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

1. ULCERS
Dr Phillipo Leo Chalya M.D. ; M.Med (Surg)
Consultant Surgeon & Senior Lecturer
CUHAS-BUGANDO

2. Leaning objectives
 Definition
 Etiology
 Classification
 Pathophysiology
 Clinical presentation
 Work up
 Treatment

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. ETIOLOGY
 Traumatic causes
 Mechanical
 Physical – electrical, radiation etc
 Chemical
 Vascular insufficiency
 Arterial
 Venous
 Neoplastic conditions
 SCC
 BCC
 KS
 Malignant melanoma etc

5. ETIOLOGY……..
 Metabolic diseases
 diabetes mellitus
 Malnutrition
 Beriberi
 Tropical ulcer
 Inflammatory processes
 cellulitis
 Infective processes
 TB
 Syphilis
 Fungal infections

6. ETIOLOGY………
 Neurogenic causes
 Bed sores
 Perforating ulcers
 Cord Lesions
 Peripheral Neuropathies
 Other causes
 Bazin ulcer
 Martorell’s (hypertensive ulcer

7. CLASSIFICATION
 Etiological classification
 Clinical classification
 Pathological classification

8. Etiological classification
 Traumatic ulcers
 Vascular ulcers
 Neoplastic ulcers
 Metabolic ulcers
 Ulcers due to malnutrition
 Inflammatory ulcers
 Infective ulcers
 Miscellaneous ulcer

9. Clinical classification
 Spreading ulcer
 Healing ulcer
 Callous ulcer

10. Spreading ulcer
 Surrounding skin is inflamed
 Floor is covered by slough
 No evidence of granulation tissue
 Purulent discharge

11. Healing ulcer
 Surrounding skin not inflamed
 Floor covered with granulation
tissue
 Edges show bluish outline of the
growing epithelium
 Slight serous discharge

12. Callous ulcer
 Pale granulation tissue in the floor
 Considerable induration at the base,
edge and surrounding skin
 Show no tendency towards healing

13. Pathological classification
 Non-specific ulcers
 Specific ulcers
 Malignant ulcers

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. 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. Malignant ulcers
 These include:-
 Squamous cell carcinoma
 Basal cell carcinoma ( rodent ulcer)
 Malignant melanoma
 Ulcerating adenocarcinoma
 etc

17. PATHOPHYSIOLOGY
 The natural history of an ulcer
consists of three phases:-
 Extension phase
 Transition phase
 Repair phase

18. Extension phase
 The floor is covered with exudates
and sloughs
 The base is indurated
 The discharge is purulent or even
blood stained

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. 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. CLINICAL PRESENTATION
 History
 Physical examination

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. 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. Physical examination
 General examination
 Local examination
 Systemic examination

25. General examination
 Usual normal

26. Local examination
 Inspection
 Palpation
 Examination of lymph node
 Examination of vascular
insufficiency

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. 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. 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. 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. 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. 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. 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. Examination of lymph node
 Depends on the site of an ulcer

35. Examination of vascular insufficiency
 Depends on the site of an ulcer

36. WORK UP
 Laboratory
 Imaging
 Histopathology

37. Laboratory investigations
 Haematological
 FBP & ESR
 Haemoglobin levels
 Microbiological
 Gram staining
 Culture and sensitivity
 Biochemical
 Serum glucose

38. Imaging investigations
 Plain X-rays
 CXR
 X-ray of the affected limb
 Doppler US
 CT Scan
 MRI

39. Histopathology
 To confirm diagnosis

40. TREATMENT
 Depends on the cause
 Generally → treat the cause
 Conservative treatment
 Surgical treatment

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. Surgical treatment
 Surgical debridement
 Sloughectomy
 Skin grafting
 Flaps
 Limb amputation

43. COMPLICATIONS
 Limb amputation
 Chronic osteomyelitis
 Malignant change
 Septicemia
 Septic emboli

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