This document discusses the examination and treatment of ulcers. It begins by defining an ulcer and describing different types based on appearance and cause. It then provides details on examining an ulcer, including inspecting characteristics like shape, edge, floor, discharge. Investigation may include cultures, biopsies and imaging. The treatment plan is to determine the cause, address underlying factors, treat any infection, properly dress the ulcer, and promote healing.

1. in Short case
Dr Md. Sherajul Islam
MBBS,FCPS, FACS
Assistant Professor(Surgery)
Sheikh Sayera Khatun MedicalCollege

3.  Examine the case (ulcer)
 What will you do?
 What is the treatment plan?
 What is Ulcer?

4.  Ulcer is a discontinuity of an epithelial surface
due to sloughing out of inflammatory
necrotic tissue

5.  Clinical
 Pathological

6.  Spreading Ulcer: When the surrounding skin of
the ulcer is inflamed and floor is covered with
profuse and offensive slough without any
evidence of granulation tissue
 Healing ulcer:The floor is covered with pinkish
and red healthy granulation tissue
 Chronic or callous ulcer: When ulcer shows no
tendency towards healing. Floor is covered with
pale granulation tissue

7.  CENTRE- RED--Granulation tissue
 BLUE—Growing epithelium
 WHITE—Due to fibrosis of scar

8. A special type of tissue composed of newly
formed capillary and fibroblast

9. Non-specific:
 Mechanical
Traumatic—Dental ulcer, pressure sore, prolong
splint,
Physical—Burn, scalds
Chemical—Alkali, acid
 Infective—Non- specific infection due to pyogenic
organism, streptococcus, staphylococcus

10.  Nutritional—
Arterial—Renaud’s disease, buergers disease,
atherosclerosis
Venous—Varicose vein, post phlebitic limb.
Neurogenic—Due to tabes dorsalis, spina
bifida, syringomyelia, perforated ulcer,
leprosy, diabetes, peripheral nerve injury

11.  Specific –Tuberculosis, syphilis, leprosy,
actinomycosis, herpes, fungal
 Malignant—Squamous cell carcinoma, basal
cell carcinoma, malignant melanoma

12.  আপনার এই সমসযা কতদিন থেকক?
 দকভাকে শুরু হল? এটা দক ধীকর ধীকর েড় হকে না একই রকম আকে?
 েযাো আকে দক? ( Ischaemic ulcer, neuropathic ulcer)
 আপনার দক Diabetes আকে?
 আপদন দক পান, দসগাকরট, চু ন, জিদা, তামাক খান?
 থকান দচদকৎসা দনকেকেন দক?
 থোধ শদির থকান অসুদেধা আকে দক?

13. Inspection:
Site-
 Traumatic—Any where
 Venous—Leg, just above the medial
malleolus
 Arterial—Tip of the toes and fingers,
around the ankle, dorsum of the foot
 Neurogenic/Perforating—Over the sole, at
pressure points
 Diabetic—Foot, anywhere

14.  Squamous cell carcinoma/Epitheloma—Lip,
tounge, check, penis
 Basal cell carcinoma/Rodent ulcer—Upper
half of the face
 Malignamt melanoma—Any where
In female- Lower leg
In male-Front or back of the trunk, sole,
palm, beneath nail

15.  Tuberculosis—Neck, axilla, groin
 Lupus vulgaris—Face, rarely hand, fingers
 Syphilitic—Genitalia,mouth, vulva,anal
region

16.  Shape, numbers:
 Shape—
Healing ulcer-Regular
Varicose ulcer—Vertically oval.
Tuberculosis ulcer—Regular, serpiginous.
Carcinomatous—Irregular.
 Number—
Tuberculosis,Varicose ulcer and soft chancres
may be multiple.

17. Edge—
 Slopping—Healing ulcer, venous ulcer,
traumatic ulcer.
 Punched out—Arterial, Neurogenic, Syphilis,
trophic, DM, leprosy.
 Undermined--Tuberculosis, carbuncle,
pressure necrosis.
 Raised/rolled- Basal cell carcinoma.
 Raised and everted-- Squamous cell
carcinoma.

18.  Red healthy granulation tissue—Healing Ulcer
 Smooth, pale granulation tissue—Chronic ulcer
 Wash leather slough—Gummatous ulcer
 Watery or apple jelly granulation —Tuberculosis.
 Slough, bone may be seen—Neuropathic, arterial
ulcer
 (NB: FLOOR RAISED FROM SURFACE AREA –
MALIGNANT ULCER
FLOOR BELOW SURFACE AREA ---NON
MALIGNANT ULCER)

19. Discharge—Quality, colour, smell
 Purulent discharge—Active infection
 Greenish discharge—Pseudomonus infection
 Sulphur granules—Actinomycosis
 Serosanguinous discharge—Malignant ulcer,
Tuberculosis.
Surrounding skin—Colour,texture,scar, visible
vein, hairs.

20.  Temperature of the surrounding area.
 Tenderness----Neoplastic ulcer never tender
Chronic ulcer due to tuberculosis or syphilis mildly tender
Bleeding on touch—Malignancy
 Base(area on which ulcer rest)
Induration –
Tuberculosis----Minimal or absent
Benign chronic ulcer---Slight induration
Epithelioma(SCC), Hard chancre, Gummatus ulcer—
Marked induration
 Mobility or fixity-(Relation to deeper structure)
Mobile---Benign ulcer.
Fixed---- Malignant ulcer, varicose ulcer fixed to tibia.

21.  Examination of nerve lesion: Must to be seen
sensation
 Examination of regional lymph node
 Examination of vascular insufficiency
 General examination: Debility,Anaemia,
Malnutrition, cardiac failure

22.  Examination of other limb—As because
Buerger's disease is bilateral
 CNS and spine—Neuropathic ulcer
 Abdomen—Splenomegaly due to blood
dyscrasia

23.  Thinning of skin
 Loss of hair distribution
 Loss of subcutaneous fat
 Shininess of skin
 Tropic changes—Nail brittle.
 Minor ulceration—Heel, medial malleolus,
ball of foot, toes

24.  The combination of
 Rest pain
 Colour changes
 Hyperaesthesia
 With or without ulceration

25.  Colour changes.
 Loss of temperature
 Loss of sensation
 Loss of pulsation
 Loss of function

26. I shall do some investigation
 Discharge for C/s
 Incision and biopsy or excision and biopsy
 Local X-ray
 FNAC from lymph node
 Chest X-ray, USG for staging if malignancy
 Blood--- CBC-Hb%, ESR
 RBS
 VDRL

27.  Determine the aetiology
 Accurate assessment of ulcer
 Identify and correct comorbid factors
 Treat the underlying causes e.g.
Venous/Arterial insufficiency
 Treat the ulcer by adequate drainage and
desloughing
 Proper broad spectrum antibiotic—according
to C/S
 Proper dressing of an ulcer

28.  Soft
 Absorbent
 Non allergic
 Maintain high humidity
 Permit gaseous exchange but not
microorganism
 Should not impairs capillary circulation
 Not toxic to granulation tissue