GANGRENE (Greek. gangraina) — one of forms of necrosis (necrosis) of fabrics in a live organism.
Owing to damage of vessels of an extremity it is known to mankind from an extreme antiquity. In literature of mentioning of G. occur at Hippocrates and Tsels.
Can develop in all fabrics and bodies (skin, a hypodermic fatty tissue, muscles, intestines, a gall bladder, a lung etc.). Rather often G. of distal departments of the lower extremities and some abdominal organs (a worm-shaped shoot, a gall bladder) meets. Speed of development and G.'s prevalence depend as on the reason which caused it; and from the general state and anatomo-fiziol, features of an organism, existence or absence of an infection and some other factors.
The etiology and a pathogeny
Most often G. develops at ischemia of fabrics as a result of an acute disorder of blood circulation, the reasons to-rogo can be various: thrombosis or an embolism of the main artery, the opened or closed injury of an artery, bandaging of an artery during operation at badly developed collaterals, excessively long prelum of vessels a styptic plait or a pressure plaster bandage, infringement or torsion of internals, a long arteriospasm; as a result of diseases of vessels: at atherosclerosis of peripheral vessels — senile G., at an obliterating endarteritis — spontaneous G., at a Raynaud's disease — symmetric G. Nekroz of fabrics arises also because of effect of enzymes, napr, at pancreatitis, a peptic ulcer of a stomach and a duodenum, because of local impact on fabrics of bacteria and their toxins, napr, at mephitic gangrene (see) — gas G., because of exchange frustration, napr, at diabetes — diabetic. Necrosis of fabrics can be observed at impact on them high (see. Burns ) or low temperature (see. Freezing injury ), electric current, some chemical substances.
During wars the most frequent reason of G. of extremities — injury of arteries. During the Great Patriotic War ischemic G. met in 2,6% of cases of all wounds of vessels, and at wound of large vessels — from 3,5% of cases in MSB to 12,8% of cases in field hospitals (V. I. Struchkov, 1955). In peace time most often fibrinferments and embolisms are G.'s reason of extremities.
The factors influencing more bystry and more widespread development of G. are disturbances of the general condition of an organism, anemia, disturbances of collateral circulation, the factors promoting a vascular spasm (atherosclerosis, some hron, intoxications), extent of development of an anastomosis and collaterals in the struck area, a condition of a vascular wall (an endarteritis, atherosclerosis), speed of development of disturbance of blood circulation. In highly differentiated fabrics the necrosis develops quicker, than in less differentiated (aponeuroses, a fascia).
Existence in fabrics of microorganisms and their toxins considerably accelerates development and increases prevalence of a necrosis. Cooling of ischemic fabrics aggravates disturbances of blood circulation as a result of a vasospasm and promotes development of. Excessive warming of this area, raising fabric a metabolism in the conditions of insufficient blood circulation, also accelerates development and increases a zone of a necrosis.
