Ulcers- A document detailing the aetiology

Ulcers

1. U l c e r s

2. D e f i n ition U l c e r i s l o s s o f c o n t i n u i t y o f a n e p i t h e liu m , internal o r e xternal a n d u s u ally follows a g r a d u a l c e l l b y c e l l d e a t h o f c o n s t i t u e n t c e l l s . An ulcer is a discontinuity of an epithelial surface. It is characterised by destruction of the surface epithelium and a granulating base.

3. C l a s s i f i cation S p e c i fic N o n s p e c i fic M a l i g n ant

4. S p e c i fic T h e y a r e caused b y S p e c i fic o r g a n i s m s e g m y c o b a cterium u l c e r a n s b a c i l l i e t c t h e E d g e i s c h a r a c t e r i s t ic f o r e a c h t y p e . I t i n c l u d e s T u b e r c u l o u s u l c e r s B u r u l i u l c e r s S y p h i l itic u l c e r s Y a w s t r e p o n ema p e r t e n u e u l c e r s M y c o b a cterium l e p r a e u l c e r s

5. N o n s p e cific u l c e r s T h e y h a v e t h e s a m e feature o f a s l o p i n g e d g e . B u t t h e u n d e r l y ing a e t i o l o g i e s a r e v a r i e d . T h e y a r e t h e c o m m o n e s t u l c e r s T r a u m a t i c P y o g e n i c V a s c u l a r : V e n o u s A r t e r i a l Decubitus P r e s s u r e s o r e s

6. C o n t d N e u r o t r o p i c u l c e r s L e p r o s y d i a b e t i c n e u r o p a thy C o r d l e s i o n s M e t a b o l i c u l c e r s Diabetic u l c e r s H e m o g l o b i n o path i c U l c e r s

7. N e o p l a s t ic u l c e r s T h e y a r e n e o p l a s t ic i n origin . S o m e t i m es a c h r o n i c u l c e r c a n b e c o m e Neoplastic e g c h r o n i c b u r u l i u l c e r c h r o n i c b u r n u l c e r , s u c h u l c e r s a r e r e f e r r e d t o a s m a j o r l i n u l c e r s . examples i n c l u d e : S quamous c e l l c a r cinoma R o d e n t u l c e r s M a l i g n a nt m e l a n o m a K a p o s i ' s s a r c o m a P e n e t r a t i n g malignant t u m o r

8. C h a r a c t e r istics o f u l c e r E d g e : it's w h e r e t h e h e a l t h y s k i n b e g i n s . I t m a y b e s l o p i n g i n n o n s p e c i fic u l c e r s , u n d e r m i n e d i n t u b e r c u l ous u l c e r s , r a i s e d i n m a l i g n ant u l c e r s a n d p u n c h e d o u t i n s y p h i l itic u l c e r F l o o r : i t is w h a t i s s e e n , i t m a y s l o u g h i n g with p r o f u s e offens i v e y e l l o w i s h d i s charge o r c o n s i s t s o f p i n k i s h r e d g r a n u l a t i o n w i t h thin s e r o u s d i s c h arge s u g g e s t i v e o f h e a l i n g . b a s e : t h i s i s w h a t i s f e l t o r p a l p a t e d . I t m a y b e h a r d o r indurated i n a m a l i g n a n t o r l o n g s t a n d i n g c a l l o u s u l c e r

9. S y p h ilitic u l c e r It is now uncommon. It follows breakdown of a subcutaneous g u m m a , especially around the knee. It has a outline because as it heals in some parts it spreads in others. The edge is punched out . The floor is covered with yellowish slough and the discharge is thick and foul-smelling. Diagnosis: Apart from the characteristic lesion, V.D.R.L. is strongly positive. A biopsy specimen shows the t y p i c a l histology. Treatment: A course of penicillin

10. N o n s pecific u l c e r s There are several causes. The distinctive feature is a sloping edge. The ulcer goes through the following phases. Acute or infective phase: In this initial phase, the ulcer is painful and the histology is similar to that of an abscess. The sloughing floor is covered with purulent discharge in which different types of bacteria may be identified. The edge is sharp and surrounded by damaged cells. The surrounding skin is oedematous, warm and tender. Transition phase: The slough separates, the p u s drains, infection subsides, granulation tissue grows and the floor becomes clean and pinlush-red. The edge, which is sloping, has a thin bluish-white layer of young epithelium growing inwards. The surrounding s k i n i s s lightly hyperaemic o r normal. Reparative or healing phase The ulcer is now painless. The healthy granulation tissue fills the floor and the epithelium grows the edge at the rate of 1 m m / d to cover the floor

11. P r e s s u r e u l c e r ( Decubitus u l c e r ) I t i s a s a r e s u l t o f i s c h e mia from prolonged pressure between bed and body over a bony prominence , therefore I t occurs in those areas with bony points where prolonged pressure can be sustained e.g. the heel, trochanteric regions, scalp and shoulder blades .

