Gangrene Of The Leg With Diabetes Mellitus - Symptoms And Treatment

2024 Author: Josephine Shorter | [email protected]. Last modified: 2024-01-07 17:49

Gangrene of the leg with diabetes mellitus

Patients suffering from diabetes mellitus often experience negative anatomical and functional changes throughout the body. This is due to the fact that in such patients metabolism is disturbed and oxygen starvation of soft tissues occurs due to deterioration of blood circulation. Lack of nutrition in the areas of the limbs leads to their degradation and death, gangrene is formed. And since the legs are most stressed, they suffer most often.

Disturbances of microcirculation and vascular trophism of the lower extremities do not occur immediately, they develop 15-20 years after the onset of the disease. Gangrene of the legs appears in about 10% of patients with diabetes mellitus, another 40-50% of patients have prerequisites for the occurrence of necrotic changes, but they can be avoided with proper therapy and prevention.

The insidiousness of this type of gangrene is that the patient may not notice the first stages of the disease due to the decreased sensitivity of the tissues. When pathological changes become apparent, in most cases it is already difficult to return the previous functions of the limb in full. Then the question of amputation of a part of the limb is raised to save the patient's life, but often death cannot be prevented even by surgical methods.

Content:

• How does diabetic gangrene of the extremities arise?
• Forms of limb gangrene and their symptoms
• Diagnosis of limb gangrene
• Gangrene treatment methods
• How to prevent the development of gangrene in diabetes mellitus?

How does diabetic gangrene of the extremities arise?

Diabetic gangrene syndrome results from a complex of factors:

• Angiopathy - changes in blood vessels due to long-term hyperglycemia (elevated blood sugar), expressed in a decrease in the elasticity of blood vessels and impaired patency, as well as in increased blood viscosity;
• Neuropathy - changes in peripheral nerves, leading to impaired innervation, loss of tissue sensitivity;
• Infection - the introduction of pathogenic microflora (clostridia, staphylococcus, streptococcus, colibacteria) into wounds and ulcers on the skin of the limbs.

Due to a violation of protein metabolism, the mobility of the joints decreases, the bones of the lower extremities are deformed. These changes lead to increased stress on the foot. Due to the fact that the body's natural defense in the form of local immunity is reduced or completely absent, any microtrauma (bruise, abrasion, abrasion, crack, cut) leads to the appearance of non-healing ulcers. The accession of the infection promotes tissue necrosis, the spread of the process to muscles, bones, ligaments, subcutaneous fatty tissue.

Factors that increase the risk of gangrene in patients with diabetes mellitus:

• Hypertension, ischemic disease, history of atherosclerosis;
• Alcohol abuse, smoking;
• Damage to the tissues of the feet - ingrown toenail, foot and nail fungus, calluses, cracked heels;
• Failure to comply with basic hygiene for foot care;
• Incorrectly fitted shoes;
• Burns and frostbite;
• Obliterating endarteritis, which causes blood clots;
• Bedsores arising in bedridden patients.

Decreased general immunity, excess weight increase the chances of a diabetic patient to develop gangrene.

Forms of limb gangrene and their symptoms

At the initial stage of the pathological process, it is very difficult to determine the development of gangrene. Distinguish between ischemic, neuropathic and mixed forms of the disease, each of which has its own symptoms. At the beginning of the disease, there are no ulcers, but there are deformations of the epidermis in the form of corns, keratosis and other damage.

Stages of gangrene development:

• Superficial ulcers appear on the skin.
• Deep ulcers involve not only the skin, but also muscles, tendons, subcutaneous tissue, not reaching the bones.
• Deep ulcers invade the bones.
• Gangrene occupies a limited area.
• Gangrene occupies a vast area.

At the heart of ischemic gangrene is damage to the blood vessels that cause circulatory disorders. The neuropathic form arises from damage to the nervous apparatus.

Symptoms of the ischemic form of the disease:

• Pain in the legs when walking (at the beginning of the disease, the patient can pass up to 1 km before the onset of pain, at the second stage - up to 200 m, at 3 stages - less than 200 m or at rest, at 4 stages there is necrosis of the fingers)
• Persistent leg swelling;
• Intermittent claudication;
• Lack of pulsation in the arteries;
• The skin of the affected leg is pale and cold, with areas of hyperpigmentation;
• Ulcers with a black bottom appear at the site of damage.

