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Gangrene

Gangrene

Definition

Gangrene is the term used to describe the decay or death of an organ or tissue caused by a lack of blood supply. It is a complication resulting from infectious or inflammatory processes, injury, or degenerative changes associated with chronic diseases, such as diabetes mellitus.

Description

Gangrene may be caused by a variety of chronic diseases and post-traumatic, post-surgical, and spontaneous causes. There are three major types of gangrene: dry, moist, and gas (a type of moist gangrene).

Dry gangrene is a condition that results when one or more arteries become obstructed. In this type of gangrene, the tissue slowly dies, due to receiving little or no blood supply, but does not become infected. The affected area becomes cold and black, begins to dry out and wither, and eventually drops off over a period of weeks or months. Dry gangrene is most common in persons with advanced blockages of the arteries (arteriosclerosis) resulting from diabetes.

Moist gangrene may occur in the toes, feet, or legs after a crushing injury or as a result of some other factor that causes blood flow to the area to suddenly stop. When blood flow ceases, bacteria begin to invade the muscle and thrive, multiplying quickly without interference from the body's immune system.

Gas gangrene, also called myonecrosis, is a type of moist gangrene that is commonly caused by bacterial infection with Clostridium welchii, Cl. perfringes, Cl. septicum, Cl. novyi, Cl. histolyticum, Cl. sporogenes, or other species that are capable of thriving under conditions where there is little oxygen (anaerobic). Once present in tissue, these bacteria produce gasses and poisonous toxins as they grow. Normally inhabiting the gastrointestinal, respiratory, and female genital tract, they often infect thigh amputation wounds, especially in those individuals who have lost control of their bowel functions (incontinence). Gangrene, incontinence, and debility often are combined in patients with diabetes, and it is in the amputation stump of diabetic patients that gas gangrene is often found to occur.

Other causative organisms for moist gangrene include various bacterial strains, including Streptococcus and Staphylococcus. A serious, but rare form of infection with Group A Streptococcus can impede blood flow and, if untreated, can progress to synergistic gangrene, more commonly called necrotizing fasciitis, or infection of the skin and tissues directly beneath the skin.

Chronic diseases, such as diabetes mellitus, arteriosclerosis, or diseases affecting the blood vessels, such as Buerger's disease or Raynaud's disease, can cause gangrene. Post-traumatic causes of gangrene include compound fractures, burns, and injections given under the skin or in a muscle. Gangrene may occur following surgery, particularly in individuals with diabetes mellitus or other long-term (chronic) disease. In addition, gas gangrene can be also be a complication of dry gangrene or occur spontaneously in association with an underlying cancer.

In the United States, approximately 50% of moist gangrene cases are the result of a severe traumatic injury, and 40% occur following surgery. Car and industrial accidents, crush injuries, and gunshot wounds are the most common traumatic causes. Because of prompt surgical management of wounds with the removal of dead tissue, the incidence of gangrene from trauma has significantly diminished. Surgeries involving the bile ducts or intestine are the most frequent procedures causing gangrene. Approximately two-thirds of cases affect the extremities, and the remaining one-third involve the abdominal wall.

Symptoms

Areas of either dry or moist gangrene are initially characterized by a red line on the skin that marks the border of the affected tissues. As tissues begin to die, dry gangrene may cause some pain in the early stages or may go unnoticed, especially in the elderly or in those individuals with diminished sensation to the affected area. Initially, the area becomes cold, numb, and pale before later changing in color to brown, then black. This dead tissue will gradually separate from the healthy tissue and fall off.

Moist gangrene and gas gangrene are distinctly different. Gas gangrene does not involve the skin as much, but usually only the muscle. In moist or gas gangrene, there is a sensation of heaviness in the affected region that is followed by severe pain. The pain is caused by swelling resulting from fluid or gas accumulation in the tissues. This pain peaks, on average, between one to four days following the injury, with a range of eight hours to several weeks. The swollen skin may initially be blistered, red, and warm to the touch before progressing to a bronze, brown, or black color. In approximately 80% of cases, the affected and surrounding tissues may produce crackling sounds (crepitus), as a result of gas bubbles accumulating under the skin. The gas may be felt beneath the skin (palpable). In wet gangrene, the pus is foul-smelling, while in gas gangrene, there is no true pus, just an almost "sweet" smelling watery discharge.