12. P a t i e n t s a t r i s k It is usually seen in those who are unaware of the warning signals of discomfort or pain to change their position, e.g. unconscious p a t i e n ts paraplegic patients those too weak to change their position Poor nutritional status maceration of skin by sweat or urine infection predispose to the early development of D ecubitus ulcer

13. C a u s e s Prolonged pressure is essentially the main cause of a decubitus ulcer with other factors such as moisture, poor circulation, and poor nutrition contributing. Lying on a certain part of your body for long periods may cause your skin to break down. The areas around the hips, heels, and tailbone are especially vulnerable to pressure sores. Excessive moisture as well as skin irritants like urine and feces, which result from poor hygiene, can also contribute to decubitus ulcer formation. Friction is also a contributor, such as when a person who is confined to bed has sheets dragged from under them

14. S t a g e s o f p r e s s u r e u l c e r I - N o n b l a n c h a b l e e r y t h e m a I I - S k i n l o s s I I I - S u b c u taneous t i s s ue l o s s I V - M u s c l e l o s s e x p o s i n g t h e b o n e s X - e s c a r

15. P r e v e n t i o n Continuous t u r n o v e r o f t h e p a t i e n t 2 h o u r l y i n t h e absence o f a n a i r / w a t e r b e d o r 4 h o u r l y w i t h a i r b e d A d e q u a te s k i n c a r e - m a s s a ge , a p p l i c a tion air b a r r i e r c r e a m , p o w d e r i n g B l a d d e r c o n t rol : c a t h e t e r ization T h e b e d l i n e n must n o t b e c r e a s e d a n d m u s t b e c l e a n U s e o f a i r b e d N u t r i tion V i t a m i n C a n d z i n c s u p p l emen t s W o u n d dressing

16. T r e a tment l o c a l dressing o f s a l i n e a r e a p p l i e d t o a i d e a r l y s e p a r a t i o n o f s l o u g h D e s l o u g h i n g o r debridement s k i n g r a f t o r f l a p i m p r o v i n g t h e n u t i t i o n

17. M a n a g e ment o f u l c e r C l i n i cal f e a t u res P a i n B l i s t e r s D i s c h a rging a b s c e s s N i g h t s w e a t s p a i n f u l s w e l l i ng I n a l y m p h n o d e L o s s o f s e n s a t ion i n t h e l i m b J o i n t o r m u s c l e p a i n P r e v i o us c h a n c r e

18. E x a m i n ation S i t e : k n e e , m e d i a l m a l l eolus , t o e a n d d o r s u m o f f o o t , h e e l a n d s o l e o f f o o t S h a p e : s e r p i n g o u s , i r r e g u l a r o u t l i n e , i r r e g u la r l y c i r c u l a r E d g e : sloping , r a i s e d a n d r o l l e d , u n d e r m i n ed , p u n c hed o u t Floor : g r a n u l a tion t i s s u e , d e a d t i s s u e s o r s l o u g h S u r r o u n d i n g s k i n : pigmen t e d ( v e n o u s ) , c y a n o t i c h a i r l e s s a n d c o l d ( a r t e r i a l ) B a s e - s o f t , i n d u r a t e d a n d f i x e d S t a t e of l o c a l circulation - d i l a t e d v e i n s , e d e m a , s k i n t e m p e r ature , arterial p u l s e R e g i o n al L y m p h n o des

19. I n v e s t i g a tion U r i n e - s u g a r B l o o d - F b c M a n t o u x t e s t E S R W o u n d M / C / S p l a i n x r a y - b o n y c h a n g e s , c a l c i f ication o r c h e s t x - r a y f o r t b f o c u s B i o p s y

20. T r e a t m e nt A d j u v a n t M a n a g e t h e u n d e r lying c a u s e : T B , D M e t c B e d r e s t A n t i T e t a n u s s e r u m A n t i b i o tics T r e a t m e n t S i m p l e d r e s s i n g - u s i n g h o n e y Excision t h e n s p l i t s k i n g r a f t o r f l a p c o v e r P o s t d i s charge A d v i ce : L e g h y g i ene C o m p r e s s i o n t h e r a py

21. C o m p l ications L o c a l o r s y s t e m i c i n f e c tion T e t a n u s S c a r s , c o n t r a c t u r e s L y p h o e d e m a O s t e i t i s , o s t e o m yelitis M a j o r l i n ' s u l c e r