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Ulcers

SPECIAL THANKS TO
SADRU MOHAMED
FOR MAKING THESE SLIDES AVAILABLE HERE
sadru12@gmail.com
+255759212578

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Ulcers

  1. 1. ULCERS Dr Phillipo Leo Chalya M.D. ; M.Med (Surg) Consultant Surgeon & Senior Lecturer CUHAS-BUGANDO
  2. 2. Leaning objectives  Definition  Etiology  Classification  Pathophysiology  Clinical presentation  Work up  Treatment
  3. 3. DEFINITION  A break in the continuity of the covering epithelium of the skin or mucous membrane  It may either follow molecular death of the surface epithelium or its traumatic removal
  4. 4. ETIOLOGY  Traumatic causes  Mechanical  Physical – electrical, radiation etc  Chemical  Vascular insufficiency  Arterial  Venous  Neoplastic conditions  SCC  BCC  KS  Malignant melanoma etc
  5. 5. ETIOLOGY……..  Metabolic diseases  diabetes mellitus  Malnutrition  Beriberi  Tropical ulcer  Inflammatory processes  cellulitis  Infective processes  TB  Syphilis  Fungal infections
  6. 6. ETIOLOGY………  Neurogenic causes  Bed sores  Perforating ulcers  Cord Lesions  Peripheral Neuropathies  Other causes  Bazin ulcer  Martorell’s (hypertensive ulcer
  7. 7. CLASSIFICATION  Etiological classification  Clinical classification  Pathological classification
  8. 8. Etiological classification  Traumatic ulcers  Vascular ulcers  Neoplastic ulcers  Metabolic ulcers  Ulcers due to malnutrition  Inflammatory ulcers  Infective ulcers  Miscellaneous ulcer
  9. 9. Clinical classification  Spreading ulcer  Healing ulcer  Callous ulcer
  10. 10. Spreading ulcer  Surrounding skin is inflamed  Floor is covered by slough  No evidence of granulation tissue  Purulent discharge
  11. 11. Healing ulcer  Surrounding skin not inflamed  Floor covered with granulation tissue  Edges show bluish outline of the growing epithelium  Slight serous discharge
  12. 12. Callous ulcer  Pale granulation tissue in the floor  Considerable induration at the base, edge and surrounding skin  Show no tendency towards healing
  13. 13. Pathological classification  Non-specific ulcers  Specific ulcers  Malignant ulcers
  14. 14. Non-specific ulcers  These include:-  Traumatic ulcers  Arterial ulcers due to ischemia eg gangrene  Venous ulcers e.g. Varicose ulcer  Neurogenic ulcers (trophic ulcer)  Ulcers associated with malnutrition  Ulcers associated with other diseases e.g. Anemia, Avitaminosis, Gout, Rheumatoid arthritis  Miscellaneous ulcer
  15. 15. Specific ulcers  These include:-  Infective ulcers e.g. syphilitic ulcers, Tuberculous ulcer, fungal ulcers, Buruli ulcer (a neglected tropical disease caused by infection with Mycobacterium ulcerans)
  16. 16. Malignant ulcers  These include:-  Squamous cell carcinoma  Basal cell carcinoma ( rodent ulcer)  Malignant melanoma  Ulcerating adenocarcinoma  etc
  17. 17. PATHOPHYSIOLOGY  The natural history of an ulcer consists of three phases:-  Extension phase  Transition phase  Repair phase
  18. 18. Extension phase  The floor is covered with exudates and sloughs  The base is indurated  The discharge is purulent or even blood stained
  19. 19. Transition phase  Prepares for healing  The floor becomes cleaner and the slough separates  The induration of the base diminishes  The discharge become more serous  Small reddish area of granulation tissue appear on the floor
  20. 20. Repair phase  Transformation of granulation to fibrous tissue, which gradually contracts to form scar  The epithelium gradually extends from the new shelving edge to cover the floor (at a rate of 1mm/day)  The healing edge consists of three zones:-  Outer zone  This is white in color  Middle zone  bluish in color, granulation tissue covered by few layers of epithelium  Inner zone  Reddish in color, a zone of granulation tissue covered by a single layer of epithelial cells  The red granulation tissue is due to increased density of new capillaries (neo-angiogenesis)
  21. 21. CLINICAL PRESENTATION  History  Physical examination
