Ulcer

concise information regarding aetiopathogenesis , investigations & treatment.

1. Ulcer By Dr Prashant Patil MS ( gen Surgery) Reader & HOD Dept. of surgery

2. Ulcer Breach in the continuity of surface epithelium ( skin / mucus membrane ) due to molecular death of tissue cell by cell

3. Classification - -- Acute < 12 wks -- healing -- Chronic > 12 wks -- Non healing Infection TB Sq. cell carcinoma physical/ chemical agents Syphilis Melanoma local irritation /Trauma basal cell CA ( rodent) interference with circulation - arterial / venous Cropathic, Bazin’s, Martorells Diabetic, Cortisol, Tropical aetiological Duration healing Non specific specific Malignancy

4. Classification Wagner’s Classification (foot ulcers) The Wagner scale is used to classify the severity of foot ulcers in diabetics: Grade 0 Pre- or post-ulcerative site Grade 1 Superficial ulcer Grade 2 Penetration into tendon or joint capsule Grade 3 Involvement of deeper tissues Grade 4 Gangrene of the forefoot Grade 5 Gangrene involving more than two-thirds of the foot

5. Classification Classification Based on Pain Painful Ulcers Tuberculous Arterial Advanced Malignancy Painless Ulcers-         Syphilitic Trophic Early Malignancy

6. Ulcer - few concepts Trophic ulcer ( trophe ’ Greek ; lack of nutrition ) occur due to the impairment of tissue nutrition as a result of either ischemia or anesthesia . E.g. In the arm -- chronic vasospasm ( painful ) -- syringomyelia .( painless ) ulcer on fingertips . in the leg -- ischemic ulcers ( painful ) around ankle/ dorsum of foot . Neuropathic ulcer ( anesthesia ) Perforating ulcer seen in – Diabetes -- Spina bifida -- Tabes dorsalis -- Leprosy -- peripheral nerve injury It starts as acorn / bunion  penetrate foot  suppuration  Bone / joint /along fascial planes of calf .

7. Ulcer - few concepts Modes of Onset of Ulcer •      Traumatic •      Spontaneous- •      Secondary changes on a Swelling-Tuberculous lymphadenopathy •      From a Previous Scar-Marjolin’s Ulcer

8. Life history of Ulcer Extension Transition Repair Covered with slough clearer granulation tissue and exudate transforms to fibrous tissue . Indurated Induration decreases further decreases. Purulent / even blood more serous serous stained absent small areas appear & epithelisation from spread surrounding area growth rate 1 mm/d 3 layers +ve +++ ++ -- ve Floor Base Discharge Granulation Pain

9. Ulcer – clinical features Site : Rodent ulcer (95%) on upper part of face . CA affects lower lip while primary ulcer of syphilis occur on upper lip . Arterial ulcers occur at finger tips / toe . Venous ulcers occurs around ankle . Size: Variable , depends on length of history . inflammation > CA > Rodent . Shape: Irregular -- Infective / CA . Circular -- Rodent / Gummatous Sq area / straight edge -- dermatitis artefacta .

10. Ulcer - parts Edge Floor slough Base

11. Ulcer – clinical features Shelving (sloping) -- non sp.healing ulcer Rolled & pearly -- Rodent ulcer Raised & everted -- Epithelioma Undermined & blueish -- Tuberculosis Punched out -- Syphilis Edge

12. Ulcer – clinical features ( cont. ) Floor ( area seen by the observer ) Granulation -- non specific healing Slough -- infected Watery / Apple jelly Appearance -- tuberculus Wash leather appearance -- gummatous Base ( part of an ulcer which is palpated ) Indurated -- malignancy Attached to deep structures -- venous ulcer

13. Ulcer – clinical features ( con’t ) Discharge : Purulent -- active infection watery -- tuberculosis blue – green -- pseudomonas Blood stained -- extension phase of ulcer Lymph nodes : enlarged , tender -- infected enlarged , hard , fixed -- CA firm & shotty -- syphilitic chancre enlarged submandibular LN – chancre on lip not enlarged -- rodent ulcer

