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Ulcers Basics
The document outlines the definition, etiology, grading, and classification of ulcers as well as various types including arterial, venous, tropical, and diabetic ulcers. It discusses their examination, including inspection and palpation, along with the characteristics of edges, discharge, and surrounding areas. Management involves addressing underlying causes, conducting investigations, and employing various treatment methods such as debridement, dressings, and potential skin grafting for chronic ulcers.
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Ulcers Basics
- 1.
- 2. Definition A break inthe epithelial continuity Discontinuity of the skin or mucous membrane which occurs due to the microscopic death of the tissues
- 3. Aetiology Venous Disease(Varicose Veins) Arterial Disease ; Large vessel (Atherosclerosis) or Small vessel (Diabetes) Arteritis : Autoimmune (Rheumatoid Arthritis, Lupus) Trauma Chronic Infection : TB/Syphilis Neoplastic : Squamous or BCC, Sarcoma
- 4. Wagner’s Grading ofulcers Grade 0 - Preulcerative lesion/healed ulcer Grade 1 - Superficial ulcer Grade 2 - Ulcer deeper to Subcutaneous tissue exposing soft tissue or bone Grade 3 - Abscess formation or osteomyelitis Grade 4 - Gangrene of part of tissues/limb/foot Grade 5 - Gangrene of entire one area/foot
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- 6. A. Clinical Spreading :(Edge - Inflamed & Edematous) Healing : (Edge is sloping with healthy red granulation tissue & serous discharge) Callous : (Floor contains pale unhealthy granulation tissue with indurated edge)
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- 8. 1. Non specific TraumaticUlcer Arterial Ulcer Venous Ulcer Neurogenic Ulcer Infective Ulcer
- 9. 1. Non specificcontd. Diabetic Ulcer Tropical Ulcer Cryopathic Ulcer Martorell’s Ulcer Bazin’s Ulcer
- 10. • Traumatic ulcer 1.Mechanical- Dental ulcer on tongue ( jagged tooth ) 2. Physical- Electrical burn 3. Chemical- Application of caustics Acute, Superficial, Painful, Tender
- 11. • Arterial Ulcer •Caused due to peripheral vascular disease • LL : Atherosclerosis & TAO • UL : Cervical Rib, Raynauds • Chief complaint : Severe Pain • Toes, Feet, Legs & UL Digits
- 12. • Venous ulcers Medial aspect of lower 3rd of lower limb Ankle ( Gaiters Zone ) : Chronic Venous HTN Ulcers are Painless Varicose Veins or Post Phlebitic limb ( PTS )
- 13. • Trophic Ulcer •Pressure Sore or Decubitus Ulcer • Punched out edge with slough on the floor • Ex: Bed Sores & Perforating ulcers • Develop as a result of Prolonged Pressure • Sites : Ischial Tuberosity > Greater Trochanter > Sacrum > Heel > Malleolus > Occiput
- 14. • Tropical ulcer •Tropical regions : Africa, India, S.America • Trauma or Insect Bite • Fusobacterium fusiformis & Borrelia vincentii • Abrasions, Redness, Papules & Pustules • Severe Pain
- 15. • Diabetic Ulcer Itmay be caused due to • Diabetic Neuropathy • Diabetic Microangiopathy • Increased Glucose : Increased Infection • Foot ( Plantar ), Leg, Back, Scrotum, Perineum • Ischemia, Septicemia, Osteomyelitis,
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- 17. 3. Malignant Squamous cellca Basal cell ca Malignant melanoma
- 21. Examination Inspection Palpation Examination of lymphnodes Vascular insufficiency Nerve lesions
- 22. INSPECTION Location, size,shape, floor, edge, discharge, surrounding area. PALPATION Tenderness, local rise of temperature, bleeding on touch, consistency of the ulcer, edge, surrounding area - oedema, mobility. REGIONAL LYMPH NODES SENSATIONS PULSATIONS FUNCTION OF THE JOINT SYSTEMIC EXAMINATION
- 23. INSPECTION LOCATION OF THEULCER FLOOR OF THE ULCER DISCHARGE FROM THE ULCER EDGE SURROUNDING AREA
- 24. LOCATION OF THEULCER Arterial ulcer Tip of the toes, dorsum of the foot Long saphenous varicosity with ulcer Medial side of the leg. Short saphenous varicosity with ulcer Lateral side of the leg. Perforating ulcers Over the sole at pressure points. Nonhealing ulcer Over the shin
- 25. FLOOR OF THEULCER DEF : This is the part of the ulcer which is exposed or seen. Red granulation tissue Healing ulcer Necrotic tissue, slough Spreading ulcer Pale, scanty granulation tissue Tuberculous ulcer Wash-leather slough Gummatous ulcer
- 26. DISCHARGE FROM THEULCER Serous discharge Healing ulcer Purulent discharge Spreading ulcer Bloody discharge Malignant ulcer Discharge with bony spicules Osteomyelitis Greenish discharge Pseudomonas infection
- 27. EDGE DEF: This isbetween the floor of the ulcer and the margin. The margin is the junction between the normal epithelium and the ulcer. These two parts represent areas of maximum activity. 3 STAGES Stage of ex-tension. Stage of transition. Stage of repair.
