Ulcers management

1. MANAGEMENT OF
ULCERS
Dr Phillip
General Surgeon
Bugando Medical Centre

2. Outline
 Definition
 Aetiology
 Classification
 Pathophysiology
 Clinical presentation
 Workup
 Treatment

3. Definition
 A break in the continuity of the covering epithelium
of the skin or mucous membrane
 It may either follow molecular death of the surface
epithelium or its traumatic removal

4. Aetiology
 Trauma
 Vascular insufficiency
 Neoplastic conditions
 Metabolic diseases e.g. diabetis mellitus,
 Infective processes eg TB, syphilis
 Neurogenic

5. Classifications
 Clinical classification
 Pathological classification

6. Clinical classification
 Spreading ulcer
 Healing ulcer
 Callous ulcer

7. Spreading ulcer
 Surrounding skin is inflammed
 Floor is covered by slough
 No evidence of granulation tissue
 Purulent discharge

8. Healing ulcer
 Surrounding skin not inflamed
 Floor covered with granulation tissue
 Edges show bluish outline of the growing
epithelium
 Slight serous discharge

9. Callous ulcer
 Pale granulation tissue in the floor
 Considerable induration at the base, edge and
surrounding skin
 Show no tendency towards healing

10. Pathological classification
 Non specific ulcers
 Specific ulcers

11. Non specific ulcers
 Traumatic ulcers
 Mechanical
 Physical – electrical, radiation etc
 Chemical
 Arterial ulcers
 Due to ischaemia eg following atherosclerosis,
Buergers disease
 Venous ulcers
 Varicose ulcer

12.  Neurogenic ulcers (trophic ulcer)
 eg bed sores, perforating ulcers
 Ulcers associated with malnutrition
 eg tropical ulcer
 Ulcers associated with other diseases
 eg anemia, avitaminosis, gout, rheumatoid arthritis
 Miscellaneous ulcer
 eg Bazin ulcer, martorell’s (hypertensive ulcer)

13. Specific ulcers
 Infective ulcers eg
 syphilitic ulcers,
 tuberculous ulcer
 Malignant ulcers eg
 Squamous cell carcinoma
 Basal cell carcinoma ( rodent ulcer)
 Malignant melanoma
 Ulcerating adenocarcinoma

14. Pathophysiology
 The life history of an ulcer consists of three phases:-
 Extension phase
 Transition phase
 Repair phase

15. Extension phase
 The floor is covered with exudate and
sloughs
 The base is indurated
 The discharge is purulent or even blood
stained

16. Transition phase
 Prepares for healing
 The floor becomes cleaner and the slough
separates
 The induration of the base diminishes
 The discharge become more serous
 Small reddish area of granulation tissue
appear on the floor

17. Repair phase
 Transformation of granulation to fibrous tissue, which
gradually contracts to form scar
 The epithelium gradually extends from the new shelving
edge to cover the floor (at a rate of 1mm/day)
 The healing edge consists of three zones:-
 Outer zone: this is white in color
 Middle zone: bluish in color, granulation tissue covered by few
layers of epithelium
 Inner zone: reddish in color, a zone of granulation tissue covered
by a single layer of epithelial cells. The red granulation tissue is
due to  density of new capillaries (neo-angiogenesis)

18. Clinical presentation I
 History; note the following:-
 Duration i.e. how long is the ulcer present?
 Acute: present for short time
 Chronic: present for long time
 Mode of onset i.e. how has the ulcer developed?
 Following trauma
 Spontaneously eg following- swelling eg ulcerating LN in TB
or a scar of burn Marjolin ulcer
 Pain i.e. is the ulcer painful?
 Painful: ulcers associated with inflammation
 Slight painful: tuberculous
 Painless eg syphilitic, neurogenic, malignnt ulcer

19. Clinical presentation II
 History (cont’d)
 Discharge: i.e does the ulcer discharge or not?
 If YES: note the nature of discharge- pus, bloody, serous
 Associated diseases which may lead to ulcer formation
 E.g. TB, Syphilis, DM, nervous diseases
 Physical examination
 General examination
 Local examination
 Systemic examination

20. Clinical presentation III
 PE (cont)
 General examination may be normal
 Local examination
 Inspection
 Site: gives clue to the diagnosis
 Varicose ulcer- lower limb on the medial malleolus
 Rodent ulcer-face
 Tuberculus ulcer-cervical
 Trophic ulcer – heal
 Malignant ulcer- anywhere

21. Clinical presentation III
 Shape:
 Tuberculus ulcer- oval in shape
 Syphillic ulcer– circular in shape
 Varicose ulcer – vertically oval in shape
 Malignant – irregular in shape
 Size:
 May determine the time of healing
 E.g. the smaller the ulcer the shoter the time it will take to heal

22. Clinical presentation IV
 Surrounding skin
 E.g. red and edematous- acute inflamation
 Floor/surface i.e. exposed part of the ulcer may give clue
to the diagnosis
 Eg red granulation – healing ulcer
 Black floor- malignant melanoma
 Number
 Tuberculous ulcer
 Gummatous ulcer may be more than one
 Varicose ulcer

23. Clinical presentation V
 Edge: five types:-
 Undermined edge
 Eg; tuberculous ulcer-destroy subcutanous faster the skin
 Punched out edge
 Eg. Gummatous ulcer, deep trophic ulcer
 Sloping edge
 Eg healing ulcer
 Raised edge
 Rodent ulcer
 Rolled out (everted)- eg SCC,

24. Clinical presentation V
 Discharge: the character of the discharge should be
noted e.g.
 Healing ulcer- scant serous discharge
 Spreading ulcer- purulent discharge
 Tuberculus ulcer- serosanguinous
 Malignant ulcer- bloody discharge
 Whole limb: should be examined e.g. varicose veins

25. Clinical presentation VI
 Palpation: note:-
 Tenderness:-
 Tender- acutely inflamed ulcer
 Slightly tender- tuberculous ulcer, syphilitic ulcer
 Non-tender- malignant ulcer, chronic ulcer, neurogenic ulcer
 Edge and surrounding skin
 Hard induration- malignant ulcer
 Firm induration- chronic ulcer, syphilic ulcer
 Base (i.e. on which the ulcer rest)
 Slightly induration- syphilitic ulcer
 Marked induration- malignant ulcer

26. Clinical presentation VII
 Depth:
 eg trophic ulcer may be deep to reach the bones
 Bleeding;
 easy bleed on touch is a feature of malignant
 Fixity to the deep structures
 Eg malignant ulcers are usually fixed to deep structures
 Examination of lymph nodes
 Examination of vascular insufficiency eg pulses
 Examination of nervous system eg sensation

27. workup
 Lab studies
 Pus swab for- c/s
 FBP +ESR
 Imaging studies
 CXR : to detect primary focus in the lungs in case of
tuberculus ulcer
 X-ray of the bone or joint if the ulcer is situated near a
bone or joint
 Biopsy- to conform the diagnosis

28. Treatment
 Depends on the underlying cause
 Generally:
 Dressing
 Skin grafting
 flaps