Understanding gangrene and its life-threatening impact

The dreaded word “gangrene” must be familiar to many patients suffering from diabetes and their caretakers. It essentially means the death of a part of the limb or organ. Diabetics are a very high risk group for this deadly condition. Nearly one in four diabetics has some degree of block in their arterial circulation and is at risk of developing gangrene. Most patients are unaware of the severity of the problem and tend to ignore it until it is too late. Gangrene is actually the culmination of a biological process which has been happening in the body probably for years. Unfortunately, removing the gangrenous part of the finger or toe is not the solution as it only worsens the situation. This is because the gangrene or death of the organ occurs due to a blockage in the arterial circulation of the organ or the limb as it prevents an adequate supply of oxygen and other nutrients from reaching this part of the body. The further the organ is from the heart, the higher is the risk to develop gangrene. That is why it is often seen in the tips of toes. The true solution is to somehow unblock the impediment to the circulation and restore the path for blood and oxygen to reach the organ.
Epidemiological research has now substantially established that India is one of the leading countries with regards to population suffering from diabetes. Smoking which is very prevalent in almost all societies of India, augments the problems caused by diabetes. Diabetes, high blood pressure, and high cholesterol in addition to smoking and a sedentary lifestyle increase manifold the chances of having a heart attack or stroke. Gangrene of the toes or fingers is actually similar and can be described as “an attack of the leg or hand”. This is because if not recognized timely and treated correctly, it may ultimately be a limb and life threatening condition. Amputation does not always stop at the toe.  Most patients eventually require an above knee amputation which increases the risk of fatality arising out of heart attack, pneumonia or wound healing problems. Studies have shown that after an amputation, 30% patients die in the first year after operation, 30% require an amputation of the other limb and only 30% remain ambulant.
What is also known is that diabetes is only one of the causes of gangrene. Smoking is the second largest cause, especially in young men even as young as age 30. A condition called Thromboangiitis obliterans (TAO) or Buerger’s disease is very much prevalent in India and other countries like Japan. It has been proved that the nicotine content in cigarettes and bidis is responsible for a chemical reaction which slowly destroys all the arteries and nerves of the body. Unfortunately, in India though there are awareness campaigns emphasizing that smoking causes cancer and impotence, it has not been stressed enough in media that smoking also causes gangrene.
In South India, thanks to efforts made by Government hospitals like Rajiv Gandhi Govt General Hospital, NGOs like Madras Diabetes Research Foundation and private hospitals like Christian Medical CollegeHospital Vellore and Bhagwan Mahavir Jain Hospital Bangalore, awareness is catching on. Patients are identified and many receive timely treatment which prevents amputations. However, the rest of the country still lags behind in awareness of the burden of disease and the resources available for treatment.
Treatment of gangrene to avoid a life-altering amputation is very much possible. However, timely recognition and proper referral to a centre with appropriate resources and dedicated vascular / cardiovascular specialist is essential.  General practitioners should avoid amputation of toes or the gangrenous segment if the peripheral pulses are absent / feeble as it only results in progression of gangrene. They should encourage the patient to go to a specialist as a limb and life threatening emergency.
Options available for treatment include open bypass surgery, endovascular options like balloon-plasty and stenting and ‘hybrid’ options (where both open surgery and endovascular ballooning are done in the same sitting). In angioplasty, a balloon is introduced from a puncture in the groin and used to open the block from within the artery. Sometimes, a stent is required to make sure that the artery stays open. Additionally, patients need to be on lifelong medications like aspirin and lifestyle management.
The results of these procedures are good and if adopted timely, prevents the trauma of amputation and helps in saving many limbs and lives.

Figure A. A picture showing gangrene of the left third toe in a 30 year old smoker. He required a bypass operation to save his leg.

Figure B. A picture showing blackish discolouration of the tip of his right great toe (pre-gangrene)in a 50 year old diabetic male patient. He improved after angioplasty of his arteries and did not require amputation.