The reasons causing G. of skin; are various. They can be local and the general; it is quite often difficult to delimit them from each other owing to the fact that locally efficient causes can cause a necrosis of fabrics only in the presence of the general contributing conditions. According to character of the reasons the following classification of G. of skin is accepted: 1) Of skin as a result of its infection strepto-and stafilokokka, pyocyanic, diphtheritic and pseudo-diphtheritic sticks, fuzospirokheta (some forms of an ugly face, a noma, a gangrenous balanitis, gangrene of generative organs, etc.); 2) Of skin, arising for the second time against the background of acute infectious diseases (e.g., natural and chicken pox, shingles, a malignant anthrax); 3) F. skin, arising for the second time against the background of hron, infectious diseases (e.g., tuberculosis, syphilis, leprosy, a frambeziya); 4) Of skin at poisoning (e.g., Ergotinum, carbon monoxide, lead, phosphorus, etc.); 5) Of skin as a result of action physical. reasons (burns, freezing injuries, radiation injuries); 6) Of skin as a result of effect of various chemical substances (strong to - t and alkalis, phosphorus, hypertensive solutions of some salts at their hypodermic introduction — tsvetn. fig. 1); 7) Of skin as a result of an artherothrombosis an oil suspension of medicinal substances, most often bismuthic drugs (see. Eshara ); 8) Of skin in the form of usually multiple limited centers of a necrosis, arising for various reasons at the weakened children exhausted heavy acute and hron, infectious or other general diseases (a wedge, kinds of this form G. called by gangraena cutis multiplex cachectica are described in literature by various authors under different names); 9) Of skin as manifestation of an allergic vasculitis (fagadenichesky ulcer, gangrenous pyoderma); 10) Of skin «diatezichesky» (tsvetn. fig. 2): a) senile mummificating G., b) the dry youthful G. described for the first time L. Buerger, c) diabetic G.; 11) Of skin, arising at some dermatomycoses (a sporotrichosis, a zymonematosis, an actinomycosis); 12) gangraena factitia arising at intentional use of the caustic cauterizing substances. In special group allocate seldom found multiple G. of skin caused by disturbance of activity of a nervous system (gangraena cutis multiplex neurotica).
For, the changes typical for a necrosis of fabrics are characteristic (see. Necrosis ). On clinical and pathoanatomical signs distinguish dry and wet.
Dry. meets on limited sites of skin and distal departments of extremities, It is characterized by a coagulative necrosis of cytoplasm of cells, kariolizy, an erythrocytolysis, leukocytes, fibrinoid dystrophy of fibrous structures or their full dissolution. Blood from vessels diffuses in surrounding dead fabric where the blood pigment is exposed to disintegration with turning into ferrous sulfide, causing dirty-brown, bluish-greenish or black coloring of devitalized sites. Fabrics lose moisture, dry, shrivel, become dense, are mummified. In the living tissue adjoining on sites of a necrosis there is reactive inflammation (see), expressiveness to-rogo depends on reactive ability of an organism. The inflammation is shown by the expressed plethora of fabrics, a vykhozhdeniye from a vascular bed of leukocytes and exudate. The otgranicheniye — formation of the line of demarcation representing a zone of an acute inflammation on border of live and dead fabrics is a consequence of this process. The exudate which is coming out together with leukocytes. in a zone of an inflammation destroys the died fabrics which lyse with proteolytic enzymes, and decomposition products are englobed by leukocytes and macrophages. The happening processes cause a softening and removal through demarcation of necrotic fabrics which are replaced with the expanding young granulyatsionny fabric with the subsequent formation of a hem. In the area of a demarcation inflammation there can sometimes occur spontaneous rejection of a devitalized part of an extremity — mutilation (spontaneous amputation).
Wet G. develops at impossibility of drying, generally in internals more often (intestines, a gall bladder, etc.), and on extremities — at quickly occurred extensive necrosis in the conditions of hypostasis and a venous plethora of the fabrics favoring to development of the joining putrefactive infection (see). At the same time nekrotizirovanny fabrics are exposed to ichorization and fusion by proteolytic enzymes, products to-rogo, coming to blood of the patient, lead to heavy intoxication of an organism.
Thrombosis of a large vein (ileal, femoral, axillary, mesenteric, etc.) and insufficiency of venous collaterals at an undisturbed arterial blood-groove sometimes can be also given to wet. Long stagnation of blood and puffiness of fabrics cause a spasm of arteries with the subsequent paralytic trichangiectasia that, even more increasing stagnation of blood, leads to a hypoxia of fabrics and their necrosis. Such mechanism of development of G. takes place at fibrinferment of mesenteric veins and a necrosis of intestines more often. Nekrotizirovanny fabrics are a good medium for microflora; its rough reproduction leads to bystry distribution of the wet G. called by also progressing.
The clinical picture
the Clinical picture of different types of G. is various and is defined by features of anatomic area and body in whom the necrosis, the volume of defeat and its character, and also degree of intoxication of an organism decomposition products of fabrics and bacterial toxins developed.
