Gangrene is a complication of necrosis characterized by the decay of body tissues. Results from ischemia, infection, or trauma (or a combination of these processes).
Two main categories: infectious gangrene (which includes necrotizing fasciitis and gas gangrene) and ischemic gangrene (which can arise from arterial or venous obstruction).
Risk factors include diabetes, smoking, atherosclerosis, renal disease, drug and alcohol abuse, malignancy, trauma or abdominal surgery, contaminated wounds, malnutrition, hypercoagulable states, prolonged use of tourniquets, and community-acquired MRSA.
Successful treatment of infectious gangrene requires early recognition and a combination of aggressive surgical debridement, appropriate intravenous antibiotics, and intensive supportive care.
Ischemic gangrene requires revascularization for obstruction and thromboembolism, along with optimal treatment of any underlying disease. Measures to prevent superimposed infection must also be performed.
Prognosis is highly variable, but can involve significant morbidity and mortality.
Gangrene is a complication of necrosis characterized by the decay of body tissues. There are two major categories: infectious gangrene (wet gangrene) and ischemic gangrene (dry gangrene). The condition may result from ischemia, infection, or trauma (or a combination of these processes). Ischemia may result from either arterial or venous compromise, and may be an acute or chronic process (or a combination of both). Critically insufficient blood supply is the most common cause of gangrene, and is often associated with diabetes and long-term smoking.
History and exam
Key diagnostic factors
- edema or swelling
- skin discoloration
- crepitus (gas gangrene)
Other diagnostic factors
- diminished pedal pulses and ankle-brachial index (ischemic gangrene)
- low-grade fever and chills (infectious gangrene)
- diabetes mellitus
- atherosclerosis (ischemic gangrene)
- smoking (ischemic gangrene)
- renal disease
- drug and alcohol abuse
- trauma or abdominal surgery (infectious gangrene)
- contaminated wounds (infectious gangrene)
- immunosuppression (infectious gangrene)
- malnutrition (infectious gangrene)
- hypercoagulable states (ischemic gangrene)
- prolonged application of tourniquets (ischemic gangrene)
- community-acquired MRSA
1st investigations to order
- comprehensive metabolic panel
- serum LDH
- coagulation panel
- blood cultures
- serum CRP
- plain x-rays
- CT of affected site
- MRI of affected site
- Doppler ultrasonography
Investigations to consider
- surgical exploration and skin biopsy
- CT angiography
- magnetic resonance angiography (MRA)
- CT chest and abdomen
- antinuclear antibodies (ANA), lupus anticoagulant, anticardiolipin, and anti beta2 glycoprotein-1 antibodies
- serum cold agglutinins
- serum cryofibrinogens
- plasma cryoglobulin
necrotizing fasciitis awaiting confirmation of microbial culture and sensitivity results
confirmed type I necrotizing fasciitis (polymicrobial)
confirmed type II necrotizing fasciitis (monomicrobial)
Jason Jacob, MD
Department of Medicine
JJ declares that he has no competing interests.
Robert J. Gionfriddo, DO
Department of Medicine
RJG declares that he has no competing interests.
Dr Jason Jacob and Dr Robert J. Gionfriddo would like to gratefully acknowledge Dr William Tennant, Dr Badr Aljabri, Dr Mohammed Al-Omran, Dr Jose Contreras-Ruiz, and Dr Iris Galvan-Martinez, the previous contributors to this topic.
WT, BA, MA, JC, and IG declare that they have no competing interests.
Meryl Davis, MD
Consultant Vascular Surgeon
Royal Free Hampstead
MD declares that she has no competing interests.
Charles Fox, MD
Department of Surgery
Walter Reed Army Medical Center
CF declares that he has no competing interests.
- Staphylococcal skin lesions
- Surgical site infections: prevention and treatment
- PICO negative pressure wound dressings for closed surgical incisions
Diabetes: what is it?
Diabetes type 2: should I take insulin?More Patient leaflets
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer