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Sunday, September 25, 2022

Diabetic foot ulcers

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By Alfusainey Ceesay
5th year medical student

Diabetes over the recent years has earned its fair share of attention and space in public health discussions. Rightly so, owing to its growing prevalence in the country and the world at large. Diabetes is simply known as an abnormal or pathologic rise in the blood sugar levels. It has been estimated that about 5% of the global population have diabetes. Diabetes is a chronic illness that has over the years caused a significant rise in both mortality and morbidity within this country and beyond. Many among its numerous consequences is the ever-rising rates of amputations within our healthcare settings due to diabetic foot ulcers During my short stint at the surgery department, diabetic foot amputations was among the most common surgical operations conducted at the Edward Francis small teaching hospital (EFSTH). Most often recently, at least two amputations are carried out at the EFSTH weekly.

In an effort to raise the alarm on diabetes related amputations, we look at the causes of diabetic foot ulcers, how the need for amputation arises, its effects and, most importantly, how to prevent it.

What are diabetic foot ulcers?

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Diabetic foot ulcers are open wounds that occur on the feet of an estimated 15% of known diabetic patients universally. What sets them apart from any other foot wounds is that they occur on diabetic patients. This may sound quite obvious on the surface but we will explain why it is not so obvious.

Although the etiology of diabetic foot ulcers vary and many cannot tell specifically how they got it, the mechanisms involved in its pathogenesis remain almost the same. Generally, every diabetic patient has a risk of developing diabetic foot ulcer, even more so for those having other underlying predisposing conditions.

The need for amputation arises from the compounding of three pathologic conditions, namely: peripheral neuropathy, arterial occlusive disease and perhaps the most grievous of the three, infectious and gangrenous foot.

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To care for, and to prevent having a diabetic foot ulcer, is to understand the stages in the pathogenesis of the foot ulcers.

Causes of diabetic foot ulcers

Firstly, we begin the pathogenesis with peripheral arterial disease. Diabetes over a long period causes the calcification of the lining of the blood vessels. This in turn reduces the flexibility of the peripheral blood vessels and thus reduces the smooth flow of blood to the distal part of the lower limbs. The smooth flow of blood is most essential as that part of the limbs are deprived of relevant nutrients, oxygen and the removal of metabolic waste products. Deprivation of the body tissue of its required nutrients could eventually lead to ischemia of the target organs and finally cause gangrene of the feet. Peripheral arterial occlusive disease could also cause peripheral neuropathy.

Neuropathy is nerve damage resulting from high blood sugar levels sustained over a long period. Impairment of blood supply to vessel damage from high cholesterol levels could as well cause peripheral neuropathies. When the nerve supply to a certain part of the limbs is damaged, that area becomes numb and incapable of detecting sensation. The lack of detecting any sensation at a part of the body presents a risk of undetected damage. Normally, whenever a part of the body is damaged, painful stimuli alerts the brain to excite protective reflex responses to limit the damage and treat the wound. If wounds are undetected, they are deprived of attention hence treatment as well. With time, as the wound is exposed to foreign bodies and agents of infection it becomes septic and begins to slowly ascend the limb. The infection spreads until the time it is detected.

Finally, we come to impaired immune response. The function of white blood cells is impaired in diabetic patients. The white blood cells have reduced chemotaxis, reduced adherence to vascular endothelium, reduced phagocytosis and intracellular killing activity. Thus, the white blood cells are described to be lazy. If white blood cells cannot confront agents of infection, they leave the body vulnerable to pathogenic invasion. Without the ability to fight back, the body’s defenses succumb to the pathogens.

How to prevent diabetic foot ulcers

o          Diabetic patients should take time to observe their feet daily. More so at areas you know to be numb check for scrapes, bruises, swellings or any other discontinuation of the normal skin covering. A daily routine of observing your feet ensures that new ulcers are detected early and treated robustly to prevent any possible worse outcome.

o          Practice regular feet hygiene by washing your feet with warm soap and water.

o          Avoid wearing tight shoes. Put on shoes that that fit feet properly.

o          Avoid walking bare footed. Put on socks as often as possible anywhere you cannot put on shoes.

o          Use skin care products like moisturizers to hydrate the skin after washing them.

o          Avoid high cholesterol meals to reduce the risk of arterial vascular disease. also avoid high blood glucose states by taking your diabetes drugs as instructed by your physician.

Why is amputation necessary?

Amputations are among the most traumatic experiences any human could face. It takes more than just a mere counseling for any person to consent to it. One that is born differently abled grows, adapts and accept their limitations but having to loss use of your limbs when you have been using them all your life presents a far greater challenge than the former, as you abruptly have to get used to living your limb. It takes immense psychosocial support to rehabilitate.  

After foot ulcers is detected on diabetic patients, it becomes a race to stop it on its track, as chances are it has already been infected. A visit to a Healthcare specialist becomes necessary at this point. The approach is to carryout regular wound dressings to prevent of limit the infection of the wound. But if the wounds are septic, drain any present abscess that may have formed at the site of the wound and debride the wound properly if gangrenous tissues are present. The removal of the dead tissues is very crucial to eliminate potential reservoir for pathogens.

Should all the above-mentioned approaches fail to yield desirable outcomes, then we turn to the last resort, which is to amputate. Amputation is done to stop the impending spread to infection to the bones and other soft tissues and the death of tissue to the healthy parts of the limbs. If the local infection is not arrested with amputation, it may enter the blood stream and cause a generalized infection causing bacteremia. This occurrence is potentially life threatening. In essence, amputation is done to save your life.

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