14. Ulcer – clinical features ( cont. ) Pain non sp ulcer in ext & ulcer in phase of repair transition phase Tuberculous ulcer on Tuberculous ulcer tongue Syphilitic Ulcer on anal Syphilitic ulcer canal Apthos ulcer present absent

15. Ulcer – Regional examination Examination of draining LNs Tender & enlarged – secondary infection Enlarged hard fixed – malignant ulcer Enlarged , firm , matted – tuberculous ulcer Enlarged and shotty – syphilis Examination for impaired circulation look for absent pulse/ weak pulse, trophic changes – thin limb, shiny skin, loss of hairs, brittle nails Look for varicose veins Neurological examination Sensation, motor power, reflexes

16. Ulcer – general examination Look for -- Aneamia , Malnutrition , Diabetes . Rule out -- Cardiac Failure .

17. Ulcer -- Investigations Haematological LFT / Protein Blood sugar -- fasting & post prandial Montoux test Serological tests for Syphilis Biopsy ( wedge/ Excision ) / scraping – histopath Swab -- culture / sensitivity Discharge – gm. staining, ZN staining for AFB, PCR for Koch. FNAC of enlarged LNs X-ray of affected part

18. Ulcer - principles of management Determine aetiology Accurate assessment of ulcer Identify and correct comorbid factors . Treat underlying cause Adequate drainage and desloughing . Avoid adherent dressings .

19. Ulcer -- treatment local applications ( lotions / ointments ) -- treatment of cause -- to separate slough -- correct Aneamia -- hasten granulation -- treat metabolic -- stimulate epithelisation disorders. Na hypochlorite -- Antibiotics 0.5% AgNo3 early phase -- treatment of DM Zinc Sulphate Ointments ( mupirocin, soframycin , povidon iodine ) Vinegar ( 1: 6 ) for pseudomonas Amnion ( fresh & cleaned with sodium hypochlorite stored at 4*C Silver Foil / SWD / Infra red Hydrocolloids , Alginates ,Tegaderm Recombinant epidermal growth factor treatment general local

20. Ulcer treatment - points to remember Determining exact aetiology is important - note the site & local characteristics - thorough history & physical assessment Detect & treat comorbid factors Biopsy of the lesion may be necessary sometimes for exact cause. Treat the underlying cause -- infection /DM / venous or arterial insufficiency . Adequate drainage & desloughing required – surgical excision is cost effective. Antibiotic treatment is required for – infected ulcer / ulcer due to sp cause e.g. TB Clean ulcer should be dressed twice /day or more if copious discharge. Avoid adherent dressings . Wounds can be cleaned safely with normal saline solution.

21. Ulcer treatment – basic requirement of ideal dressing Maintain high humidity between wound & dressings. Absorbent , removes excess exudate. Non- adherent , allowing easy removal without trauma at changing Safe & acceptable to patients ( non allergic ) Permit gaseous exchange but impermeable to micro- organisms . Cost - effective

22. Ulcer treatment ( Loco + Gen ) Healing excision & curettage AgN03 application swab to r/o staph coagulase + organism pseudomonas beta- hemo. Strepto . clean with tetracycline treatment & confirm with swab Loco + gen Treatment Small ulcer Large ulcer granulation Excessive granulation (proud flesh ) Large area but granulation ++ + ve - ve SSG

23. Ulcer - factors causing delayed healing Aneamia Hypoproteinemia Absence of rest Malnutrition Diabetes Ureamia Irradiation Ischemia Neutropenia Active infection

24. Ulcer -- photo gallery

25. Ulcer -- photo gallery

26. R eferences Bailey & love’s Short Practice of surgery 22 nd & 24 th edition Short cases in surgery - Bhattacharya Text book of surgery for dental students- Dr. Sanjay Marwah Clinical surgery – Hamilton Bailey Text book of Clinical Surgery – S Das

27. Thank You