Gangrene (गैंग्रीन) — MBBS/MD Level Clinical Guide
Contents (Jump to)
1) Definition & Types 2) Causes & Risk Factors 3) Pathogenesis & Pathology 4) Symptoms & Clinical Features 5) Diagnosis & Tests (Algorithms) 6) Treatment Overview 7) Antibiotics — Full Adult Dosing 8) Ischemic Gangrene & Revascularization 9) Surgical Management 10) Wound Care, Dressings & HBOT 11) Supportive Medicines 12) Diet, Avoiding & Recommended Foods 13) Prevention & Foot Care 14) Complications & Prognosis 15) FAQ 16) Internal Links (Related Guides) 17) Disclaimer1) Definition & Types
Gangrene का अर्थ है ऊतकों (tissues) की मृत्यु (necrosis) जो रक्त-संचार के कम/रुक जाने (ischemia), संक्रमण (infection) या दोनों के संयुक्त प्रभाव से होती है। त्वचा, सबक्यूटेनियस टिशू, मसल, यहाँ तक कि आंत जैसे आंतरिक अंग भी प्रभावित हो सकते हैं।
मुख्य प्रकार
- Dry gangrene: शुष्क, काला/भूरा, स्पष्ट demarcation; प्रायः chronic ischemia/atherosclerosis/diabetes से; दर्द प्रारम्भ में, बाद में sensation कम।
- Wet gangrene: संक्रमण सहित necrosis; सूजन, बदबू, discharge; systemic toxicity का खतरा अधिक — surgical emergency।
- Gas gangrene (Clostridial myonecrosis): Clostridium perfringens/novyi/septicum आदि; तीव्र दर्द, crepitus, systemic toxicity, muscle necrosis; तेजी से life-threatening — immediate surgery + toxin-suppressive antibiotics + supportive care।
- Fournier's gangrene: perineal/genital necrotizing infection — बहु-जीवाणु (polymicrobial), तीव्र progression, high mortality — emergent debridement + broad-spectrum antibiotics।
- Internal gangrene: जैसे bowel gangrene (mesenteric ischemia), gallbladder (emphysematous cholecystitis) — abdominal pain/sepsis के साथ।
- Mummification: prolonged ischemia से सूखा, काला, shriveled भाग; auto-amputation तक हो सकता है (पर संक्रमण का खतरा बना रहता है)।
2) Causes & Risk Factors
Common causes
- Atherosclerosis/Peripheral arterial disease (PAD), acute arterial thrombosis/embolism
- Diabetes mellitus (neuropathy + micro/macroangiopathy) — Hypertensionव dyslipidemia के साथ जोखिम ↑
- Severe infection/necrotizing fasciitis; Clostridial contamination of wounds
- Trauma, crush injury, tight casts/bandages, compartment syndrome
- Frostbite, burns, radiation injury, vasculitis, smoking/ergot poisoning
- Venous gangrene (phlegmasia cerulea dolens) in massive DVT — देखें: Deep Vein Thrombosis Guide
Risk factors
- Uncontrolled nutritionissues (obesity, poor protein intake), smoking, age
- Peripheral neuropathy (diabetes, alcoholism), immobility/pressure
- Immunosuppression (steroids, chemotherapy, HIV/AIDS)
- Cardiac failure/low-flow states — diet ref: Heart Failure Diet
3) Pathogenesis & Pathology
Ischemic cascade
Arterial inflow में कमी ⇒ hypoxia ⇒ aerobic से anaerobic metabolism ⇒ lactic acidosis, ATP depletion ⇒ Na⁺/K⁺-ATPase failure ⇒ cellular swelling, Ca²⁺ influx ⇒ mitochondrial damage, ROS generation ⇒ membrane lipid peroxidation ⇒ necrosis. Reperfusion से ROS surge और neutrophil-mediated injury बढ़ता है।
Infective (wet/gas) pathogenesis
Polymicrobial (Gram-negative, anaerobes) या clostridial toxins (α-toxin lecithinase) मसल-नेक्रोसिस, hemolysis, shock पैदा करते हैं। Tissue planes में rapid spread; gas production (H₂/CO₂) से crepitus व radiological gas shadows दिखते हैं।
Pathology
- Dry: coagulative necrosis with mummification; minimal bacterial load.
- Wet: liquefactive changes, edema, heavy bacterial burden, thrombosed vessels.
