Venous Ulcers.pptx

Lecture notes for medical students

1. Tips on using my ppt. You can freely download, edit, modify and put your name etc. Don’t be concerned about number of slides. Half the slides are blanks except for the title. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. At the end rerun the show – show blank> ask questions > show next slide. This will be an ACTIVE LEARNING SESSION x three revisions. Good for self study also. See notes for bibliography.

2. An ulcer is a defect with loss of epidermis and atleast part of the dermis

3. Causes of lower limb ulceration

4. Causes of lower limb ulceration Venous insufficiency (45 -60%) Arterial insufficiency (10 -20%) Diabetes (15 -25%) Vasculitis Haematological dissease Infections Trauma Drugs/therapy:- hydroxy urea Skin conditions:- pyoderma gangrenosum , necrobiosis lipoidica malignancies Genetic :- prolidase deficiency, klinefelter`s syndrome

5. Venous Return

6. Venous Return With muscle contraction, deep veins are compressed, one way valves in deep system allow the high pressure flow to move against gravity One way valves in perforators close to prevent pressure injury to the skin In all patients with venous disease there is failure of these one way valves Worsened by impairment of leg muscle function or ankle joint range of motion

7. Causes of venous ulcer

8. Risk Factors

9. Maternal history of venous insufficiency History of DVT, DM, chronic heart failure or recent edema Obesity Severe trauma to the leg Vigorous exercise Number of pregnancies Risk Factors

10. Pathogenesis Capillary stasis : ` Homans ` postulated that stasis of venous blood in post-thrombotic syndrome gave rise to anoxia and hence venous ulcers Fibrin cuff theory: ` Browse and Bermand ` postulated that venous ulcer could be result of deposition of pericapillary fibrin due to leakage of fibrinogen through pericapillary spaces. fibrinogen polymerizes to form fibrin Oxygen diffusion barrier Increase in collagen IV in and around capillary .

11. Pathogenesis

12. Pathogenesis White cell trapping : Endothelium is damaged by increased venous pressure and leukocyte activation. Proteolytic enzymes and free radicals are released, escape through the leaky vessel walls, and damage the surrounding tissue, leading to injury and ulceration.  Impaired lymphatic function

13. A non-healing open wound Often near the ankle With or without visible varicose veins

14. Signs and symptoms

15. Signs and symptoms Usually preceded by patchy erythema or discoloration of an intense bluish red colour (capillary congestion) Ulcer is typically painless. Patients develop typical ischemic pain on elevation of the ulcerated leg, which is oedematous . Associated with arterial disease can ( 1/3 of cases). Ulcer is covered with yellowish exudate over granulation tissue Non-healing ulcer resembles severe paronychia being boggy, undermined and congested from oedema . Base is white and fibrous

16. Clinical Features

17. Clinical Features Non healing ulcer in Gaiter area Shallow ulcers Moist granulating base Irregular border. The base oozes venous blood when manipulated. The tissue surrounding these ulcers may exhibit signs of stasis dermatitis. Patients often report mild pain that is relieved by elevation. Signs of venous hypertension are present- varicose veins, varicose eczema or oedema An oedematous leg not responding to diuretics is a strong clue to the diagnosis

18. Clinical Features Patients often report mild pain that is relieved by elevation. Signs of venous hypertension are present- varicose veins, varicose eczema or oedema An oedematous leg not responding to diuretics is a strong clue to the diagnosis

19. Imaging Studies

20. Imaging Studies Duplex ultrasonography saphenofemoral junction incompetence, incompetent perforating veins, anatomic variants. Venography via computed tomography (CT) scanning or magnetic resonance imaging (MRI ) Catheter-directed venography is typically reserved for direct evaluation of anatomic variations such as May- Thurner syndrome, in which the left common iliac vein is compressed by the right common iliac artery.

21. Treatment

22. Treatment Modify activity to promote blood flow Apply compression therapy Provide local wound andskin care Treat and control infection inflammation Improve nutrition

23. Poor circulation decreases delivery of oxygen and nutrients, prevents removal of metabolic waste products such as carbon dioxide, and ultimately delays healing. Blood Flow: The key to Wound Healing

24. First Step: Assess for PAD (Peripheral Arterial Disease) Check pedal pulses before compression Use Doppler to check ABPI >0.8 (ankle/brachial press. index) If ABI is <0.5 NOcompression needs referral to vascular surgeon

25. Mechanical therapy

26. Compression bandaging Reduces venous pressure Improves calf muscle pump function Opposing gravitational venous reflux Improving lymph drainage Stimulates fibrinolytic activity TYPES: Non-elastic wraps (short stretch) Elastic wraps (long stretch) Stockings Graduated multilayer compression bandaging regimens capable of sustaining pressure for 1 week should be 1 st line Should exert pressure of 30 to 40 mmHg at ankle for effective compression

27. Surgical treatment

28. Surgical treatment Ligation and stripping of saphenous veins Endovenous Ablation/ endovenous laser ablation (EVLA) Compressive sclerotherapy Complete extirpation of the communicating veins `feeding` the ulcer

29. IV- deep vein bypass V – valvuloplasty VI- brachial valve transplant Shave therapy: Excision of ulcer followed by meshed split skin graft. Heals 88% of ulcers Skin grafting Punch grafting Split skin grafts Mesh grafts

30. Advanced Cases: Surgical Treatment

31. Advanced Cases: Surgical Treatment S ubfascial endoscopic perforator surgery (SEPS) Improves healing rates, and reoccurence

32. Lifelong: Compression Therapy After healing of ulcer,fit for custom stockings Remove and bathe each evening, apply moisturizer Each morning put on to prevent edema Metal frame used to assist Pt should purchase in pairs of two, replace every 6 months

33. Get this ppt in mobile Download Microsoft PowerPoint from play store. Open Google assistant Open Google lens. Scan qr code from next slide.

34. Get this ppt in mobile

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