Ulcers

SPECIAL THANKS TO
SADRU MOHAMED
FOR MAKING THESE SLIDES AVAILABLE HERE
[email protected]
[phone]

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
[email protected]
[phone]