Paracentesis as an aid to the diagnosis of intestinal gangrene: experience in 50 infants and children

We performed paracentesis or peritoneal lavage on 50 seriously ill infants and children in whom the diagnosis of intestinal gangrene or perforation was suspected. Thirty-four infants had necrotizing enterocolitis and 16 had other conditions. In infants with suspected intestinal gangrene, the presence of brown peritoneal fluid and/or bacteria on Gram's stain was indicative of intestinal gangrene. In infants with pneumoperitoneum, the presence of cloudy fluid with leukocytosis was indicative of gastrointestinal perforation. Using these two criteria, the accuracy of paracentesis in predicting the need for operation was 90%. When combined with clinical judgment, the accuracy rose to 97.5%. The rate of negative findings from abdominal explorations was 5%. Analysis of the peritoneal fluid may improve the timing and accuracy of the operative decision.

Buerger's disease (thromboangiitis obliterans): an analysis of the arteriograms of 119 cases

One hundred and forty-four lower extremity arteriograms of 119 patients with Buerger's disease have been analysed. The 'corkscrew' appearance of collateral circulation was seen in 27.1% of 144 limbs affected by thromboangiitis obliterans, but in only 3.2% of 63 limbs affected by arteriosclerosis obliterans. We believe that the corkscrew vessel is highly characteristic of Buerger's disease and represents dilated vasa vasorum of the occluded main artery. The appearance of corkscrew vessels extending from the arterial occlusion sites to the periphery of the feet without opacification of the main pedal arteries indicated a poor prognosis.

Purpura fulminans

Purpura fulminans presents as a catastrophic illness with gangrene of the distal extremities and necrosis of skin. The clinical picture consists of septicemia, shock, and disseminated intravascular coagulation. The Shwartzman and Arthus reactions are thought to be responsible for the pathogenesis of purpura fulminans. The exact mechanisms of these reactions are not completely understood. Immediate resuscitation is the treatment for shock and sepsis. Heparin is recommended to reverse the disseminated intravascular coagulation component of this disease. Surviving patients require treatment of skin necrosis and digital and extremity gangrene. The former are managed in a fashion similar to the management of burns. Amputation should be delayed until maximal collateral circulation has developed. A series of 10 patients is presented and 58 cases from the literature are analyzed.

Bilateral gangrene of the feet associated with Salmonella infection in children with sickle cell anaemia

Two cases of bilateral gangrene of the feet associated with salmonella infection in Nigerian children with sickle cell anaemia are described. Healing was spontaneous and complete in both cases. A search for sickling phenomenon and salmonella infection is advocated in all African children with so-called idiopathic bilateral gangrene of childhood.

Diabetic gangrene in black patients

We reviewed diabetic gangrene in 104 American blacks and found that the clinical features were similar to those reported for the general diabetic population. We observed, however, that there was a significant association of hypertension with above-knee and bilateral amputations in our patients (P less than .001 and .01, respectively), and that the mean blood pressure of the bilateral amputees (124.5 +/- 3.8 mm Hg) (SEM) was significantly higher (P less than .005) than that of the unilateral amputees (114.4 +/- 1.7 mm Hg). There results suggest a strong association of hypertension with far-advanced occlusive vascular disease of the lower limbs. Moderately severe anemia (hematocrit 20% to 30%) was associated significantly with primary above-knee amputation and mortality (P less than .02 and .05, respectively). Mortality resulted mostly from mixed causes (cardiopulmonary failure, uremia, sepsis, diabetic coma). The dead patients had significantly increased prevalence of cardiac disease (P less than .02), higher frequency of above-knee amputation (P less than .01), and a duration of diabetes (17.4 +/- 2.8 years) significantly longer (P less than .025) than that of the surviving patients (12.0 +/- 1.0 years).

[Treatment of gangrene of the lower extremities in diabetics]

The authors believe that the main criterion for choice of the method of treatment of diabetic patients with gangrene of lower extremities is the degree of compensation of blood circulation which was estimated by temperature asymmetry of necrosis on the crus. The conclusion is made on the basis of treatment of 62 patients. The amputation at the femur level is indicated in decompensated blood circulation, amputations on the foot associated with intensive pharmacotherapy are indicated in subcompensation. Complex conservative treatment is possible in patients with a starting gangrene.

Necrotizing fasciitis-a disease of temperate and warm climates

Necrotizing fasciitis is a distinct clinical entity. It is usually due to Streptococcus pyogenes but may occasionally be caused by Staphylococcus aureus. It needs to be considered in relationship to other infections due to Streptococcus pyogenes, in which the clinical disease that occurs may be associated with the depth of inoculation of the coccus. Mild cases have been identified that are self-limiting as well as serious cases which would have succumbed without surgical debridement. It is likely that some cases of necrotic tropical ulcer are due to necrotizing fasciitis.