Gangrene of extremities meets rather often; it can be dry and wet.
Dry G. (tsvetn. fig. 3 and 4) usually develops at slowly progressing disturbance of blood circulation of an extremity and at a favorable current strikes a part of a segment of an extremity, does not progress (limited, or stationary, G.). The first symptom of disturbance of the blood circulation preceding G. is severe pain distalny the level of arterial occlusion; caused by ischemia of fabrics. Integuments of the struck segment become at first pale, then get a marble-bluish shade. The affected extremity is colder healthy, the pulsation of peripheral arteries is absent, disorders of sensitivity from paresthesia accrue to: full anesthesia; its function is broken (see. Obliterating defeats of vessels of extremities ). As a rule, at disturbance of passability main arteries the spasm of collaterals takes place that accelerates development of a necrosis., beginning with distal departments of an extremity, extends up to the level of full-fledged collateral circulation — border of nekrotizirovanny and healthy fabrics. At the termination of distribution the line of demarcation is accurately outlined by G., at the continuing distribution of necrosis it can have indistinct borders. At dry G. disintegration of the died fabrics and according to intoxication of an organism does not happen therefore the general condition of the patient remains satisfactory. However penetration of a putrefactive infection into devitalized fabrics to their through cure can cause dry G.'s transition to wet.
Local clinical manifestations of wet G. begin with blanching of integuments, then in a zone of a necrosis there are spots and phlyctenas filled with sanious contents. As well as at dry G., the affected extremity is colder healthy, pulse on peripheral arteries is not defined, there are no sensitivity and the movements. Quickly progressing hypostasis of an extremity and lack of signs of an otgranicheniye of process are characteristic of wet G. The fabrics which are exposed to ichorization get a pasty consistence, dirty-gray or black color, a fetid smell.
Wet G. is always followed by the expressed general symptoms: a serious general condition, slackness, block of the patient, tachycardia, decrease in the ABP, the high temperature increasing anemization and other symptoms of intoxication of an organism. The line of demarcation, as a rule, does not manage to develop, and the patient perishes from intoxication or sepsis.
Gangrene of internals always happens wet. Of abdominal organs (a worm-shaped shoot, a gut, a gall bladder) is shown a wedge, a picture peritonitis (see). Of a lung is characterized by the expressed intoxication and allocation of a fetid putrefactive phlegm, sometimes with sites of nekrotizirovanny pulmonary fabric (see. Lungs , pulmonary suppurations).
Gangrene of skin it is characterized by formation of single or multiple infarctions of integuments. Distinguish dry and wet G. of skin.
the Diagnosis at the developed G. of an extremity or skin in most cases does not represent difficulties. However at G. of an extremity in early stages of acute impassability of the main arteries to specify character and level of defeat and to estimate weight of ischemia distalny occlusions on the basis only a wedge, signs can be difficult; for this purpose special methods of a research are required: arteriography (see), a reovazografiya (see. Reografiya ), sfigmografiya (see), termografiya (see), thermometry, kapillyaroskopiya (see), angioskopiya (see), research of microcirculation by method of radio isotope indication. Of abdominal organs is diagnosed usually during operation, and G. of a lung — on the basis kliniko-rentgenol. signs (see. Lungs ).
Treatment of patients with G. includes the actions directed to improvement of the general condition of the patient, an otgranicheniye of the nekrotizirovanny site from viable fabrics and surgical removal of devitalized fabrics.
General actions consist in fight against intoxication, an infection and in improvement of functions of the vital systems (cardiovascular, breath) and bodies (a liver and kidneys). For this purpose parenterally enter enough liquid (solutions of glucose, fiziol, solution, blood substitutes, solutions of electrolytes), antibiotics taking into account sensitivity of microflora, cardiacs, vitamins, diuretics, make hemotransfusions etc. Apply to increase in protective forces of an organism also means of specific and nonspecific immunization (staphylococcal anatoxin, hyperimmune plasma or serum, specific gamma-globulin, etc.). At specific G.'s treatment (syphilis) include treatment of the basic disease which served as the reason of in a complex of the general actions. At diabetic G. an important role is played by timely correction of carbohydrate metabolism and acid-base equilibrium.