- Gas: muscle pallor to dish-water fluid; myonecrosis; Gram stain—Gram-positive rods बिना leukocytes (toxin-mediated leukostasis).
4) Symptoms & Clinical Features
Local features
- Color change: pale→dusky→black; blistering/bullae (wet)
- Severe pain (disproportionate to exam) early; later anesthesia (nerve death)
- Swelling, foul smell, purulent/serosanguinous discharge (wet)
- Crepitus (gas) on palpation; rapidly advancing skin discoloration
- Absent/weak distal pulses (ischemic), low ABPI
Systemic signs
- Fever, tachycardia, hypotension, sepsis/organ dysfunction
- Leukocytosis/left shift; raised CRP/Procalcitonin
Red flags: rapidly progressive pain/swelling, crepitus, systemic toxicity, skin anesthesia with severe pain earlier — necrotizing soft-tissue infection (NSTI) का संदेह; तत्काल surgical exploration/debridement आवश्यक।
5) Diagnosis & Tests (Algorithms)
Bedside/initial
- Vitals & sepsis screen; resuscitation शुरू करें (ABC)
- ABPI (Ankle–Brachial Pressure Index) — PAD/ischemia का संकेत
- Bedside Doppler for pulses; capillary refill, temperature gradient
Laboratory
- CBC, CRP/ESR, Procalcitonin
- RFT/LFT, electrolytes, lactate, blood glucose (diabetes control)
- Blood cultures (if sepsis), wound swab/tissue culture post-debridement
- Coagulation profile (heparin planning), blood group & crossmatch
Imaging
- Plain X-ray: soft tissue gas, bone involvement (osteomyelitis)
- Doppler USG: arterial flow assessment; venous DVT screening यदि edema/venous congestion
- CTA/MRA: arterial occlusion level, collateral circulation — revascularization planning
- MRI: extent of fasciitis/myonecrosis; osteomyelitis delineation
Diagnostic algorithm (practical)
- Suspect NSTI/gas gangrene? → Immediate broad-spectrum IV antibiotics + emergent surgical exploration (delay mortality बढ़ाता है) → tissue for Gram stain/culture.
- Predominant ischemic limb? → Heparinization (if not contraindicated) + urgent vascular imaging (CTA/Doppler) → revascularization (thrombectomy/thrombolysis/bypass/angioplasty) योजना।
- Diabetic foot (wet) without systemic toxicity? → Debridement + targeted antibiotics; offloading + glycemic optimization; osteomyelitis rule-out।
6) Treatment Overview
- Resuscitation: IV fluids, analgesia, glycemic control, broad-spectrum antibiotics (NSTI/gas/wet)
- Source control: Early and adequate debridement (repeat/serial as needed)
- Ischemia management: heparin, thrombolysis/angioplasty/bypass; compartment syndrome में fasciotomy
- Advanced cases: amputation (life over limb dictum), then rehabilitation & prosthesis planning
- Adjuncts: negative pressure wound therapy (NPWT), hyperbaric oxygen (selected), optimized nutrition
7) Antibiotics — Full Adult Dosing (Empiric → Targeted)
डोजिंग सामान्य वयस्कों हेतु है; renal/hepatic dysfunction, pregnancy, drug–drug interactions (जैसे digoxin) और स्थानीय गाइडलाइन के अनुसार समायोजन आवश्यक है।
Necrotizing soft-tissue infection / Gas-Wet gangrene (empiric)
| Regimen (choose one base) | Typical adult dose | Add-ons / Notes |
|---|---|---|
| Piperacillin–Tazobactam | 4.5 g IV every 6–8 h (extended infusion preferred) | ± Clindamycin 900 mg IV q8h (toxin suppression for strep/clostridia); ± Vancomycin (15–20 mg/kg IV q8–12h; trough-guided) यदि MRSA जोखिम |
| Meropenem | 1 g IV every 8 h | + Clindamycin 900 mg IV q8h; ± Vancomycin as above |
| Imipenem–Cilastatin | 500 mg IV every 6 h | + Clindamycin; MRSA कवरेज आवश्यकतानुसार |
Duration: source control और clinical response पर; अक्सर 10–14 दिन या अधिक; de-escalate करें culture/susceptibility के अनुसार।
Targeted scenarios
| Pathogen/situation | Example regimen | Notes |
|---|---|---|
| Clostridial gas gangrene | Penicillin G 4 MU IV q4h + Clindamycin 900 mg IV q8h | Clindamycin toxin inhibition के लिए महत्वपूर्ण; surgery अनिवार्य |
| MRSA suspected/confirmed | Vancomycin (15–20 mg/kg IV q8–12h, trough-guided) या Linezolid 600 mg IV/PO q12h | Renal dosing/monitoring; linezolid—myelosuppression risk |
| Diabetic foot moderate–severe (polymicrobial) | Pip-Tazo 4.5 g q6–8h या Ertapenem 1 g IV q24h (no Pseudomonas) ± MRSA कवरेज | Osteomyelitis हो तो लंबा कोर्स (4–6 हफ्ते) और surgical debridement |
Glycemic control: insulin infusion/ basal–bolus protocols से glucose 140–180 mg/dL टार्गेट करें—wound healing बेहतर होता है। देखें: Complete Nutrition Guide.