Fever, rapid heart rate, rapid breathing, altered mental state, loss of appetite, diarrhea, vomiting, and vascular collapse may also occur if the bacterial toxins are allowed to spread in the bloodstream. Gas gangrene can be a life-threatening condition and should receive prompt medical attention

Diagnosis

A diagnosis of gangrene will be based on a combination of the patient history, a physical examination, and the results of blood and other laboratory tests. A physician will look for a history of recent trauma, surgery, cancer, or chronic disease. Blood tests will be used to determine whether infection is present and determine the extent to which an infection has spread.

A sample of drainage from a wound, or obtained through surgical exploration, may be cultured with oxygen (aerobic) and without oxygen (anaerobic) to identify the microorganism causing the infection and to aid in determining which antibiotic will be most effective. The sample obtained from a person with gangrene will contain few, if any, white blood cells and, when stained (with Gram stain) and examined under the microscope, will show the presence of purple (Gram positive), rod-shaped bacteria.

X-ray studies and more sophisticated imaging techniques, such as computed tomography scans (CT) or magnetic resonance imaging (MRI), may be helpful in making a diagnosis since gas accumulation and muscle death (myonecrosis) may be visible. These techniques, however, are not sufficient alone to provide an accurate diagnosis of gangrene.

Precise diagnosis of gas gangrene often requires surgical exploration of the wound. During such a procedure, the exposed muscle may appear pale, beefy-red, or in the most advanced stages, black. If infected, the muscle will fail to contract with stimulation, and the cut surface will not bleed.

Treatment

Gas gangrene is a medical emergency because of the threat of the infection rapidly spreading via the bloodstream and infecting vital organs. It requires immediate surgery and administration of antibiotics.

Areas of dry gangrene that remain free from infection (aseptic) in the extremities are most often left to wither and fall off. Treatments applied to the wound externally (topically) are generally not effective without adequate blood supply to support wound healing. Assessment by a vascular surgeon, along with x rays to determine blood supply and circulation to the affected area, can help determine whether surgical intervention would be beneficial.

Once the causative organism has been identified, moist gangrene requires the prompt initiation of intravenous, intramuscular, and/or topical broad-spec-trum antibiotic therapy. In addition, the infected tissue must be removed surgically (debridement ), and amputation of the affected extremity may be necessary. Pain medications (analgesics ) are prescribed to control discomfort. Intravenous fluids and, occasionally, blood transfusions are indicated to counteract shock and replenish red blood cells and electrolytes. Adequate hydration and nutrition are vital to wound healing.

Although still controversial, some cases of gangrene are treated by administering oxygen under pressure greater than that of the atmosphere (hyperbaric) to the patient in a specially designed chamber. The theory behind using hyperbaric oxygen is that more oxygen will become dissolved in the patient's bloodstream, and therefore, more oxygen will be delivered to the gangrenous areas. By providing optimal oxygenation, the body's ability to fight off the bacterial infection are believed to be improved, and there is a direct toxic effect on the bacteria that thrive in an oxygen-free environment. Some studies have shown that the use of hyperbaric oxygen produces marked pain relief, reduces the number of amputations required, and reduces the extent of surgical debridement required. Patients receiving hyperbaric oxygen treatments must be monitored closely for evidence of oxygen toxicity. Symptoms of this toxicity include slow heart rate, profuse sweating, ringing in the ears, shortness of breath, nausea and vomiting, twitching of the lips/cheeks/eyelids/nose, and convulsions.

The emotional needs of the patient must also be met. The individual with gangrene should be offered moral support, along with an opportunity to share questions and concerns about changes in body image. In addition, particularly in cases where amputation was required, physical, vocational, and rehabilitation therapy will also be required.

Prognosis

Except in cases where the infection has been allowed to spread through the blood stream, prognosis is generally favorable. Anaerobic wound infection can progress quickly from initial injury to gas gangrene within one to two days, and the spread of the infection in the blood stream is associated with a 20-25% mortality rate. If recognized and treated early, however, approximately 80% of those with gas gangrene survive, and only 15-20% require any form of amputation. Unfortunately, the individual with dry gangrene most often has multiple other health problems that complicate recovery, and it is usually those other system failures that can prove fatal.