Since dry necrosis is manifested in ischemic form, exudate is not released. In the future, the affected areas dry out, "mummify", and may even fall off spontaneously.

If an infection joins, the inflammatory process develops rapidly, leading to edema, severe pain. There are almost no boundaries between the gangrenous and healthy areas. This complication quickly leads to sepsis and, in many cases, death.

Symptoms of the neuropathic form of gangrene in diabetes mellitus:

• Burning sensation in the feet, feeling of running "goose bumps", mild pain in the legs at night, typical in the initial stage of the disease;
• The skin is warm and dry, and dark spots appear on it;
• The nails are thickened;
• Thermal, tactile, pain sensitivity is reduced;
• The edges of the ulcers that appear are swollen and hyperemic;
• Interstitial fluid accumulates under the skin;
• The pulsation in the arteries is preserved;
• The toes become hooked, the heads of their bones protrude;
• The joints of the legs become swollen and deformed.

In the later stages of the development of the disease, severe pain appears, a smell of decay appears, the temperature rises, and blood pressure drops. The pain is not relieved even by the most powerful analgesics, there are convulsions, trembling of the limbs, delirium.

Diagnosis of limb gangrene

Timely detection of changes in the skin of the foot is very important. For this, a patient with diabetes should regularly conduct self-examination of the extremities. In addition to an endocrinologist, you need to undergo preventive examinations with a vascular surgeon, orthopedist. The doctor examines the limbs, evaluates their reflexes, sensitivity to touch, temperature effects, vibration.

Laboratory tests in the diagnosis of gangrene:

• Study of blood glucose and hemoglobin levels;
• Blood test for cholesterol and lipoprotein levels;
• Analysis of urine for the content of sugar and ketone bodies;
• Bacterial inoculation of the discharge from the ulcer into the microflora.

Instrumental diagnostic methods:

• USDG of the vessels of the legs;
• X-ray contrast angiography;
• X-ray of the foot;
• Ultrasound with densitometry;
• Peripheral CT arteriography.

Gangrene treatment methods

The main directions of therapy for gangrenous process of the lower extremities:

• Lowering blood sugar by adjusting the dosage of insulin;
• Antiseptic treatment of wounds using antibacterial drugs;
• Systemic drug therapy;
• Unloading the affected leg - using crutches, a gurney, special shoes and insoles;
• Lowering blood pressure with diuretics, calcium antagonists, ACE inhibitors, beta-blockers.

Systemic therapy drugs:

• Improving blood circulation - Trental, Actovegin, Reopligluken, Vasaprostan;
• Dissolution of blood clots - Heparin;
• Relief of spasms - Drotaverine, Papaverine;
• Improving immunity - multivitamin complexes.

The rapid spread of the infection, the lack of effect from conservative treatment is a reason for surgical intervention.

For this, not only amputation is used, there are other methods in the arsenal of modern vascular and general surgery:

• Peripheral artery stenting;
• Endovascular dilatation;
• Arterialization of the veins of the foot;
• Autodermoplasty to close a large area of the wound;
• Drainage of emerging abscesses;
• Thromboembolectomy.

At the same time, antibacterial therapy, treatment with hormone-based anti-inflammatory drugs, diuretics are carried out. The radical measure - removal of toes, feet, or shins - is used as a last resort. This need arises in 12-25% of cases in the later stages of the disease.

How to prevent the development of gangrene in diabetes mellitus?

In order to prevent the appearance of wounds or ulcers on the legs, it is important to carefully care for the feet, avoid injuring them, wear high-quality shoes, orthopedic insoles. The patient must definitely control glucose levels, follow a diet, and regularly use medications.

Socks and tights should contain a minimum amount of synthetic materials. In hot weather, shoes are regularly washed, dried and changed. Feet is often washed in cool water and examined for microtrauma and cracks between the toes.

In case of diabetes mellitus, it is important to be attentive to your health, to observe preventive measures.

The author of the article: Volkov Dmitry Sergeevich | c. m. n. surgeon, phlebologist

Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma from the Educational and Scientific Medical Center of the Presidential Administration of the Russian Federation.