Character local to lay down. actions at G. is defined by localization and prevalence of a necrosis. E.g., at G. of abdominal organs the immediate surgery — a laparotomy and removal of nekrotizirovanny body or its part is shown. At G. of extremities topical treatment includes the actions directed to otgranicheny zones of a necrosis and the prevention of its infection, improvement of blood circulation in fabrics proksimalny G. (rest, an aseptic bandage, novocainic blockade, long regional intra arterial infusions of antibiotics, use of analgetics, vasodilators, anticoagulants, topical administration of proteolytic enzymes etc.), and finally at any kind of G. — removal of devitalized fabrics or body. At dry G., besides, apply the means interfering its transition in wet and accelerating process of drying of fabrics: an open method of treatment under a framework (sukhovozdushny bathtubs of low temperature), processing of devitalized fabrics spirit solution of a tannin, uv radiation of the affected extremity. Operation — amputation of a segment of an extremity — is made in a planned order after formation of a line of demarcation. At wet G. extremities at first aim to transfer it to dry, applying early necrotomy (see) and necretomy (ohm.). But in most cases according to vital indications make amputation of an extremity within healthy fabrics at once (see Amputation). During amputation concerning ischemic G. it is recommended to make audit of the main arteries for the purpose of identification of degree of their passability. Removal, e.g., of blood clot or an embolus from an artery considerably normalizes a blood stream in an amputating stump, and in some cases allows to keep viable a part of a segment of the extremity which is subject originally to removal (N. I. Krakovsky, B. N. Varava, 1972). Success of operation in many respects depends on a condition of collateral circulation (see. Collaterals vascular ).
Results of treatment of ischemic and anaerobic G. considerably improve at use hyperbaric oxygenation (see).
At threat of development of G. in connection with wound and bandaging of an artery for improvement of food of ischemic fabrics B. V. Ognev suggested to pour in blood in the distal end of the injured artery. The majority of the main arteries of extremities which were injured with damage has a massive blood loss and shock therefore even early recovery of a blood vessel without adequate completion of blood loss and intensive antishock care quite often comes to an end with thrombosis of a vessel in a zone of operation with the subsequent development of.
Development of vascular surgery, broad use of anticoagulants and fibrinolitic means promoted implementation in practice of the emergency surgery of vessels of such operations as primary vascular seam, blood clot - and embolectomies (see. Thrombectomy ), an intimektomiya, an endarteriektomiya by method of a reversing, creation of continuous bypass shunting (see. Shunting of blood vessels ), various plastic surgeries that considerably reduced risk of development of ischemic G. at disturbance of passability of the main vessels.
At G. skin apply the general treatment depending on the reason which caused G., local — depending on a wedge, pictures. Quite often it is necessary to resort to surgical methods — to excision of nekrotizirovanny sites of skin.
the Forecast concerning life of the patient at dry G. favorable, at wet G. it is more serious and depends on the term which passed from the beginning of a disease, localization and the reason of development of a necrosis of fabrics, on the volume of defeat, the general condition of the patient, the nature of the carried-out treatment and some other the reasons.
Prevention: 1) the prevention, early diagnosis and timely treatment of diseases which complication G. can be (e.g., acute surgical diseases of abdominal organs, diseases of cardiovascular system, an injury, burns, freezing injuries, infectious diseases and radiation injuries of skin); 2) bystreyshy recovery of the broken blood circulation, e.g., as a result of a long prelum of an extremity a plait or a plaster bandage, and also the fastest performance blood clot - or embolectomies, sewing together of damages of a vessel, etc.
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