ULCERS_BY_ML_CHISHALA.pptxfjujjhgyhhyujg

Learn about ulcers

1. Ulcers By ML Chishala

2. Contents Definition of an Ulcer Parts of an Ulcer Classifications of ulcers Induration of an Ulcer Wagner’s classification of ulcers Granulation tissue Examination and assessment of ulcer Investigations for an ulcer

3. Definition ULCERS  An ulcer is a break in the continuity of the covering epithelium (either skin/ mucous membrane) associated with microscopic/molecular death.

4. PARTS OF AN ULCER

5. MARGIN
 This may be regular or irregular.
 It may be round or oval.
EDGE
 This connects the floor to the margin.
 There are different types of edges.

6. SLOPING EDGE  This is seen in a healing ulcer.
 Its inner part is red because of red, healthy granulation tissue.
 Its outer part is white due to scar/ fibrous part.
 Its middle part is blue due to epithelial proliferation.

7. Healing ulcer

8. UNDERMINED EDGE  Seen in a tuberculous ulcer.
 Disease process advances in deeper plane (in subcutaneous tissue) whereas (skin) proliferates inwards.

9. Tuberculous ulcer

10. ELEVATED EDGE (ROLLED OUT EDGE) It is seen in a carcinomatous ulcer due to spill of the proliferating malignant tissues over the normal skin.

11. RAISED AND BEADED EDGE (PEARLY WHITE)  Seen in a rodent ulcer (Basal cell carcinoma).
 Beads are due to proliferating active cells.

12. FLOOR It is the one that is seen.
 It may contain discharges, slough, or granulation tissue. BASE  This is where the ulcer rests on. It is not seen but felt.  It may rest on bone or soft tissue.

13. WAGNER’S CLASSIFICATION OF AN ULCER Grade 0: pre-ulcerative lesion/ healed ulcer
Grade 1: superficial ulcer
Grade 2: Ulcer deeper to subcutaneous tissue exposing soft tissue or bone
Grade 3: abscess formation underneath/ osteomyelitis Grade 4: Gangrene of part of the tissue/ limb foot Grade 5: Gangrene of entire one area/foot

14. CLASSIFICATION OF ULCERS Uses two types of classification systems:
 Clinical
 Pathological

15. CLINICAL  Ulcers classified based on:  Location : o Venous- dorsum/ medial part of foot o Arterial ulcer- lateral  Floor of ulcer : granulation

16. Discharge o Serous (granulation)
o Blood (malignant)
o Purulent (spreading) Edges o Slooping : healing O Punched out: syphilis and trophic ulcers/pressure ulcers
o Undermined- TB
o Rolled out/ elevatedmalignan

17. O Raised and beaded- rodent (malignant) Surrounding area
o Thick and pigmented skin (varicose ulcer)
o Thick and dark (arterial ulcer) PATHOLOGICAL Ulcers can either be:

18. Specific ulcers which are associated with a cause
o Tuberculous ulcer, syphilitic ulcer (punched out, deep. With “wash leather” slough in the floor and with indurated base). Actinomycosis , meleney’s ulcer. Non-specific ulcers not associated with a specific cause
o Traumatic ulcer (common): may be mechanical, physical, chemical
o Arterial ulcer: Atherosclerosis, TAO

19. Diabetic ulcer Tropical ulcers: it occurs in tropical countries. It is callous type of ulcer e.g. Vincent’s ulcer. Infective ulcer: pyogenic Venous ulcer, Gravitational ulcer, Post- phlebitic ulcer Trophic/ pressure ulcer

20. GRANULATION TISSUE HEALTHY GRANULATION TISSUE  Occurs in a healing ulcer.
 It has a slopping edge.
 It bleeds on touch and has a serous discharge. 5Ps of granulation:  Pink
 Punctate hemorrhage (bleeds on touch)
 Pulsates

21.  Painless
 Pin head granulation Skin grafting takes up well with healthy granulation tissue.  Streptococci growth in culture should be <105/gram of tissue before skin grafting.

22. UNHEALTHY GRANULATION TISSUE  It is pale with purulent discharge.
 Its floor is covered with slough, its edge is inflamed and edematous.
 It is a spreading ulcer.
 Unhealthy, pale, flat granulation tissue is seen in chronic nonhealing (callous ulcer).

23. EXAMINATION AND ASSESMENT OF AN ULCER HISTORY  Mode of onset
 Duration
 Pain- its time of onset, progress, severity
 Discharge from ulcer
 History suggestive of associated
disease/ treatment history
 The cause of the ulcer should be
found- diabetes/ venous/ arterial/
infective

24. LOCAL EXAMINTION OF AN ULCER INSPECTION Site of ulcer  Arterial ulcer: digits o Arterial ulcers are usually
found on the lateral aspect of the foot.
 Venous ulcer: malleoli (medial malleolus- commonly)
o Venous ulcers are usually found on the medial aspect of the foot.
 Trophic ulcer: heel/pressure points.

