Ulcer ppt by the surgery department of hospital

It is the basic study ppt of ulcer designed and prepared by the resident doctor of the surgey department of hospital

1. Ulcer

2. Definition An ulcer is a break in the continuity of the covering epithelium, either skin or mucous membrane due to molecular death.

3. Parts of a ulcer 1.Margin : it may be regular or irregular. It may be rounded or oval. 2.Edge: It connects floor of the ulcer to the margin.

4. Different edges: Sloping edge . It is seen in a healing ulcer. Undermined egde . It is seen in tuberculous ulcer. Punched out edge. It is seen in syphilitic & trophic ulcer.

5. Raised & beaded edge . It is seen in a rodent ulcer. Everted (rolled out) edge. It is seen in carcinomatous ulcer.

6. 3.Floor: It is the one which is seen. Floor may contain discharge, granulation tissue or slough. 4.Base: Base is the one on which ulcer rests. It may be bone or soft tissue.

7. Classification Ulcer classified into two ways. Clinical classification Pathological classification

8. Clinical 1. Spreading ulcer: Here edge is inflamed and edematous.

9. 2. Healing ulcer: Edge is sloping with healthy red granulation tissue with serous discharge.

10. 3. Callous ulcer: Floor contains pale unhealthy granulation tissue with indurated egde /base. It lasts for many months to years. Ulcer does not shows any tendency towards healing.

11. Pathological Specific ulcers Tuberculous ulcer Syphilitic ulcer Actinomycosis Meleney’s ulcer

12. Malignant ulcers: Carcinomatous ulcer Rodent ulcer Melanotic ulcer

13. Non specific ulcers: Traumatic ulcer Arterial ulcer Venous ulcer Trophic ulcer Tropical ulcer Ulcers due to chilblains and frost bite Martorell’s ulcer Diabetic ulcer Ulcers due to leukemia, polycythemia , jaundice, collagen diseases, lymphedema.

14. Wagener’s grading/ classification of ulcer Grade 0: Preulcerative lesion/ healed ulcer Grade 1: Superficial ulcer Grade 2: Ulcer deeper to subcutaneous tissue exposing soft tissue or bone Grade 3: Abscess formation underneath/ osteomylitis Grade 4: Gangrene of part of the tissues/limb/foot. Grade 5: Gangrene of entire one area/foot

15. Granulation tissue Its prolifertion of new capillaries and fibroblasts intermingled with RBCs and WBCs with thin fibrin cover over it.

16. Healthy granulation tissue: It occurs in a healing ulcer. It has got slopping edge. It has got serous discharge. 5 Ps- Pink, Punctate hemorrhages, Pulseful , Painless, Pin head granulation. Skin grafting takes up well with this.

17. Unhealthy granulation tissue: It is pale with purulent dicharge . Its floor is coverd with slough. Its egde is inflamed and edematous. It’s a spreading ulcer. Unhealthy , pale, flat granulation tisssue : Its seen in chronic nonhealing ulcer.( callous ulcer)

18. Different discharges in an ulcer Serous : in healing ulcer Purulent : in infected ulcer Staphylococci: yellowish and creamy Streptococci: bloody and opalescent Pseudomonas: greenish color Bloody : malignant ulcer , healing ulcer Seropurulent : Serosanguinous : serous and blood Serous with sulphur granules : Actinomycosis Yellowish : tuberculous ulcer

19. Investigations for an ulcer Routine blood investigations X rays of local part to look for periostitis / osteomyelitis MRI local part particularly for diabetic ulcers ( foot) X ray chest , Mantoux test in suspected case of tuberculous ulcer. Study of discharge: Culture & sensitivity, AFB study, Cytology. Egde biopsy : biopsy is taken from the edge because edge contains multiplying cells. FNAC of the lyphnode . Doppler study in suspected case of arterial or venous ulcer.

20. Management of an ulcer Cause should be found and treated Correct deficiencies like anemia, protein and vitamins deficiencies. Transfuse blood if required. Control the pain. Investigate properly. Control infection and give rest to the part. Care of ulcer by debridement, ulcer cleaning and dressing done. Remove the exuberant granulation tissue. Topical antibiotics Antibiotics are not required once healthy granulation tissue formed Once granulates : defect should be coverd with secondary suturing , skin grafts or flaps.

