The document discusses various types of ulcers, detailing their definitions, etiologies, classifications, pathophysiology, clinical presentations, workup, and treatments. It categorizes ulcers based on causes including traumatic, vascular, neoplastic, metabolic, and infective factors, and outlines three phases of ulcer development: extension, transition, and repair. Additionally, it emphasizes both conservative and surgical treatment approaches tailored to the underlying causes of the ulcers.

1. ULCERS
Dr Phillipo Leo Chalya M.D. ; M.Med (Surg)
Consultant Surgeon & Senior Lecturer
CUHAS-BUGANDO

2. Leaning objectives
 Definition
 Etiology
 Classification
 Pathophysiology
 Clinical presentation
 Work up
 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. ETIOLOGY
 Traumatic causes
 Mechanical
 Physical – electrical, radiation etc
 Chemical
 Vascular insufficiency
 Arterial
 Venous
 Neoplastic conditions
 SCC
 BCC
 KS
 Malignant melanoma etc

5. ETIOLOGY……..
 Metabolic diseases
 diabetes mellitus
 Malnutrition
 Beriberi
 Tropical ulcer
 Inflammatory processes
 cellulitis
 Infective processes
 TB
 Syphilis
 Fungal infections

6. ETIOLOGY………
 Neurogenic causes
 Bed sores
 Perforating ulcers
 Cord Lesions
 Peripheral Neuropathies
 Other causes
 Bazin ulcer
 Martorell’s (hypertensive ulcer

7. CLASSIFICATION
 Etiological classification
 Clinical classification
 Pathological classification

8. Etiological classification
 Traumatic ulcers
 Vascular ulcers
 Neoplastic ulcers
 Metabolic ulcers
 Ulcers due to malnutrition
 Inflammatory ulcers
 Infective ulcers
 Miscellaneous ulcer

9. Clinical classification
 Spreading ulcer
 Healing ulcer
 Callous ulcer

10. Spreading ulcer
 Surrounding skin is inflamed
 Floor is covered by slough
 No evidence of granulation tissue
 Purulent discharge

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

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

13. Pathological classification
 Non-specific ulcers
 Specific ulcers
 Malignant ulcers

14. Non-specific ulcers
 These include:-
 Traumatic ulcers
 Arterial ulcers due to ischemia eg gangrene
 Venous ulcers e.g. Varicose ulcer
 Neurogenic ulcers (trophic ulcer)
 Ulcers associated with malnutrition
 Ulcers associated with other diseases e.g. Anemia,
Avitaminosis, Gout, Rheumatoid arthritis
 Miscellaneous ulcer

15. Specific ulcers
 These include:-
 Infective ulcers e.g. syphilitic ulcers,
Tuberculous ulcer, fungal ulcers, Buruli
ulcer (a neglected tropical disease
caused by infection with Mycobacterium
ulcerans)

16. Malignant ulcers
 These include:-
 Squamous cell carcinoma
 Basal cell carcinoma ( rodent ulcer)
 Malignant melanoma
 Ulcerating adenocarcinoma
 etc

17. PATHOPHYSIOLOGY
 The natural history of an ulcer
consists of three phases:-
 Extension phase
 Transition phase
 Repair phase

18. Extension phase
 The floor is covered with exudates
and sloughs
 The base is indurated
 The discharge is purulent or even
blood stained

19. 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

20. 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 increased density of
new capillaries (neo-angiogenesis)

21. CLINICAL PRESENTATION
 History
 Physical examination

22. 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 e.g. following- swelling e.g.
ulcerating lymph node in Tuberculosis or a scar of
burn Marjolin’s ulcer
 Marjolin's ulcers are the malignant transformation
of chronic wounds

23. History………
 Pain (i.e. is the ulcer painful?)
 Painful: ulcers associated with inflammation
 Slight painful: tuberculous ulcer
 Painless eg syphilitic, neurogenic, malignant ulcers
 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. Tuberculosis , Syphilis, Diabetes Mellitus,
nervous diseases

24. Physical examination
 General examination
 Local examination
 Systemic examination

25. General examination
 Usual normal

26. Local examination
 Inspection
 Palpation
 Examination of lymph node
 Examination of vascular
insufficiency

27. 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

28. Inspection……….
 Shape:
 Tuberculus ulcer- oval in shape
 Syphilitic 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 shorter the time
it will take to heal

29. Inspection……….
 Surrounding skin
 E.g. red and edematous- acute inflammation
 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
 Varicose ulcer
 Note: the number of ulcers may be more than one

30. Inspection……….
 Edge: five types:-
 Sloping edge e.g.
healing ulcer
 Punched out edge
e.g. Gummatous
ulcer, deep trophic
ulcer
 Undermined edge
e.g. tuberculous
ulcer-destroy
subcutaneous faster
the skin
 Raised edge e.g.
Rodent ulcer
 Rolled out (everted)-
e.g. Squamous Cell
Carcinoma

31. Inspection……….
 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

32. Palpation
 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, syphilitic ulcer

33. Palpation……….
 Base (i.e. on which the ulcer rest)
 Slightly induration- syphilitic ulcer
 Marked induration- malignant ulcer
 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

34. Examination of lymph node
 Depends on the site of an ulcer

35. Examination of vascular insufficiency
 Depends on the site of an ulcer

36. WORK UP
 Laboratory
 Imaging
 Histopathology

37. Laboratory investigations
 Haematological
 FBP & ESR
 Haemoglobin levels
 Microbiological
 Gram staining
 Culture and sensitivity
 Biochemical
 Serum glucose

38. Imaging investigations
 Plain X-rays
 CXR
 X-ray of the affected limb
 Doppler US
 CT Scan
 MRI

39. Histopathology
 To confirm diagnosis

40. TREATMENT
 Depends on the cause
 Generally → treat the cause
 Conservative treatment
 Surgical treatment

41. Conservative treatment
 Dressing
 Treat infections
 Bacteria, fungal, syphilis, TB etc
 Steroids
 Trace elements
 Topical antimicrobial agents
 Nutritional support
 Limb elevation
 Control blood glucose
 Hyperbaric oxygen therapy
 Compression bandage

42. Surgical treatment
 Surgical debridement
 Sloughectomy
 Skin grafting
 Flaps
 Limb amputation

43. COMPLICATIONS
 Limb amputation
 Chronic osteomyelitis
 Malignant change
 Septicemia
 Septic emboli

44. SPECIAL THANKS TO
SADRU MOHAMED
FOR MAKING THESE SLIDES AVAILABLE
HERE
sadru12@gmail.com
+255759212578