25. Size of ulcer
 Shape of ulcer
 Depth of the ulcer
 Number
 Margin whether regular/irregular/well-defined/ ill-defined
 Edge of the ulcer
 Indurated (fibrosis): squamous cell carcinoma and chronic ulcers

26. Floor of the ulcer - floor is what one sees. It rests on the base (base is not seen; it is only felt).
 Red color in floor- healing ulcer
 Slough with pale/purulent discharge- non-healing ulcer or tubercular
 Wash leather slough-syphilitic ulcer
 Proliferative and nodular flowsquamous cell carcinoma
 Pigmented- melanoma, Pigmented basal cell carcinoma

27. Discharge from ulcer bed  Serous: in healing ulcer  Purulent: in infected ulcer  Bloody: malignant ulcer, healing ulcer from healthy granulation tissue
 Seropurulent  Seroanguinous : serous and blood
 Serous with Sulphur granules: acitnomycosis

28.  Surrounding area to be examined for inflammation, edema, eczema, scarring, pigmentation
 Inspection of the entire part/ limb PALPATION Tenderness over edge, base and surrounding area.  Warmness over surrounding area.
 Edge palpation for induration
 Palpation of base for induration/fixity
 Fixed: malignant
 Non-fixed: non malignant

29.  Depth of ulcer- trophic ulcer is deep with bone as its base- often it is measured gently in mm.  Bleeding on palpation and touching.
 Palpation for deeper structures and its relation to ulcer. Surrounding skin and tibia/ calcaneum / other related bones for thickening.
 Examination of adjacent joint for mobility.
 Examination of regional lymph
nodes is essential- tenderness (Acute infection), mobility,

30. consistency may be hard
(Carcinoma metastasis)/ firm/soft and non-tender (inflammatory),
fixity (malignancy), ulceration or fungation (malignancy), sinus (nonspecific, tuberculosis or carcinoma)  Palpation also of arterial pulse, peripherally in relation to ulcer

31. AUSCULATION Auscultation of peripheral arteries for any bruits. SPECIFIC SYSTEM  Examination for varicose veins in standing position.
 Examination of the abdomen for splenomegaly (sickle cell disease), hepatomegaly.
 Examination of spine ( gibbbus , paraspinal spasm, movements) and neurological system like sensation and muscle power.

32. INVESTIGATIONS FOR AN ULCER Study of discharge: culture and sensitivity, AFB study, cytology Edge biopsy: biopsy taken from the edge because contains multiplying cells. FNAC of the lymph node (fine needle aspiration cytology) X-ray of the part to look for periostitis / osteomyelitis CXR, Mantoux test is suspected in cases of a tuberculous ulcer. Full blood count  NOTE: ulcer will not granulate if Hb is less than 10gm% and serum albumin is <3gm%

33. MANAGEMENT OF AN ULCER 1. Cause should be found and treated.
2. Correct the deficiencies like anemia, protein and vitamin deficiencies. 3. Transfuse blood if required.
4. Control pain
5. Investigate properly
6. Control infection and give rest to the part

34. Care of ulcer by debridement, ulcer cleaning and dressing Ulcer cleaning o Done using dilute povidone iodine and normal saline (ideal)
o It should be done daily or 2 times a day depending on the severity. Debridement of ulcer o It is removal of devitalized tissue.
o Small ulcers are debrided in ward.
o Large ulcers are debrided in operation theatre under general anesthesia

35. Often devitalized tissue separates on its own by autolysis.
o Enzymes like collagenase are used for debridement. Note: debridement can be surgical, mechanical, autolytic or enzymatic. Dressing of an ulcer aims to:
o Keep the ulcer moist

36. O Keep the surrounding skin dry
o Reduce pain
o Soothe the tissue
o Protect the wound
o Absorb any discharge

37. Ulcer dressing Cotton dressing- cheap but traumatic
o Paraffin dressing
o Polyurethane dressing used in clean wounds.
o Alginates (Seaweed)
dressing used when there are heavy exudates o Type 1 collagen dressing
cause hemostasis,
proliferation of fibroblast and improves blood supply

38. Causes of formation of chronic ulcer on skin Recurrent infection, trauma, absence of rest, poor blood supply, hypoxia, edema of area, loss of sensation, malignancy, specific causes like tuberculosis, fibrosis, periostitis or osteomyelitis of the underlying bone.