Prevention

Patients with diabetes or severe arteriosclerosis should take particular care of their hands and feet because of the risk of infection associated with even a minor injury. Education about proper foot care is vital. Diminished blood flow as a result of narrowed vessels will not lessen the body's defenses against invading bacteria. Measures taken towards the reestablishment of circulation are recommended whenever possible. Any abrasion, break in the skin, or infection tissue should be cared for immediately. Any dying or infected skin must be removed promptly to prevent the spread of bacteria.

KEY TERMS

Aerobic Organism that grows and thrives only in environments containing oxygen.

Anaerobic Organism that grows and thrives in an oxygen-free environment.

Arteriosclerosis Build-up of fatty plaques within the arteries that can lead to the obstruction of blood flow.

Aseptic Without contamination with bacteria or other microorganisms.

Crepitus A crackling sound.

Gram stain A staining procedure used to visualize and classify bacteria. The Gram stain procedure allows the identification of purple (Gram positive) organisms and red (Gram negative) organisms.

Hyperbaric oxygen Medical treatment in which oxygen is administered in specially designed chambers, under pressures greater than that of the atmosphere, in order to treat specific medical conditions.

Incontinence A condition characterized by the inability to control urination or bowel functions.

Myonecrosis The destruction or death of muscle tissue.

Sepsis The spreading of an infection in the bloodstream.

Thrombosis The formation of a blood clot in a vein or artery that may obstruct local blood flow or may dislodge, travel downstream, and obstruct blood flow at a remote location.

Penetrating abdominal wounds should be surgically explored and drained, any tears in the intestinal walls closed, and antibiotic treatment begun early. Patients undergoing elective intestinal surgery should receive preventive antibiotic therapy. Use of antibiotics prior to and directly following surgery has been shown to significantly reduce the rate of infection from 20-30% to 4-8%.

Resources

BOOKS

Berktow, Robert, editor. The Merck Manual of Diagnosis and Therapy. 17th ed. Rahway, NJ: Merck Research Laboratories, 1997.

PERIODICALS

Basoglu, M., et al. "Fournier's Gangrene: Review of Fifteen Cases." American Surgeon November 1997: 1019-1021.

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Gangrene

Gangrene

Definition

Gangrene is a term used to describe the decay or death of an organ, tissue, or bone caused by a lack of oxygen and nutrients. It is a complication resulting from tissue injuries (such as frostbite), the obstruction of blood flow, or the processes of chronic diseases such as diabetes mellitus . Externally, the hands and feet are the areas most often affected by gangrene; internally, it is most likely to affect the gallbladder and the intestines. Gangrene is referred to as wet, or moist, if a bacterial infection is involved. In dry gangrene, there is no infection.

Description

Gangrene is often characterized by pain followed by numbness. The infection may first go unnoticed, especially in the elderly or those individuals with a loss of sensation. The area affected by gangrene may be cold and pale, especially early in the disease. Blisters may be apparent and the patient may experience an increased heart rate and profuse sweating. As the tissue dies, the skin begins to darken. The dead tissue gradually separates and falls away from the healthy tissue.

Dry gangrene is often seen in advanced cases of diabetes and arteriosclerosis. The tissue doesn't become infected, rather it dries out and shrivels over a period of weeks or months. Wet gangrene progresses much more rapidly. The affected area becomes swollen and gives off a foul smelling discharge. Death may occur within a matter of hours or days. Fever , rapid heart rate, rapid breathing, altered mental state, loss of appetite, diarrhea, vomiting , and vascular collapse may occur as the infection progresses.

Causes & symptoms

The primary cause of gangrene is often an injury to the blood vessels, causing either an interruption of blood flow, the introduction of a bacterial infection, or both. Such injuries may include burns , infected bedsores, boils , frostbite, compound fractures , deep cuts, or gunshot wounds . Gangrene can also develop due to the poor circulation and obstructions in the blood vessels associated with abnormal blood clots , torsion of organs, and diseases such as diabetes, heart disease , and Raynaud's disease. Gangrene of the internal organs may be attributed to a ruptured appendix, internal wounds, or the complications of surgery.

The bloodstream is the body's main transport system. When blood flow is diminished, the flow of the oxygen and nutrients needed to keep tissues healthy is greatly decreased. The white blood cells needed to fight infection are not readily available. In such an environment, invading bacteria thrive and multiply quickly. Streptococcus spp. and Staphylococcus spp. are the most common agents of external skin infection.