- 28. A. Sloping edgeAll healing ulcers like traumatic ulcers, venous Ulcers
- 29. B. Punched out edge Gummatous ulcersand trophic ulcers.
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- 31. D. Raised edge (beadededge) Rodent ulcers or basal cell carcinoma .
- 32. E. Everted edge (Rolledout) Squamous cell carcinoma.
- 33. SURROUNDING AREA Thick and pigmented Varicoseulcer. Thin and dark Arterial ulcer. Red and oedematous Spreading ulcers like diabetic ulcer.
- 34.
- 35. EDGE Induration (hardness) ofthe edge is very characteristic of squamous cell carcinoma. It is said to be a host defense mechanism. Tenderness of the edge is characteristic of infected ulcers and arterial ulcers.
- 36. BASE It is thearea on which ulcer rests. Marked induration at the base is diagnostic of squamous cell carcinoma.
- 37. INDURATION • The edge,base and the surrounding area should be examined for induration. Maximum induration Squamous cell carcinoma Minimal induration Malignant melanoma. Brawny induration Abscess. Cyanotic induration Chronic venous congestion as in varicose ulcer.
- 38. MOBILITY Gentle attempt ismade to move the ulcer to know its fixity to the underlying tissues. Malignant ulcers are usually fixed, benign ulcers are not.
- 39. BLEEDING Malignant ulcer isfriable like a cauliflower. On gentle palpation, it bleeds. Granulation tissue as in a healing ulcer also causes bleeding.
- 40. SURROUNDING AREA Thickening andinduration is found in squamous cell carcinoma. Tenderness and pitting on pressure indicates spreading inflammation surrounding the ulcer.
- 41. RELEVANT CLINICAL EXAMINATION REGIONAL LYMPH NODES Tender and enlarged Acute secondary infection. Non-tender and enlarged Chronic infection. Non-tender and hard Squamous cell carcinoma. Non-tender, large, firm, multiple Malignant melanoma.
- 42.
- 43. Investigations 1) Complete bloodpicture: Hb%, TC, DC, ESR, PS 2) Urine and blood examination to rule out diabetes 3) Chest X-ray - PA. view to rule out P.TB 4) Pus for culture/sensitivity 5) Lower limb angiography in cases of arterial diseases 6) X-ray of the part to see for Osteomyelitis 7) Biopsy: Non-healing/malignant ulcers
- 44. Treatment Address cause Correct deficiencies Controlpain, infection Debridement, dressing Closure of defect
- 45. TREATMENT OF THEULCERS Treatment of Spreading Ulcers Treatment of Healing Ulcers Treatment of Chronic Ulcers Treatment of The Underlying Disease
- 46. TREATMENT OF SPREADINGULCERS Pus Culture/Sensitivity report, Appropriate Antibiotics Solutions to treat the Slough : H₂O₂ & EUSOL - Edinburgh University Solution (Hypochlorite solution) Excessive Granulation Tissue (Proud Flesh) : Excision or Application of Copper Sulphate or Silver Nitrate Repeated Dressings,
- 47. TREATMENT OF HEALINGULCER Regular dressings are done for a few days Antiseptic creams like Liquid Iodine, Zinc Oxide or Silver Sulphadiazine. Culture swab is taken to rule out Streptococcus Haemolyticus ( contraindication for skin grafting ) Ulcer is small - Heals by itself ( Epithelialization ) Large - Free Split Skin Graft applied
- 48. TREATMENT OF CHRONICULCERS These do not respond to conventional methods of treatment. The following are tried: Infrared radiation, short-wave therapy, ultraviolet rays decrease the size of the ulcer. Amnion helps in epithelialization. Chorion helps in granulation tissue. These ulcers ultimately may require skin grafting.