21. Debridement of an ulcer It is removal of devitalized tissue. Small ulcers are debrided in ward. Large ulcers are debrided in OT under anesthesia. All dead, devitalized , necrotic tissue are removed. Enzymes like collagenase are used for debridement. Hydrotherapy and dressings are mechanical non selective method of debridement.

22. Ulcer cleaning is done using dilute povidone iodine, Hydrogen peroxide and normal saline (ideal and better). It should be done daily or twice daily depending on severity. Debridement can be surgical, mechanical, autolytic or enzymatic.

23. Ulcer dressings Cotton dressings. Paraffin dressings. Alginates dressing used when there are heavy exudates Type 1 collagen dressings cause hemostasis , proliferation of fibroblasts and improb = ve the blood supply. Foam dressings (hydrophilic polyurethane foam) are highly absorbent, decrease the wound maceration and frequency of dressing Hydrocolloid dressings help in seprartion of slough and autolysis of dead tissue. Transparent film dressings are waterproof , permit oxygen and water vapour across and prevent contamination. Hydrogel dressing used for clean wounds.

24. Causes for chronic ulcer formation Recurrent infection Trauma Absence of rest Poor blood supply Hypoxia Edema of area Loss of sensations Malignancy Specific cause like TB Fibrosis Osteomyelitis of underlying bone

25. Tuberculous ulcer It caused by Mycobacterium tuberculosis. Results following the burst of a cold abscess or tuberculous lesions of the bones and joints.

26. Clinical presentation Usually multiple. Shape is irregular Edges are undermined Floor is covered with pale granulation tissue Surrounding skin show pigmentation. Regional lymphnodes may be enlarged, which are firm, non tender and matted. There may be associated systemic evidence of tuberculosis in the lungs or other parts of the body.

27. Investigations Bacteriological examination may identify Mycobacterium tuberculosis which is established by Ziehl Neelsen staining. Culture in Lowenstein-Jensen medium. Xray chest may identify pulmonary lesions. Mantoux test may be useful.

28. Treatment Anti tuberculous drugs are mendatory . Antibiotics are needed to treat secondary infections. Dressings are needed to cover the ulcers.

29. Lupus vulgaris Tuberculosis of skin seen mostly in children and young. Sinle or multiple cutaneous nodules with ulcerations. Common on face and occasionally on the arm. Ulcers remain active at the periphery , but show signs of healing at centre.

30. Biopsy of the ulcer for TB bacilli. Anti tuberculous drugs are mendatory . Antibiotics are needed to treat secondary infections. Dressings are needed to cover the ulcers.

31. Syphilitic ulcer Caused by Treponema pallidum . Transmitted by sexual contact.

32. Clinical presentation Ulcer is a manifestation of the first stage of the disease. Manifests about 3-4 weeks after infection. Single painless ulcer on the genitalia (hard chancre). Found on the coronal sulcus , frenum and rarely on the glans and shaft.

33. Has characteristic hard feel like a button with well defined margins. Regional lymphnodes are mobile, discrete and shotty in nature with no tendency towards suppurate. Extragenital chancres are also seen on the lips, tongue, nipple and rectum.

34. Investigations & Treatment Dark field microscopy of the exudates demonstrates Treponema pallidum . Wassermann reaction & Kahn tests are positive in the primary stage. Enzyme immunoassay for T. Pallidum is specific for primary syphilis. Chancres heal spontaneously but may recur at a later stage.

35. Gummatous ulcer A late manifestation of syphilis. Occurs 3-12 years after primary infection and It is due to inflammatory reaction in perivascular lymphatics of the terminal vessels producing obliterative endarteritis, necrosis and fibrosis.

36. Clinical presentation Painless ulcers. Common on the areas of thin skin over the bones like sternum, tibia, ulna and skull . Edges are round in shape and punched out . Floor is covered by yellowish grey slough (wash-leather). Lymphnodes are rarely involved unless secondarily involved.

37. Investigations & Treatment Wassermann reaction & Kahn tests are positive. Aqueous procaine penicillin is the standard drug of choice. Doxycycline is also good alternative.

38. Soft chancre ( chancroid ) Caused by Haemophillus ducreyi . Spreads through sexual contact . Develops about 3-7 days after the exposure.

39. Clinical presentation Single or multiple painful ulcers. (Rail road track appearnce ) The ulcers are soft. Edges are umdermined . Margins are edematous, Floor is covered by typical yellow slough. Base is non- indurated . Discharge copious and purulent. Bleeds readily to touch. Ingunal lymphnodes are enlarged, hard, tender may form inguinal abscess, ulcer or sinus.

