Diabetic Foot Ulcer

Diabetic Foot Ulcer is sometimes referred to as “ENYI ULE” (Diabolical foot decay).

SCENARIO X

It all started one fateful morning. She had woken up earlier than usual to go pick palm nuts from her farm. She had done so against the better counsel of the seat of caution within.

From her waking up from the left side of her bed, to her stubbing her left big toe against the kitchen stool and having a bush rat run across the road from left to right while she was on her way to the farm: everything pointed towards a bad omen.

She would have turned back, should have, but she really needed the palm nuts. And having denounced the ways of her ancestors a few months back, she was taught to exercise her newly found “Christian Faith” with each little opportunity she got and shame the devil and his superstitious gimmicks. And this was one.

As she entered her farm that morning, she suddenly felt a tingling on her left foot, and an electric shock-like sensation shot up from there up to her thighs. And that was it: o zota go ; she has stepped on some piece of diabolic craft.

Prior to that, she had been feeling a little bit unwell, was loosing weight and was feeling weak most of the times despite the fact that she had been eating a lot of “in-between meals” out of excessive hunger. Also she has been urinating a lot and gulping water like the fabled “Ggwongwolo ogba anu mmiri”, the Trailer that gulps water [petrol] with an insatiable thirst.

Just the other day she noticed that the place she used to urinate at her backyard was being clustered with ants. But only so because a neighbour told her as her vision had become blurred of late.

After the incident in the farm, things got worse. She was no longer feeling her legs well, and sometimes it seems as if she was walking on a soft mattress, so soft it seems she was gliding on air.

Then there was this excruciating pain she feels in her calf[back of the leg]. If she walks a small distance the pain builds up slowly, manageable at first, until it gets to a point where it is so unbearable she has to take the weight off her feet. After some rest, the pain resolves and she starts walking again, and the vicious cycle continues.

About 2 weeks later, her legs started turning black. And on a closer look she noticed she had a wound in-between her toes, a rather ugly and foul smelling wound. It beat her imagination how she didn’t notice it, and didn’t feel pain when it occurred.

At this stage, she was tired of exercising her newly found Faith, she has to go back to the ways of her fathers. Maybe they will have a solution for her.

Within minutes of her arrival at the Native doctor’s, the cowry shells chasing each other on the floor had somehow told her that her co-wife, the one she had a dispute with over  that same piece of land, has given her “Enyi ule”, o zota go ya!

 Discussion

The above is a classical depiction of Diabetes Melitus complicated by Peripheral Neuropathy and Peripheral Artery Insufficiency, all culminating in Diabetic Foot Ulcer.

 What is diabetic foot ulcer (DFU)?

Diabetes Mellitus (DM) is a group of metabolic disorders characterised by Hyperglycaemia (excessive levels of blood sugar) due to an absolute or relative deficiency of insulin (a hormone that controls blood sugar).

DFU is a chronic complication of uncontrolled diabetes mellitus characterized by a predisposition to foot ulceration (development of unhealing wounds), which if untreated could lead to gangrene amputation and DEATH.

diabetic foot ulcers can cause foot gangrene
diabetic foot ulcers can cause foot gangrene

It is a component of the DIABETIC FOOT SYNDROME which includes:

  • Foot Ulceration.
  • Infection

And

-Charcot’s Osteoathropathy (abnormal arrangement of the foot joints and skeleton)

Mechanism of Diabetic Foot Ulcer

Diabetic Foot Ulcerdevelops because DM messes with blood vessels and nerves leading the following:

NEUROPATHY

  • Abnormal nerve function which leads to;
  • Loss of sensation (they don’t feel pain. So they get injured without knowing, and may thus contaminate the wound leading to a poor outcome).
  • Dryness of the skin (leads to small cracks which develop into a wound).
  • Abnormal foot shape (leads to abnormal pressure/weight-bearing and ulcers]).