[Arterial vascular occlusion in penicillin allergy (author's transl)]

A nodular exanthema of the skin was observed in an 8-year-old girl. She had been treated with penicillin a few days ago because of a gastrointestinal infection. Continuation of penicillin treatment led to occlusion of larger arteries with gangrene of the forefoot. This was accompanied by septic temperatures and superinfected skin lesions. Angiologic and angiographic investigations showed a right-sided femoro-popliteal occlusion and occlusions of the arteries of the lower leg. On the left side there was spasm of the superficial femoral artery. After cessation of penicillin and high-dose steroid therapy rapid restitution occurred. Arterial spasms regressed, the occlusions remained persistent, but there was adequate collateral blood supply and ischaemic acral necroses healed. An allergic reaction of the intermediary type involving major arteries can be considered causative underlying pathology.

Dopamine gangrene. Association with disseminated intravascular coagulation

Multiple extremity gangrene developed in five patients as a complication of dopamine therapy. The clinical conditions were (1) penetrating chest trauma requiring pneumonectomy with postoperative sepsis, (2) cardiac arrest with aspiration pneumonia, (3) lymphoma with sepsis, (4) Klebsiella pneumonia, and (5) myocardial infarction. The development of acrocyanosis leading to gangrene occurred at dopamine dosages of 5.1 to 10.2 micrograms/kg/min. The alpha-adrenergic vasoconstriction effects of dopamine would not be expected from the doses employed in these patients. Thus, other factors beside pure alpha vasoconstriction are responsible for tissue necrosis after the use of dopamine. We believe that the embolic complications of disseminated intravascular coagulation and hypovolemia are serious risk factors in the development of dopamine gangrene. Peripheral vasoconstriction from dopamine, even at low doses, may set the stage for thrombotic complications of disseminated intravascular coagulation and lead to tissue damage. In laboratory models of disseminated intravascular coagulation, an alpha-adrenergic drug is required to produce peripheral ischemic tissue damage. Treatment of tissue ischemia related to dopamine depends on early recognition of acrocyanosis. Phentolamine, an alpha blocker, has been recommended for treating dopamine ischemia, either through local instillation into ischemic tissues or intravenous infusion. We recommend a high index of suspicion for, and early treatment of, underlying consumptive coagulopathy in all patients requiring dopamine.

Gangrenous bowel. Benin experience

A retrospective study of 115 patients who presented to the University of Benin Teaching Hospital with intestinal gangrene over a 5 year period is presented. Although hernia is the most common cause of bowel gangrene, more patients with volvulus end up with gangrenous bowel. Because Nigerian patients present with late intestinal obstruction, more dead bowel would have been expected than is currently noted. Is it possible that the African is resistant to intestinal strangulation?

Bacteriological study of diabetic foot ulcers

Bacteriological study of 61 patients with diabetic gangrene or non-gangrenous foot ulcers was undertaken to determine the pattern of infection and antimicrobial susceptibility with a view to suggest optimal antibiotic therapy for these patients. Gangrenous ulcers showed a higher frequency of mixed infection; the predominant organisms being enterococci, Proteus sp., Pseudomonas sp. and Klebsiella sp. Infected non-gangrenous ulcers showed Staph. pyogenes, and beta haemolytic Streptococcus as single organism in 12 patients. Anaerobes were more frequently isolated in gangrenous lesions than in non-gangrenous ulcers. Antimicrobial susceptibility showed that gram positive organisms were sensitive to co-trimoxazole, cephaloridine, ampicillin and penicillin. Gram negative aerobic bacilli were sensitive to gentamycin, chloramphenicol, cotrimoxazole and streptomycin. Anaerobes were sensitive to chloramphenicol, clindamycin and metronidazole. Antibiotics of choice for gangrenous lesions with spreading infection and septicaemia are a combination of gentamycin, ampicillin and metronidazole as an adjuvant to surgical treatment.

Tibial arteriovenous fistula: successful use for limb salvage

Embolization of atheromatous material from abdominal aortic aneurysms to the distal arterial circuit is a well-recognized clinical entity causing the "blue toe syndrome." A case is presented in which this phenomenon resulted in obliteration of the pedal arch and thrombosis of the tibial arteries. As a result, forefoot gangrene, severe leg ischemia and anterior and posterior compartment syndromes occurred. Salvage of the extremity required an extraordinary approach with the construction of an arteriovenous fistula between the posterior tibial vessels. The literature on the use of therapeutic and adjunctive arteriovenous fistulas and their physiology is discussed.

Gangrene of the gallbladder: a complication of acute cholecystitis

Eighteen cases of gangrenous cholecystitis were reviewed to better define causes of morbidity and mortality. All patients in the series presented with signs and symptoms of acute cholecystitis. Cholecystectomy was done as an emergency procedure in 12 patients, while in six patients cholecystectomy followed a failure of nonoperative therapy. Gangrenous cholecystitis in this series was commonly associated with empyema and perforation of the gallbladder. Three of six patients having cholecystectomy after failure of nonoperative treatment died, while only one of 12 patients with immediate cholecystectomy died. This series illustrates that gangrenous cholecystitis usually presents with a clinical picture identical to that of acute cholecystitis. Early operation in the natural history of acute cholecystitis should reduce the frequency as well as the morbidity and mortality of gangrenous cholecystitis.