Gas gangrene, also called progressive or clostridial myonecrosis, is a type of moist gangrene most commonly caused by an infection of Clostridium perfringens, or other species that are capable of thriving under conditions where there is little oxygen. These bacteria produce gases and poisonous toxins as they grow in the tissues. Gas gangrene

causes the death of tissue, the destruction of red blood cells, and the damaging of the walls of the blood vessels and parts of the kidneys. Early symptoms include sweating, fear, and anxiety . Gas gangrene is a life-threatening condition and should receive prompt medical attention.

Diagnosis

A diagnosis of gangrene will be based on a combination of patient history, a physical examination, blood test results, and other laboratory findings. A physician will look for a history of recent trauma, surgery, cancer , or chronic disease. Blood tests will be used to determine whether infection is present and to determine how much the infection has spread. A sample of drainage from a wound or obtained through surgery may be tested to identify the bacteria causing the infection and to aid in determining treatment. In the case of gas gangrene, the gas produced by the bacteria may be detected beneath the skin by pressing into the swollen areas. The crackling sounds of gas bubbles may also be heard in the affected area and the surrounding tissues.

X-ray studies and other imaging techniques, such as computed tomography (CT) scans or magnetic resonance imaging (MRI), may be helpful in making a diagnosis by showing evidence of gas accumulation or muscle tissue death. These techniques, however, are not sufficient alone to provide an accurate diagnosis of gangrene. Precise diagnosis often requires surgical exploration of the wound.

Treatment

Chelation therapy is a treatment that uses an intravenous solution containing the drug ethylenediamine tetra-acetic acid (EDTA), among other substances. In the bloodstream, EDTA binds and removes toxins and plaque formation on arterial walls. It promotes circulation throughout the body, and is reportedly, although not proven, able to reverse the processes leading to gangrene. Early intervention is necessary, however.

Other alternative and complementary treatments are used to treat gangrene. Herbal remedies such as goldenseal can be applied topically. Biofeedback and hypnosis can increase blood flow. Diabetics will receive herbal and traditional Chinese medicine remedies and nutritional supplements to help prevent gangrene.

Allopathic treatment

Pain medications and large amounts of intravenous antibiotics are given. Prompt surgical removal of infected and destroyed tissue is required for healing to take place. Gas gangrene is often treated with the antitoxin for clostridium as well. In a number of cases, amputation may have to be used to keep the infection under control.

In hyperbaric oxygen (HBO) therapy the patient is placed in a pressurized chamber and receives 100% pure oxygen to breathe. This has been shown useful in inhibiting the production of toxins in gas gangrene and for getting oxygen quickly to tissues, especially following a crushing injury that might lead to gangrene. HBO therapy must be carried out early in the process and used before any surgical removal. The therapy, though useful, does have adverse side effects. It requires skilled technicians and may not be widely available.

Expected results

The outcomes for gangrene are generally favorable if the infection is recognized and treated early in the progression of the disease. Left untreated, gas gangrene will result in a decrease in blood pressure, kidney failure, and coma. Overall, about 20% of those infected with gas gangrene die from the disease, and another 20% require an amputation. Gangrene is most dangerous to the elderly, those who are immuno-compromised, and those who have internal infections and chronic conditions such as diabetes. Individuals suffering from dry gangrene often have multiple health problems that complicate recovery and may prove fatal.

Prevention

Infections and injuries should be thoroughly cleaned and monitored; medical attention should be pursued if symptoms worsen or remain unresolved. Gastrointestinal wounds should be surgically explored, drained, and repaired. Use of antibiotic therapy prior to and directly following surgery has been shown to reduce the rates of infection.

Patients with diabetes or severe arteriosclerosis should take particular care of their hands and feet to avoid the decreased circulation and unchecked infection that may lead to gangrene. Any injury or infection, however slight, should be cared for promptly. There should be a focus on proper foot care, including keeping the feet clean, dry, and warm, wearing well-fitting shoes and not going barefoot. It is important to avoid smoking , since tobacco use constricts the blood vessels of the hands and feet, decreasing circulation.

Resources

BOOKS

Bunch, Bryan, ed. The Family Encyclopedia of Diseases: a Complete and Concise Guide to Illnesses and Symptoms. New York: Scientific Publishing, Inc., 1999.

The Burton Goldberg Group Alternative Medicine: The Definitive Guide. Tiburon, CA: Future Medicine Publishing, 1993.

OTHER

drkoop.com http://www.drkoop.com/conditions/foot_care/library/gangrene.asp.

drkoop.com http://www.drkoop.com/conditions/ency/article/000620.htm.

The Merck Manual http://www.merck.com/pubs/mmanual/section21/chapter292/292a.htm.

Patience Paradox

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gangrene

gangrene, local death of body tissue. Dry gangrene, the most common form, follows a disturbance of the blood supply to the tissues, e.g., in diabetes, arteriosclerosis, thrombosis, or destruction of tissue by injury. A second type, moist gangrene, results from an invasion of toxin-producing bacteria that destroy tissue. Gangrene usually affects an arm or leg, but it may occur anywhere, e.g., pulmonary gangrene may follow an abscess of the lung. Treatment of gangrene includes rest and the administration of antibiotics if the gangrene is moist and bacterial invasion is present. Excision of the diseased portions of the body may be necessary and, in advanced involvement, amputation of the part. In gas gangrene, which results from the invasion of wounds by anaerobic bacteria, gas forms under the skin and a watery exudate is produced. Emergency treatment with penicillin and antitoxin is needed; without treatment, gas gangrene is invariably fatal.

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"gangrene." The Columbia Encyclopedia, 6th ed.. 2016. Encyclopedia.com. 30 Jul. 2016 <http://www.encyclopedia.com>.

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Gangrene

Gangrene

What Is Gangrene?

How Do Doctors Diagnose and Treat Gangrene?

Can Gangrene Be Prevented?

Resource

Gangrene (GANG-green) is the decay or death of living tissue caused by a lack of oxygen supply to the tissue and/or bacterial infection of the tissue.

KEYWORDS

for searching the Internet and other reference sources

Clostridium perfringens

Debridement

Frostbite

Hyperbaric chamber

What Is Gangrene?

Gangrene is not a contagious disease. It is a condition in which living tissue (e.g., skin, muscle, or bone) begins to decay and die because blood flow (and oxygen) to an area is blocked or because harmful bacteria invade the bodys tissues after entering through a wound or sore. Gangrene most commonly affects the feet, toes, hands, and fingers. Gangrene can also occur inside the body in abdominal organs such as the intestines.

Doctors recognize three major forms of gangrene: dry, wet, and gas gangrene.

Dry gangrene

Dry gangrene is the most common form of gangrene, and it occurs most frequently in the feet of people with diabetes*. Dry gangrene results from the gradual loss of blood supply to a part of the body. The tissue slowly dies because it receives little or no oxygen and nutrients from the blood, but it does not become infected. The first symptoms of dry gangrene are often numbness and tingling in the affected area. This is usually followed by severe pain as the condition progresses and the tissue begins to die; the skin temperature drops, and the color of the tissue changes, eventually turning black.

*diabetes
(dye-uh-BEE-teez) is a condition in which the bodys pancreas does not produce enough insulin or the body cannot use the insulin it makes effectively, resulting in increased levels of sugar in the blood. This can lead to increased urination, dehydration, weight loss, weakness, and a number of other symptoms and complications related to chemical imbalances within the body.

Dry gangrene is most often a complication of diabetes, arteriosclerosis*, or frostbite*. Because this condition usually develops gradually, it may go unnoticed for weeks or months, especially in elderly people. Dry gangrene usually is not life threatening, but it needs to be treated promptly.

*arteriosclerosis
(ar-teer-e-o-sklah-RO-sis) is a condition in which arteries of the body have become narrowed and hardened from the buildup of calcium, cholesterol, and other substances, causing decreased blood flow through these vessels.
*frostbite
is damage to tissues resulting from exposure to low environmental temperatures. It is also called congelation (kon-jeh-LAY-shun).

Wet gangrene

Wet gangrene is caused by a bacterial infection from severe wounds or burns or by a crushing injury that causes blood to stop flowing to a certain part of the body. When blood flow stops, bacteria begin to invade the damaged tissue. In wet gangrene, there is pain, swelling, and blistering of the skin, and the wound gives off a foul smell. Organisms that are commonly involved in wet gangrene include Streptococcus (strep-tuh-KAH-kus) and Staphylococcus (stah-fih-lo-KAH-kus) bacteria. Without treatment, wet gangrene can be fatal.