40. Investigations & Treatment Smear examination ( Gram’s , Wright staining) Culture with special media can isolate the organism. PCR tests are useful. Ciprofloxacin, ceftriaxone , azithromycin and erythromycin are effective drugs. Abscess need drainage.

41. Arterial ( ischaemic ) ulcers Devlops due to impaired blood supply as in thrombo-angiitis obliterans and atherosclerosis. Common in chronic smokers .

42. Clinical presentation Dry punched out painful ulcer on the feet especially on the toes. Penetrates deep fascia. History of intermittent claudication , rest pain and discoloration of the toes may suggest arterial etiology. Floor covered with minimal granulation tissue and also reveals the underlying structures like tendons and nerves. Absent pulses of the lower limbs is conclussive .

43. Investigations & Treatment Arteriography and Doppler studies are useful in diagnosis. Vasodilators are essential. Tromboembolectomy is the treatment of choice if the arteriography does not show enough collaterals.

44. Venous (Varicose) ulcer These ulcers develop due to increased hydrostatic pressure in the vein (gravitational ulcer). Commonly in the lower limbs. Ulcerations occur due to defective exchange of oxygen and metabolites following edema.

45. Clinical presentation Solitary ulcer, usually seen on the lower leg. More common on the medial aspect of lower leg at the level of the perforators .

46. It is a superficial ulcer . Margin is thin and blue. Edge is sloping. Floor is covered with pale, unhealthy granulation. Discharge is scanty. Surrounding skin is pigmented. Varicose veins are always present. There may be associated edema of the lower limb.

47. Investigations & Treatment Doppler studies and venography are diagnostic. Phlebotonic drugs and limb elevation are useful. Compression bandages or stockings are essential.

48. Marjolin ulcer Its low grade epidermoid carcinoma arising from the epithelium covering the scar tissue commonly burns, keloid or long standing venous ulcer .

49. Clinical presentation Slow growing painless ulcer. Clinically it mimics a squamous cell carcinoma .

50. Investigations & Treatment Biopsy is confirmative. Treatment is wide excision .

51. Diabetic ulcer Develops due to neuro-vasculopathy . This is a metabolic neuropathy associated with atherosclerotic changes causing microangiopathy .

52. Clinical presentation Starts as a painless ulcer usually on the toes or the heel of the feet. It becomes deep and penetrating due to repeated infections. Edge is inflammed and indurated . Floor may contain seropurulent discharge. Base may be fixed to the deeper structures.

53. Investigations & Treatment Determination of blood glucose level is necessary. Treatment of diabetes mellitus. Local care of ulcer.

54. Trophic ulcer Occurs due to neuropathy , producing loss of sensation commonly in the foot.

55. Clinical presentation Painless punched out ulcer. Common at the pressure points like heads of metatarsals and sacral region (bed sore) Central part is deep and burrows deep into the tissues, creating foul smelling slough. Egde is thickened. Surrounding skin is anaesthetic .

56. Investigations & Treatment Nerve conduction studies may be required to confirm the diagnosis. Excision of slough (Thorough debridement). Reconstruction with skin flaps for large defect.

57. Tropical ulcer Occurs due to infection of Vincent’s organisms ( Bacteroides fusiformis ). Start from an insect bite.

58. Clinical presentation Papule- pustule with a zone of surrounding inflammation and induration . These lesions burst in 2-3 days to form painful foul smelling ulcers with undermined and raised egdes . Ulcers become indolent and refuse to heal for long time.

59. Investigations & Treatment Determination of blood sugar level is important for rule out DM. Heals spontaneously after a long time with leaving behind circular pigmented scar.

60. Traumatic ulcer Results due to direct trauma Mechanical Chemical Thermal Electrical Radiation

61. It shows feature of active ulcer. Proper history is required to localize the incriminating agent. Ulcers heal when incriminating agent is removed followed by administration of antibiotics and dressing.

62. Martorell’s ulcer Seen in atherosclerotic women on leg. Bazin’s ulcer Seen in fatty young girls perticularly on the calves. Meleny’s ulcer It is seen on abdominal wall following surgeries operated for perforated appendix or peptic perforation. Occurs due to symbiotic action of micro- aerophilic non hemolytic streptococci and staphylococcus.