception of medicines, observance of a low-carbohydrate diet and mode of physical activity. It is worth refusing the addictions promoting development of atherosclerosis (smoking, alcohol intake and greasy food), to avoid casual wounds, to choose orthopedic footwear and to watch its purity inside, to regularly perform hygienic procedures for care of legs.