  22. 22. History  Note the following:-  Duration (i.e. how long is the ulcer present?)  Acute: present for short time  Chronic: present for long time  Mode of onset (i.e. how has the ulcer developed?)  Following trauma  Spontaneously e.g. following- swelling e.g. ulcerating lymph node in Tuberculosis or a scar of burn Marjolin’s ulcer  Marjolin's ulcers are the malignant transformation of chronic wounds
  23. 23. History………  Pain (i.e. is the ulcer painful?)  Painful: ulcers associated with inflammation  Slight painful: tuberculous ulcer  Painless eg syphilitic, neurogenic, malignant ulcers  Discharge (i.e. does the ulcer discharge or not?)  If YES: note the nature of discharge- pus, bloody, serous  Associated diseases which may lead to ulcer formation  e.g. Tuberculosis , Syphilis, Diabetes Mellitus, nervous diseases
  24. 24. Physical examination  General examination  Local examination  Systemic examination
  25. 25. General examination  Usual normal
  26. 26. Local examination  Inspection  Palpation  Examination of lymph node  Examination of vascular insufficiency
  27. 27. Inspection  Site: gives clue to the diagnosis  Varicose ulcer- lower limb on the medial malleolus  Rodent ulcer-face  Tuberculus ulcer-cervical  Trophic ulcer – heal  Malignant ulcer- anywhere
  28. 28. Inspection……….  Shape:  Tuberculus ulcer- oval in shape  Syphilitic ulcer– circular in shape  Varicose ulcer – vertically oval in shape  Malignant – irregular in shape  Size:  May determine the time of healing  E.g. the smaller the ulcer the shorter the time it will take to heal
  29. 29. Inspection……….  Surrounding skin  E.g. red and edematous- acute inflammation  Floor/surface i.e. exposed part of the ulcer may give clue to the diagnosis  Eg red granulation – healing ulcer  Black floor- malignant melanoma  Number  Tuberculous ulcer  Gummatous ulcer  Varicose ulcer  Note: the number of ulcers may be more than one
  30. 30. Inspection……….  Edge: five types:-  Sloping edge e.g. healing ulcer  Punched out edge e.g. Gummatous ulcer, deep trophic ulcer  Undermined edge e.g. tuberculous ulcer-destroy subcutaneous faster the skin  Raised edge e.g. Rodent ulcer  Rolled out (everted)- e.g. Squamous Cell Carcinoma
  31. 31. Inspection……….  Discharge: the character of the discharge should be noted e.g.  Healing ulcer- scant serous discharge  Spreading ulcer- purulent discharge  Tuberculus ulcer- serosanguinous  Malignant ulcer- bloody discharge  Whole limb: should be examined e.g. varicose veins
  32. 32. Palpation  Tenderness:-  Tender- acutely inflamed ulcer  Slightly tender- tuberculous ulcer, syphilitic ulcer  Non-tender- malignant ulcer, chronic ulcer, neurogenic ulcer  Edge and surrounding skin  Hard induration- malignant ulcer  Firm induration- chronic ulcer, syphilitic ulcer
  33. 33. Palpation……….  Base (i.e. on which the ulcer rest)  Slightly induration- syphilitic ulcer  Marked induration- malignant ulcer  Depth:  eg trophic ulcer may be deep to reach the bones  Bleeding  easy bleed on touch is a feature of malignant  Fixity to the deep structures  Eg malignant ulcers are usually fixed to deep structures
  34. 34. Examination of lymph node  Depends on the site of an ulcer
  35. 35. Examination of vascular insufficiency  Depends on the site of an ulcer
  36. 36. WORK UP  Laboratory  Imaging  Histopathology
  37. 37. Laboratory investigations  Haematological  FBP & ESR  Haemoglobin levels  Microbiological  Gram staining  Culture and sensitivity  Biochemical  Serum glucose
  38. 38. Imaging investigations  Plain X-rays  CXR  X-ray of the affected limb  Doppler US  CT Scan  MRI
  39. 39. Histopathology  To confirm diagnosis
  40. 40. TREATMENT  Depends on the cause  Generally → treat the cause  Conservative treatment  Surgical treatment
  41. 41. Conservative treatment  Dressing  Treat infections  Bacteria, fungal, syphilis, TB etc  Steroids  Trace elements  Topical antimicrobial agents  Nutritional support  Limb elevation  Control blood glucose  Hyperbaric oxygen therapy  Compression bandage
  42. 42. Surgical treatment  Surgical debridement  Sloughectomy  Skin grafting  Flaps  Limb amputation
  43. 43. COMPLICATIONS  Limb amputation  Chronic osteomyelitis  Malignant change  Septicemia  Septic emboli
  44. 44. SPECIAL THANKS TO SADRU MOHAMED FOR MAKING THESE SLIDES AVAILABLE HERE sadru12@gmail.com +255759212578

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