8) Ischemic Gangrene & Revascularization
Acute limb ischemia — immediate steps
- Systemic unfractionated heparin (if no contraindication): bolus 80 U/kg IV → infusion 18 U/kg/h; aPTT-guided titration
- Analgesia, limb low and straight (dependent position), keep warm; avoid tight dressings
- Urgent vascular consult; CTA/Doppler to locate occlusion
Revascularization options
- Endovascular: catheter-directed thrombolysis (alteplase/urokinase), angioplasty ± stenting
- Surgical: thromboembolectomy (Fogarty), bypass graft (fem-pop/tibial), endarterectomy
- Compartment syndrome: fasciotomy (4-compartment leg) if pressures high/ischemia-reperfusion swelling
Antiplatelet/vascular meds (post-revasc/chronic PAD)
- Aspirin 75–150 mg OD या Clopidogrel 75 mg OD (GI risk देखें; PPI यदि ज़रूरी)
- Statin (high intensity, e.g., Atorvastatin 40–80 mg OD) — plaque stabilization
- BP/Diabetes/Smoking control — संबंधित गाइड: Hypertension
9) Surgical Management
Debridement principles
- Early, aggressive, and repeated debridement until only viable tissue remains
- Send tissue for Gram stain/culture/histopathology
- Hemostasis, irrigation (saline), avoid primary closure in contaminated wounds
Amputation — indications & levels
- Nonviable limb, life-threatening sepsis, irreversible ischemia, intractable pain
- Levels: toe/ray → transmetatarsal → below-knee (BKA) → above-knee (AKA); adequate perfusion for stump healing आवश्यक (transcutaneous oxygen/skin perfusion pressure)
Reconstruction
- Split-thickness skin grafts, local/regional flaps once clean granulating bed achieved
- NPWT to optimize granulation, manage exudate
Fournier's gangrene pearls
- Wide debridement of necrotic fascia; urinary/fecal diversion if required
- ICU care, broad-spectrum antibiotics, fluid resuscitation
10) Wound Care, Dressings & Hyperbaric Oxygen
- Clean with saline; avoid cytotoxic antiseptics on viable tissue routinely
- Dressings: alginate (exudative), hydrofiber, foam; silver-impregnated for high bioburden
- Offloading (diabetic foot): total contact cast/boot; podiatry care
- HBOT (Hyperbaric oxygen): selected refractory clostridial/diabetic foot cases as adjunct; surgery/antibiotics replace नहीं करते
- Tetanus toxoid/Ig per wound status & immunization history
11) Supportive Medicines (Adult Typical Dosing)
| Indication | Drug & Dose | Notes |
|---|---|---|
| Pain/fever | Paracetamol 500–1000 mg PO/IV q6h PRN (max 3–4 g/day) | Hepatic disease में ceiling कम करें; NSAIDs केवल renal/GI risk आकलन के बाद |
| Severe pain | Tramadol 50–100 mg q6–8h PRN; Morphine titrated IV/PO under monitoring | Renal dose adjust; constipation prophylaxis |
| Anticoagulation (ALI/DVT) | UFH bolus 80 U/kg → 18 U/kg/h infusion (aPTT target); या Enoxaparin 1 mg/kg SC q12h | Bleeding risk & renal function देखें; DVT गाइड लिंक ऊपर |
| Glycemic control | Basal–bolus insulin regimen per glucose; correction scale | Target 140–180 mg/dL inpatient |
| Ulcer prophylaxis (ICU/major surgery) | Pantoprazole 40 mg IV/PO OD | Indication-based use |
12) Diet, Avoiding & Recommended Foods
Wound healing और संक्रमण से recovery के लिए उच्च-गुणवत्ता प्रोटीन, पर्याप्त ऊर्जा, और चयनित माइक्रोन्यूट्रिएंट्स ज़रूरी हैं। विस्तृत पोषण संदर्भ हेतु: Complete Medical Nutrition Guide.
