Transcript
ULCERSDR.V.MUKESH KRISHNA
Definition
A break in the epithelial continuity
Discontinuity of the skin or mucous membrane which occurs due to the microscopic death of the tissues
Aetiology
Venous Disease (Varicose Veins)Arterial Disease ; Large vessel (Atherosclerosis) or
Small vessel (Diabetes)Arteritis : Autoimmune (Rheumatoid Arthritis, Lupus)TraumaChronic Infection : TB/SyphilisNeoplastic : Squamous or BCC, Sarcoma
Wagner’s Grading of ulcersGrade 0 - Preulcerative lesion/healed ulcerGrade 1 - Superficial ulcerGrade 2 - Ulcer deeper to Subcutaneous tissue
exposing soft tissue or boneGrade 3 - Abscess formation or osteomyelitisGrade 4 - Gangrene of part of tissues/limb/footGrade 5 - Gangrene of entire one area/foot
Classification A. ClinicalB. Pathological
A. Clinical
Spreading : (Edge - Inflamed & Edematous) Healing : (Edge is sloping with healthy red
granulation tissue & serous discharge)Callous : (Floor contains pale unhealthy
granulation tissue with indurated edge)
B.Pathological
1. Nonspecific 2. Specific 3. Malignant
1. Non specific
Traumatic UlcerArterial UlcerVenous UlcerNeurogenic UlcerInfective Ulcer
1. Non specific contd.
Diabetic UlcerTropical UlcerCryopathic UlcerMartorell’s UlcerBazin’s Ulcer
• Traumatic ulcer
1. Mechanical- Dental ulcer on tongue ( jagged tooth )2. Physical- Electrical burn3. Chemical- Application of caustics
Acute, Superficial, Painful, Tender
• Arterial Ulcer
• Caused due to peripheral vascular disease• LL : Atherosclerosis & TAO• UL : Cervical Rib, Raynauds• Chief complaint : Severe Pain• Toes, Feet, Legs & UL Digits
• Venous ulcers
Medial aspect of lower 3rd of lower limbAnkle ( Gaiters Zone ) : Chronic Venous HTNUlcers are PainlessVaricose Veins or Post Phlebitic limb ( PTS )
• Trophic Ulcer
• Pressure Sore or Decubitus Ulcer• Punched out edge with slough on the floor• Ex: Bed Sores & Perforating ulcers• Develop as a result of Prolonged Pressure• Sites : Ischial Tuberosity > Greater Trochanter >
Sacrum > Heel > Malleolus > Occiput
• Tropical ulcer
• Tropical regions : Africa, India, S.America• Trauma or Insect Bite• Fusobacterium fusiformis & Borrelia
vincentii• Abrasions, Redness, Papules & Pustules• Severe Pain
• Diabetic Ulcer
It may be caused due to• Diabetic Neuropathy• Diabetic Microangiopathy• Increased Glucose : Increased Infection• Foot ( Plantar ), Leg, Back, Scrotum, Perineum• Ischemia, Septicemia, Osteomyelitis,
2. Specific
TuberculosisSyphilis Actinomycosis Meleney’s ulcerSoft sore
3. Malignant
Squamous cell caBasal cell caMalignant melanoma
Examination
Inspection PalpationExamination of lymph nodesVascular insufficiency Nerve lesions
INSPECTIONLocation, size, shape, floor, edge, discharge, surround ing area.
PALPATIONTenderness, local rise of temperature, bleeding on touch, consistency of the ulcer, edge, surrounding area - oedema, mobility.
REGIONAL LYMPH NODES SENSATIONS PULSATIONS FUNCTION OF THE JOINT SYSTEMIC EXAMINATION
INSPECTION
LOCATION OF THE ULCERFLOOR OF THE ULCER DISCHARGE FROM THE ULCEREDGESURROUNDING AREA
LOCATION OF THE ULCER
Arterial ulcer Tip of the toes, dorsum of the foot
Long saphenous varicosity with ulcer
Medial side of the leg.
Short saphenous varicosity with ulcer
Lateral side of the leg.
Perforating ulcers Over the sole at pressure points.
