ULCERS, SINUSIS AND FISTULAE. EDITED.pptx

This presentation is about some of the surgical cases occuring commonly in tropics.
Evaluation, prevention and definitive treatment is very vital in medical practice.
Prepared by some students under supervision and guidance from their teachers/trainers and colleagues.

1. CUTANEOUS ULCERS, SINUSES AND FISTULAE

2. PRESENTERS UG20/MDMD/1042 UG20/MDMD/1044 UG20/MDMD/1048

3. OUTLINE ULCERS Definition Causes Classification Characteristics Wagner’s grading of ulcers Examination Management (Investigation & Treatment)

4. OUTLINE… SINUSES Definition Classification Causes Clinical features Complications Management

5. OUTLINE… FISTULAE Definition Types/forms Examples Clinical features Complications Management

6. ULCERS

7. Definitions A break in the epithelial continuity. Discontinuity of the skin or mucous membrane, which occurs due to the microscopic death of the tissues. An ulcer is a break in the continuity of the skin or mucous membrane with loss of surface tissue, disintegration and necrosis of epithelial tissue and often pus formation.

8. Aetiology Venous Disease (Varicose Veins) Arterial Disease: Large vessel (Atherosclerosis), Small vessel (Diabetes) Arteritis: Autoimmune (Rheumatoid Arthritis, Lupus) Traumatic: pressure sores, physical injury Chronic Infection (TB/Syphilis, leprosy) Neoplastic Causes: Squamous Cell Carcinoma (SCC), Basal Cell Carcinoma (BCC), Sarcoma. Tropical: Buruli ulcer (mycobacterium ulcerans ) Neuropathic: diabetic foot ulcer

9. Characteristics of an ulcer EDGE: It is where the healthy skin begins FLOOR: It is what is seen. BASE: It is what is palpated, it may be indurated or hard

10. Classification of ulcers Nonspecific Specific Neoblastic

11. 1. Non-Specific Ulcers Traumatic Pyogenic Ulcers of vascular origin Arterial Venous Pressure sores D. Neurotropic (tropic) Leprosy Diabetic neuropathy Cord lesions E. Ulcers ass. With metabolic or systemic diseases Diabetic

12. Traumatic ulcer A traumatic ulcer is an ulcer caused by injury or irritation rather than an underlying disease. It can be classified into three types based on the cause: Mechanical : Dental ulcer on the tongue due to a jagged tooth, ill-fitting dentures, or excessive brushing. Physical : Electrical burns from biting live wires or exposure to hot substances. Chemical : Application of caustic substances (e.g., acid, strong antiseptics, aspirin burns in the oral cavity).

13. Traumatic ulcer con`t Clinical Features of Traumatic Ulcers Acute (develops suddenly after trauma). Superficial (affects only the surface of the mucosa). Painful and Tender (due to exposed nerve endings).

14. Arterial ulcer Caused due to peripheral vascular disease LL : Atherosclerosis & TAO( Thromboangitis Obliterance ) UL : Cervical Rib, Raynauds Chief complaint : Severe Pain Location: Toes, Feet, Legs & UL Digits

15. Venous ulcers Also called stasis ulcer . Are skin breakdowns that typically occur when chronic venous insufficiency leads to increased pressure in the leg veins location Medial aspect of lower 3rd of lower limb Ankle ( Gaiters Zone ) : Chronic Venous HTN Ulcers are Painless Varicose Veins or Post Phlebitic  limb ( PTS )

16. Diabetic ulcer It may be caused due to Diabetic Neuropathy Diabetic Microangiopathy Increased Glucose : Increased Infection Common location Foot (Plantar ), Leg, Back, Scrotum, Perineum complications Ischemia, Septicemia, Osteomyelitis

17. 2. Specific ulcers Tuberculous ulcers Syphilitic ulcers Actinomycosis ulcers Meleney`s ulcers Buruli ulcers