Recommended
- Protein 1.2–1.5 g/kg/day (renal/hepatic अनुसार समायोजन) — दालें, चना/राजमा, अंडा, पनीर/दूध, चिकन/मछली, सोया/टोफू
- Vitamin C & antioxidants: अमरूद/साइट्रस — Guava benefits
- Zinc: कद्दू बीज, नट्स, दालें — घाव भरने में सहायक
- Energy-dense whole foods: मिलेट्स/ओट्स/ब्राउन राइस; हेल्दी फैट्स (MUFA/PUFA)
- Probiotic dairy (दही/छाछ) यदि सहन हो; फाइबर संतुलित रखें
- सूखे मेवे: Anjeer (Fig) — आयरन/फाइबर
- Potassium-rich recovery snacks: Banana benefits
Avoid / Limit
- Uncontrolled sugar (poor glycemic control → wound healing खराब)
- Excess salt in heart/renal comorbids — Low-sodium strategies
- Alcohol, smoking (vasoconstriction, immunity ↓)
- Raw/undercooked meat/seafood in immunocompromised
- अनुचित high-dose supplements बिना लैब/डॉक्टर सलाह
एंटीइन्फ्लेमेटरी फाइटोन्यूट्रिएंट्स: प्याज़/Allium — Onion health guide.
13) Prevention & Foot Care (Diabetes/PAD)
- Daily foot inspection; proper footwear; callus/corn care by trained podiatry
- Keep feet clean, dry; moisturize but avoid webspace maceration
- Toenail care (straight cut), avoid barefoot walking
- Prompt treatment of minor wounds; offloading for ulcers
- Smoking cessation; BP, lipids, glucose control — देखें: Hypertension Guide
- Vaccination (tetanus updated); in immunocompromised, infection vigilance — संदर्भ: HIV / AIDS
14) Complications & Prognosis
- Sepsis, septic shock, multiorgan dysfunction
- Osteomyelitis, chronic nonhealing ulcers
- Amputation-related disability, phantom limb pain
- Recurrent ischemia if risk factors uncontrolled
Prognosis source control, perfusion restoration, comorbids optimization और प्रारम्भिक हस्तक्षेप पर निर्भर है। Delay mortality significantly बढ़ा देता है।
15) FAQ
क्या हर काले पड़े पैर में अम्प्यूटेशन आवश्यक है?
नहीं। Dry gangrene में demarcation/auto-amputation का इंतज़ार किया जा सकता है यदि infection नहीं है और pain manageable है; पर vascular assessment आवश्यक है। Wet/gas gangrene में early debridement/अम्प्यूटेशन life-saving हो सकता है।
Hyperbaric oxygen (HBOT) सभी में देना चाहिए?
नहीं। HBOT एक adjunct है — चयनित refractory clostridial/diabetic foot केसों में लाभ; surgery/antibiotics का विकल्प नहीं।
Antibiotics कितने दिन?
Source control, clinical response और culture report पर निर्भर: NSTI में आमतौर पर 10–14 दिन; osteomyelitis में 4–6 सप्ताह तक।
Diabetes कैसे मैनेज करें?
Inpatient में insulin-based protocols; discharge पर individualized plan; Nutrition व low-GI strategies के लिए Nutrition guide देखें।
16) Internal Links — Related Guides on Mahfooz Medical Health
- Complete Medical Nutrition Guide (5000+ words)
- Heart Failure Diet — Complete Guide & Menu
- Hypertension — MBBS/MD Guide
- Deep Vein Thrombosis — MBBS/MD Guide
- Fever — Pathogenesis, Workup & Supportive Medicines
- HIV — Comprehensive Medical Guide & AIDS — OI Dosing
- Biotin Deficiency — Hair/Nails
- Epistaxis — Bleeding/Clotting Basics
- Onion (Allium cepa) — Anti-inflammatory, Guava — Vitamin C, Banana — Potassium, Anjeer — Fiber/Iron
- Medical Health Guide — Body Font Family (Design)