Ulcers Basics

A Basic Session on Ulcers, Classifications, Types, Clinical Examination, Investigations, Treatment & Management

1. ULCERS Dr.V.Mukesh Krishna

2. Definition A break in the epithelial continuity Discontinuity of the skin or mucous membrane which occurs due to the microscopic death of the tissues

3. Aetiology Venous Disease (Varicose Veins ) Arterial Disease ; Large vessel (Atherosclerosis ) or Small vessel (Diabetes ) Arteritis : Autoimmune (Rheumatoid Arthritis , Lupus) Trauma Chronic Infection : TB/Syphilis Neoplastic : Squamous or BCC, Sarcoma

4. Wagner’s Grading of ulcers 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 or osteomyelitis Grade 4 - Gangrene of part of tissues/limb/foot Grade 5 - Gangrene of entire one area/foot

5. Classification A. Clinical B. P athological

6. 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 )

7. B.Pathological 1. Nonspecific 2. Specific 3. Malignant

8. 1. Non specific Traumatic Ulcer Arterial Ulcer Venous Ulcer Neurogenic Ulcer Infective Ulcer

9. 1. Non specific contd. Diabetic Ulcer Tropical Ulcer Cryopathic Ulcer Martorell’s Ulcer Bazin’s Ulcer

10. Traumatic ulcer Mechanical- Dental ulcer on tongue ( jagged tooth ) Physical- Electrical burn Chemical- Application of caustics Acute, Superficial, Painful, Tender

11. Arterial Ulcer Caused due to peripheral vascular disease LL : Atherosclerosis & TAO UL : Cervical Rib, Raynauds Chief complaint : Severe Pain Toes, Feet, Legs & UL Digits

12. Venous ulcers Medial aspect of lower 3 rd of lower limb Ankle ( Gaiters Zone ) : Chronic Venous HTN Ulcers are Painless Varicose Veins or Post Phlebitic limb ( PTS )

13. 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

14. Tropical ulcer Tropical regions : Africa, India, S.America Trauma or Insect Bite Fusobacterium fusiformis & Borrelia vincentii Abrasions, Redness, Papules & Pustules Severe Pain

15. Diabetic Ulcer I t may be caused due to Diabetic Neuropathy Diabetic Microangiopathy Increased Glucose : Increased Infection Foot ( Plantar ), Leg, Back, Scrotum, Perineum Ischemia, Septicemia, Osteomyelitis,

16. 2. Specific Tuberculosis Syphilis Actinomycosis Meleney’s ulcer Soft sore

17. 3. Malignant Squamous cell ca Basal cell ca Malignant melanoma

18. Examination Inspection Palpation Examination of lymph nodes Vascular insufficiency Nerve lesions

19. INSPECTION Location , size, shape, floor, edge, discharge, surround­ing area. PALPATION Tenderness, 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

20. INSPECTION LOCATION OF THE ULCER FLOOR OF THE ULCER DISCHARGE FROM THE ULCER EDGE SURROUNDING AREA

21. 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

22. 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 ul­cer Wash-leather slough Gummatous ulcer

23. 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

24. EDGE DEF: 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.

25. Sloping edge All healing ulcers like traumatic ulcers, venous Ulcers

26. B. Punched out edge Gummatous ulcers and trophic ulcers.

27. C. Undermined edge Tuberculous ulcers

28. D. Raised edge (beaded edge) Rodent ulcers or basal cell carcinoma .

29. E. Everted edge (Rolled out) Squamous cell carcinoma.

30. SURROUNDING AREA Thick and pigmented Varicose ulcer. Thin and dark Arterial ulcer. Red and oedematous Spreading ulcers like dia­betic ulcer.

31. PALPATION EDGE BASE MOBILITY BLEEDING SURROUNDING AREA

32. EDGE Induration (hardness) of the edge is very char­acteristic 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 .

33. BASE It is the area on which ulcer rests. Marked induration at the base is diagnostic of squamous cell carcinoma .

34. 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.

35. MOBILITY Gentle attempt is made to move the ulcer to know its fixity to the underlying tissues. Malignant ulcers are usually fixed , benign ulcers are not.

36. BLEEDING Malignant ulcer is friable like a cauliflower. On gentle palpation, it bleeds . Granulation tissue as in a healing ulcer also causes bleeding.

37. SURROUNDING AREA Thickening and induration is found in squamous cell carcinoma. Tenderness and pitting on pressure indicates spreading inflammation surround­ing the ulcer.

38. 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.

39. MANAGEMENT

40. Investigations Complete blood picture : Hb %, TC, DC, ESR, PS Urine and blood examination to rule out diabetes Chest X-ray - PA. view to rule out P.TB Pus for culture/sensitivity Lower limb angiography in cases of arterial diseases X-ray of the part to see for Osteomyelitis Biopsy : Non-healing/malignant ulcers

41. Treatment Address cause Correct deficiencies Control pain, infection Debridement, dressing Closure of defect

42. TREATMENT OF THE ULCERS Treatment of Spreading Ulcers Treatment of Healing Ulcers Treatment of Chronic Ulcers Treatment of The Underlying Disease

43. TREATMENT OF SPREADING ULCERS Pus Culture/Sensitivity report, Appropriate Antibiotics Solutions to treat the Slough : H₂O₂ & EUSOL - Edinburgh University Solution (Hypochlorite solution ) Excessive Granulation T issue (Proud F lesh) : Excision or Application of Copper Sulphate or Silver Nitrate Repeated Dressings,

44. TREATMENT OF HEALING ULCER Regular dressings are done for a few days A ntiseptic 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

45. 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.

46. HAVE A GOOD DAY