18. 3. Neoplastic Squamous cell carcinoma Basal cell carcinoma (rodent) ulcer Malignant melanoma

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

20. EXAMINATION Inspection Palpation Examination of lymph nodes Vascular insufficiency Nerve lesions

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

22. FLOOR OF THE ULCER This is part of the ulcer which is exposed or seen

23. DISCHARGE FROM THE ULCER

24. EDGES OF ULCERS 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. EDGES The edge of an ulcer provides crucial clues about its causes and stage of development . Here’s the breakdown of the types ulcer edges and what they commonly indicate: Sloping Edge Description: gradual slope from the skin to the ulcer base Seen in: healing ulcers Significance: indicates healthy granulation tissue and healing process

26. EDGES… 2. Undermined Edge Description: base of ulcer extends beyond the skin margin Seen in: tuberculous ulcers Significance: destruction of subcutaneous tissue faster than the skin due to caseous necrosis 3. Punched-out Edge Description: sharp, clean-cut, with vertical sides Seen in: Sphilitic ulcers Trophic ulcers Ischemic/arterial ulcers Significance: often painless and indicates deep tissue necrosis

27. EDGES… 4. Raised and Beaded Edge Description: elevated, poorly or rolled edge Seen in: basal cell carcinoma(rodent ulcer) Significance: suggests a malignant ulcer; typically painless and slow-growing 5. Everted (Rolled-out) Edge Description: raised, outward-turned margins Seen in: squamous cell carcinoma Significance: common in malignant or non-healing ulcers, often indurated (hard)

28. EDGES… 6. Inflamed Edge Description: red, swollen, tender Seen in: acute ulcers e.g., traumatic or infected Significance: suggests active infection or acute inflammation

29. EDGES…

30. SURROUNDING AREA

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

33. 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. BLEEDING ► Malignant ulcer is friable like a cauliflower. On gentle palpation, it bleeds. ► Granulation tissue, as in a healing ulcer, also causes bleeding. SURROUNDING AREA ► Thickening and induration is found in squamous cell carcinoma. ► Tenderness and pitting on pressure indicates spreading inflammation surrounding the ulcer.

34. Clinical Features Pain (varies with cause) Discharge (serous, purulent, or blood-stained) Base and edge characteristics Surrounding tissue changes (inflammation, pigmentation, induration)

35. Complications Secondary infection Hemorrhage Malignant transformation Delayed healing or chronicity

36. Management 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

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

38. TREATMENT OF SPREADING ULCERS ► Pus Culture/Sensitivity report ► Appropriate Antibiotics ► Solutions to treat the Slough: H₂O₂ & EUSOL – Edinburgh University Solution (Hypochlorite solution) ► Excessive Granulation Tissue (Proud Flesh): Excision or Application of Copper Sulphate or Silver Nitrate ► Repeated Dressings

39. TREATMENT OF HEALING ULCER ► Regular dressings are done for a few days. ► Antiseptic 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). ► Ulcer is large – Free Split Skin Graft applied.

40. 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 formation. ► These ulcers ultimately may require skin grafting.

41. SINUSES

42. Definition Blind tract lined by granulation tissue leading from epithelial surface down into the tissue . Latin: hollow or a bay Classification of sinuses Physiological pathological

43. Physiological sinuses These are naturally occurring cavities or spaces in the body that serve important function. Types of Physiological Sinuses: Paranasal Sinuses – Air-filled spaces in the skull (FEMS) that help in voice resonance, humidifying air, and reducing skull weight. Venous Sinuses – Large veins in the brain (e.g., superior sagittal sinus) that drain blood from the brain to the heart. Dental Sinuses – Small spaces in the gums or bones associated with teeth. Bony Sinuses – Small air-filled cavities in bones (e.g., mastoid air cells in the temporal bone). Fistulous Tracts (when congenital) – Some sinuses may develop normally in embryology but close later, like the thyroglossal duct.