PERIPHERAL ARTERY DISEASE

  • The vessels that supply blood to the foot are blocked predisposing to tissue death and hence ulceration [wounds].
  • Also materials in the blood that fight infection and help wound healing doesn’t get to the foot making wounds easy to get infected and difficult to heal.

DEPRESSED IMMUNITY

  • Even if the “materials” get there, the immune system is weak, too weak to fight infections effectively.
  • All these lead to a wound that is infected, difficult to heal, foul-smelling, and with “decay” in some cases

.

 Risk factors for Diabetic Foot Ulcer

  • Smoking [Lol …Again? Still wondering why we smoke]
  • Poor sugar control
  • Previous Diabetic Foot Ulcer
  • Features suggestive of Neuropathy

 Features of Diabetic Foot Ulcer

 General Features of DM

  • Polyuria [ frequent passage of large volume urine]
  • Polydipsia [excessive thirst]
  • Polyphagia [excessive hunger]
  • Weight loss

 Features of Neuropathy

  • Loss of sensations in the legs
  • Abnormal sensations [tingling, “electric shocks”]
  • Abnormal pains
  • Loss of ability to sweat [dryness of the skin]
  • Abnormal shape of the foot

 Features Peripheral Artery Occlusion

  • The coldness of the legs
  • Intermittent claudication [ calf pain on walking a distance which resolves with rest]
  • Nighttime leg pains
  • Foot discolouration [usually dark or black]

Features of Infection [when ulcer eventually develops]

  • Fever
  • Shaking chills
  • Loss of appetite
  • Nausea
  • Vomiting

.

Complications of Diabetic Foot Ulcer

This includes:

  • Sepsis [overwhelming life-threatening systemic infections].
  • Amputation.
  • Hyperglycemic crisis and coma
  • Death

.

Treatment of Diabetic Foot Ulcer

  • Due to the defective wound healing and predisposition to infections in Diabetics, treatment is difficult and takes a comparatively longer time.
  • Cure can be effected depending on the severity and extent of the ulcer.
  • Based on the severity, treatment options include:
  • Use of Antibiotics, Insulin and regular wound cleaning and debridement [cutting off of dead tissues to allow healthy ones to grow out]
  • Amputation.

Prevention of Diabetic Foot Ulcer

A stubborn condition saddled with loads of complications, prevention is the mainstay in the treatment approach to DFU .

This includes:

  •  Ensuring good blood sugar control. By daily checking of blood sugar, judicious adherence to taking anti-diabetic drugs as prescribed, dietary discretion, and lifestyle modifications, moving from more to less disease-prone habits.
  • Cessation of smoking and excessive alcohol intake.
  • Diabetic Foot Vigilance/Care
  • Wearing of loose-fitting shoes
  • Avoidance of walking around on barefoot
  • Constant pruning of the nails (by a third party as the Diabetic may have impaired vision and may mistakenly cut him/herself)
  • Regular [daily] thorough foot inspection for cuts and wounds by a 3rd party [reason is same as above].
  • Keeping the feet clean
  • Use of moisturising creams to keep the feet from drying up and predisposing to skin cracks.
  • Prompt treatment of wounds no matter how small.

DISCLAIMER/CLARIFICATION

The term “Enyi Ule” in the medical community actually refers to STASIS DERMATITIS [due to chronic venous insufficiency i.e Chronic Venous Ulcer].

Some schools of thought also use it to describe BURULI ULCER.

However it is loosely used by the common man to describe most chronic leg ulcerations[ irrespective of the cause],while reflecting the supposed diabolical origin of such unhealing ulcers.

This is the same reason I have taken the liberty to apply it to DFU in this article.

Share this

Dr Chibuike Joseph Chukwudum

Dr Chibuike Joseph Chukwudum is a doctor who Studied Medicine and Surgery at Nnamdi Azikiwe University Awka. He is the former Medical Officer at Oakland specialist hospital,obosi.He also previously worked at Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State.