People with poor circulation may experience dry gangrene from loss of oxygen and nutrients carried by blood to the extremities. If the tissue turns black and dies, it must be removed surgically. Photo Researchers, Inc

Gas gangrene

Gas gangrene, which is a form of wet gangrene, involves infection of body tissue by certain types of bacteria (such as Clostridium perfringens, klah-STRIH-de-um per-FRING-enz) that are capable of thriving in anaerobic (ah-nuh-RO-bik) conditions (in which there is little or no oxygen). Once present in the tissue, these bacteria release toxins* and gas. Gas gangrene is marked by a high fever, brownish pus*, gas bubbles under the skin, skin discoloration, and a foul odor. It is the rarest form of gangrene, and only 1,000 to 3,000 cases occur in the United States each year. Like wet gangrene, gas gangrene can be fatal if not treated immediately.

*toxins
are poisons that harm the body.
*pus
is a thick, creamy fluid, usually yellow or greenish in color, that forms at the site of an infection. Pus contains infection-fighting white cells and other substances.

How Do Doctors Diagnose and Treat Gangrene?

A doctor will make the diagnosis of gangrene based on a physical examination, the patients medical history, and the results of blood and other laboratory tests. Cultures from the gangrenous area may be taken and laboratory tests performed to identify the type of bacterial infection and determine the extent to which an infection has spread.

Dead gangrenous tissue must be removed surgically by a procedure called debridement (deh-BREED-ment) so that the wound can heal and healthy new tissue can grow. People with gangrene caused by bacterial infections are treated with antibiotics. In more severe cases, amputation* of a finger, toe, or part of a limb may be necessary. Sometimes patients with gangrene are treated in a hyperbaric chamber, where they are exposed to oxygen at a high pressure to help the affected tissue heal.

*amputation
(am-pyoo-TAY-shun) is the removal of a limb or other appendage or outgrowth of the body.

The outcome for gangrene is usually favorable if the condition is recognized and treated early. Full recovery and new tissue growth can take several weeks to months. Sepsis, a potentially serious spread of infection through the bloodstream and body, can result from wet and gas gangrene. If left untreated, sepsis can result in shock* or death.

*shock
is a serious condition in which blood pressure is very low and not enough blood flows to the bodys organs and tissues. Untreated, shock may result in death.

Can Gangrene Be Prevented?

Carefully cleaning and watching wounds for signs of infection can help prevent gangrene. It is wise to seek medical attention for any wounds that are not healing well or look infected. People who are susceptible to dry gangrene, such as those with decreased circulation in their legs and feet from diabetes or arteriosclerosis, are advised to pay attention to any skin infection in those areas (because such infections could lead to the development of wet gangrene) and to avoid smoking (because smoking constricts the blood vessels, further decreasing circulation). Daily foot care and hygiene is very important in people with advanced diabetes. Treatment with antibiotics before and after abdominal surgery has been shown to reduce the rate of infection and the possibility of developing wet or gas gangrene.

See also

Sepsis

Staphylococcal Infections

Streptococcal Infections

Resource

Organization

U.S. National Library of Medicine, 8600 Rockville Pike, Bethesda, MD 20894. The National Library of Medicine has a website packed with information on diseases (including gangrene) and drugs, consumer resources, dictionaries and encyclopedias of medical terms, and directories of doctors and helpful organizations.

Telephone 888-346-3656 http://www.nlm.nih.gov

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gangrene

gangrene (gang-reen) n. death and decay of part of the body due to deficiency or cessation of blood supply. The causes include disease, injury, or atheroma in major blood vessels, frostbite or severe burns, and diseases such as diabetes mellitus and Raynaud's disease. dry g. death and withering of tissues caused simply by a cessation of local blood circulation. moist (or wet) g. death and putrefactive decay of tissue caused by bacterial infection. See also gas gangrene.

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gangrene

gan·grene / ˈganggrēn; gangˈgrēn/ • n. Med. localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection. • v. [intr.] become affected with gangrene. DERIVATIVES: gan·gre·nous / ˈganggrənəs/ adj.

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gangrene

gangrene XVI. — F. gangrène — L. gangræna — Gr. gággraina.
Hence gangrenous XVII.

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gangrene

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