An ulcer is a break in the skin or mucous membrane caused by cell death. Ulcers can occur in the mouth, as bed sores, or in serious lesions of the stomach or intestines. Ulcers are classified based on their clinical presentation, duration, or underlying cause. They consist of a margin, edge, floor, and base. Treatment involves debridement, antibiotics, analgesics, treating the underlying cause, blood transfusions if needed, and sometimes amputation for severe cases.

1. ULCER
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2. OBJECTIVES
Definition
Parts of an ulcer
Classification of ulcers
Wagner grading of ulcers
Different types of discharges from the ulcer
Types of granulation tissue
Investigations
Treatment

3. INTRODUCTION
An ulcer is a break in the continuity of the covering epithelium, either the skin or mucous
membrane due to molecular death.
Ulcers range from small painful sores in the mouth , bed sores , diabetic foot ulcers and
serious lesions of the stomach or intestines. Etiology of ulcers includes trauma ,limited
mobility ,infection causing bacteria ,metabolic diseases.

4. PARTS OF AN ULCER
An ulcer consists of;
1. Margin: this is the point where the ulcer joins the normal epithelial tissue which may be regular or
irregular.
2. Edge: the area between the margin and the floor , this is an important finding of an ulcer because its
helps in giving clue of the diagnosis and the condition of the ulcer. There are different types of edges:
1. Slopping edge
2. Undermined edge
3. Punched out edge
4. Everted (rolled out) edge
3. Floor: this is the exposed part(surface) of an ulcer.
4. Base: this is were the ulcer rests , the base can not be seen because it lays under the floor and it can be a
tissue or bone.

5. The diagram below shows parts of an ulcer

6. CLASSIFICATION OF ULCER
Ulcers are classified into three categories and these are clinical classification , duration
classification and pathological classification of ulcer.
Clinical classification of ulcers; this classification is based on the clinical manifestation of the
skin and layers of the tissue around the ulcer . examples are;
1. Spreading ulcer: it is an acute painful ulcer with inflamed irregular edges and the
surrounding area is red and oedematous , the floor does not contain healthy granulation
tissue but with the presence of slough and purulent discharge.
2. Healing ulcer: is an ulcer with slopping edges and red/pink granulation tissue with
minimal/scanty discharge in the floor.
3. Callous ulcer: it is a chronic non healing ulcer with the floor that contains pale
unhealthy,flabby whitish granulation tissue, scanty discharge and non tender edge.

10. 4.Non healing ulcer : it is a chronic ulcer with
no signs of healing , the floor contains
unhealthy granulation tissue, slough and the
presence of serosanguineous/purulent
discharge.

11. Duration classification of ulcers ; this classification is based on how long
the ulcer has been present.
1. Acute ulcer: this is an ulcer of less than two weeks duration.
2. Chronic ulcer: this is an ulcer of more than two weeks duration.
Pathological classification of ulcers; this classification of ulcers is based on
the disease that causes the ulcer to be formed. Examples are;
1. Non specific ulcers: these include venous ulcers(varicose ulcer) , arterial
ulcers due to ischemia(gangrene).
2. Specific ulcers: these are ulcers caused by specific infections e.g
syphilitic ulcer , tuberculous ulcer , fungal ulcer.
3. Malignant ulcers: these includes ; squamous cell carcinoma , basal cell
carcinoma , malignant melanoma , ulcerating adenocarcinoma.

12. WAGNER GRADING OF ULCERS
Grade 0 High risk foot with no ulceration
Grade 1 Superficial ulcer
Grade 2 Deep ulcer to subcutaneous tissue exposing soft tissue
and ligaments
Grade 3 Deep ulcer with cellulitis or abscess formation
associated with osteomyelitis
Grade 4 Gangrene of toes or forefoot (partial gangrene)
Grade 5 Gangrene of the entire foot

13. TYPES OF DISCHARGE FROM THE ULCER
1. Serous discharge
2. Serosanguineous discharge
3. Sanguineous discharge
4. Purulent discharge

14. TYPES OF GRANULATING TISSUE
Granulation tissue it is proliferation of new capillaries and fibroblasts
intermingled with red blood cells and white blood cells with thin fibrin cover
over it.
1. Healthy granulation tissue: it occurs in a healing ulcer characterized by
sloping edges,serous discharge, it is pink and may be painless.
2. Unhealthy granulation tissue: it is a pale with purulent discharge, its floor
is covered with slough, its edges are inflamed and oedematous and it is
seen in spreading ulcers.
3. exuberant granulation tissue(proud flesh): it occurs in ulcers wherein the
granulation tissue protrudes out of the ulcer bed like a proliferating
mass.

16. INVESTIGATIONS
1. Wound discharge for microscopy , Culture and sensitivity
2. histology
3. Full blood count
4. Leucocyte count
5. X-ray of the affected part
6. Magnetic resonance imaging(MRI)
7. Computed tomography (CT) scan

17. TREATMENT
1. Debridement
2. Broad spectrum
antibiotics(penicillines,cephalosporins,aminoglycosides)
3. Analgesic drugs(acetaminophen,codeine,morphine or pethidine)
4. Treatment of what caused the ulcer
5. Blood transfusion if indicated
6. Amputation in severe cases

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