Nonhealing ulcer Over the shin
FLOOR OF THE ULCER
DEF : This is the part of the ulcer which is exposed or seen.Red granulation tissue Healing ulcer
Necrotic tissue, slough Spreading ulcer
Pale, scanty granulation tissue
Tuberculous ul cer
Wash-leather slough Gummatous ulcer
DISCHARGE FROM THE ULCER
Serous discharge Healing ulcer
Purulent discharge Spreading ulcer
Bloody discharge Malignant ulcer
Discharge with bony spicules
Osteomyelitis
Greenish discharge Pseudomonas infection
EDGEDEF: This is between the floor of the ulcer and the
margin. The margin is the junction between the normal epithelium and the ulcer.
These two parts represent areas of maximum activity. 3 STAGES Stage of ex-tension. Stage of transition. Stage of repair.
A. Sloping edge All healing ulcers like traumatic ulcers, venous Ulcers
B. Punched out edge
Gummatous ulcers and trophic ulcers.
C. Undermined edge
Tuberculous ulcers
D. Raised edge (beaded edge)
Rodent ulcers or basal cell carcinoma .
E. Everted edge (Rolled out)
Squamous cell carcinoma.
SURROUNDING AREA
Thick and pigmented
Varicose ulcer.
Thin and dark Arterial ulcer.
Red and oedematous
Spreading ulcers like dia betic ulcer.
PALPATIONEDGEBASEMOBILITYBLEEDINGSURROUNDING AREA
EDGEInduration (hardness) of the edge is very
char acteristic of squamous cell carcinoma.
It is said to be a host defense mechanism.
Tenderness of the edge is characteristic of infected ulcers and arterial ulcers.
BASEIt is the area on which ulcer rests.
Marked induration at the base is diagnostic of squamous cell carcinoma.
INDURATION
• The edge, base and the surrounding area should be examined for induration.
Maximum induration Squamous cell carcinoma
Minimal induration Malignant melanoma.
Brawny induration Abscess.
Cyanotic induration Chronic venous congestion as in varicose ulcer.
MOBILITYGentle attempt is made to move the
ulcer to know its fixity to the underlying tissues.
Malignant ulcers are usually fixed, benign ulcers are not.
BLEEDINGMalignant ulcer is friable like a
cauliflower. On gentle palpation, it bleeds.
Granulation tissue as in a healing ulcer also causes bleeding.
SURROUNDING AREA
Thickening and induration is found in squamous cell carcinoma.
Tenderness and pitting on pressure indicates spreading inflammation surround ing the ulcer.
RELEVANT CLINICAL EXAMINATION REGIONAL LYMPH NODES
Tender and enlarged Acute secondary infection.
Non-tender and enlarged
Chronic infection.
Non-tender and hard Squamous cell carcinoma.
Non-tender, large, firm, multiple
Malignant melanoma.
MANAGEMENT
Investigations
1) Complete blood picture: Hb%, TC, DC, ESR, PS2) Urine and blood examination to rule out diabetes3) Chest X-ray - PA. view to rule out P.TB4) Pus for culture/sensitivity5) Lower limb angiography in cases of arterial
diseases6) X-ray of the part to see for Osteomyelitis 7) Biopsy: Non-healing/malignant ulcers
Treatment
Address causeCorrect deficienciesControl pain, infectionDebridement, dressingClosure of defect
TREATMENT OF THE ULCERS
Treatment of Spreading UlcersTreatment of Healing UlcersTreatment of Chronic UlcersTreatment of The Underlying Disease
TREATMENT OF SPREADING ULCERS
Pus Culture/Sensitivity report, Appropriate Antibiotics Solutions to treat the Slough : H₂O₂ & EUSOL -
Edinburgh University Solution (Hypochlorite solution)
Excessive Granulation Tissue (Proud Flesh) : Excision or Application of Copper Sulphate or Silver Nitrate
Repeated Dressings,
TREATMENT OF HEALING ULCER
Regular dressings are done for a few daysAntiseptic creams like Liquid Iodine, Zinc Oxide
or Silver Sulphadiazine.Culture swab is taken to rule out Streptococcus
Haemolyticus ( contraindication for skin grafting )Ulcer is small - Heals by itself ( Epithelialization )
Large - Free Split Skin Graft applied
TREATMENT OF CHRONIC ULCERS
These do not respond to conventional methods of treatment.
The following are tried: Infrared radiation, short-wave therapy, ultraviolet rays
decrease the size of the ulcer. Amnion helps in epithelialization. Chorion helps in granulation tissue. These ulcers ultimately may require skin grafting.
HAVE A GOOD DAY
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