44. Pathological sinuses These are abnormal tracts or cavities that form due to disease, infection, or trauma. Types of Pathological Sinuses: Chronic Inflammatory Sinuses – Result from long-term infections (e.g., tuberculosis sinuses, actinomycosis). Osteomyelitis-Related Sinuses – Develop when infection spreads from bone to the skin (e.g., in diabetic foot ulcers). Post-Surgical or Trauma-Induced Sinuses – Occur after poor wound healing. Pilonidal Sinus – A cyst or sinus near the tailbone, often due to ingrown hair. Dental Sinus Tract – Caused by chronic dental infections, leading to pus drainage from the gum or cheek.

45. Pathological sinus Aethiology Chronic Non-Healing Ulcers – Such as pressure sores or diabetic foot ulcers. Osteomyelitis – Bone infections can lead to sinus tracts discharging pus. Tuberculosis – Cold abscesses can drain through sinus tracts. Actinomycosis – A chronic bacterial infection that forms multiple draining sinuses. Post-Surgical Complications – Poor wound healing may result in sinus formation.

46. Pathological sinuses Clinical Features: Persistent pus or fluid discharge. External opening with granulation tissue or necrotic debris. Can be painful or painless, depending on the cause. Often associated with underlying induration May be painless or mildly painful Investigations Typically requires investigations like probe test, imaging (X-ray, MRI), or biopsy.

47. Complications Chronic infection Scar formation Secondary sinus formation Rarely malignant change ( Marjolin’s ulcer)

48. Pathological sinus Management: Identifying and treating the underlying cause (e.g., infection control in osteomyelitis). Surgical debridement if there is necrotic tissue. Antibiotic therapy for infection. Skin grafting or reconstructive surgery for chronic cases. Imaging (sinogram, X-ray)

49. FISTULAE

50. Definition Fistula is an abnormal communication between two or more epithelial surfaces. 0R An abnormal connections or passageways between two epithelial-lined surfaces such as organs, vessels or tissues that normally do not connect. Types/Forms Congenital: tracheoesophageal, branchial Acquired

51. Aetiology of acquired fistula An abscess which ruptures into two cavities or a cavity and the skin. Trauma. Granulomatous lesions- Tuberculosis, Crohn's disease, ulcerative colitis, schistosoma mansoni tend to form fistulae. Malignant disease. Intentional e.g. colostomy, ileostomy, uretero-colic fistula, gastro-jejunostomy.

52. Clinical Features Depend on the location of the fistula and may include: Persistent discharge Opening(s) with granulation tissue Passage of contents (e.g., feces, urine) Chronic drainage of pus or fluids Fecal or urinary incontinence (for rectovaginal/vesicovaginal fistulae) Recurrent infections Pain or swelling around the affected area Infection, irritation

53. Complications Fluid and electrolyte imbalance Malnutrition Infection and sepsis Skin excoriation

54. Management Conservative management: Antibiotics, wound care, and nutritional support (especially for enterocutaneous fistulae). Imaging ( fistulogram , MRI, CT) Surgical excision/repair: Closure of the fistula, often required for persistent cases. Seton placement: For perianal fistulae to promote drainage and prevent recurrence. Fibrin glue or plugs: Minimally invasive options to close certain types of fistulae.

55. CONCLUSION Ulcers, sinuses and fistulae are complex conditions that require proper understanding and management. Understanding these conditions is crucial for developing a treatment plan that addresses the underlying cause and promotes healing. It also helps to reduce the risk of infection, organ damage or other complications.

56. REFERENCES Badoe , Archampong , Jaja. BAJA’S Principles & Practice of Surgery (5 th edition) Norman Browse The Symptoms and Signs of Surgical Disease (4 th ed) www.apollohospitals.com Compendium for surgery tutorials- Bashir Bin Yunus www.medlineplus.com.org National institutes of health(NIH)-Ulcers care & treatment American Journal of surgery www.clevelandclinic.com