2. Ulcer
Breach in the
continuity of surface
epithelium ( skin /
mucus membrane )
due to molecular death
of tissue cell by cell
3. Classification
-
-- Acute < 12 wks -- healing
-- Chronic > 12 wks -- Non healing
Infection TB Sq. cell carcinoma
physical/ chemical agents Syphilis Melanoma
local irritation /Trauma basal cell CA ( rodent)
interference with circulation
- arterial / venous
Cropathic, Bazin’s, Martorells
Diabetic, Cortisol, Tropical
aetiological Duration healing
Non
specific
specific Malignancy
4. Classification
Wagner’s Classification (foot ulcers)
The Wagner scale is used to classify the severity of foot ulcers in
diabetics:
Grade 0 Pre- or post-ulcerative site
Grade 1 Superficial ulcer
Grade 2 Penetration into tendon or joint capsule
Grade 3 Involvement of deeper tissues
Grade 4 Gangrene of the forefoot
Grade 5 Gangrene involving more than two-thirds of the foot
5. Classification
Classification Based on Pain
Painful Ulcers
Tuberculous
Arterial
Advanced Malignancy
Painless Ulcers-
Syphilitic
Trophic
Early Malignancy
6. Ulcer - few concepts
Trophic ulcer ( trophe’ Greek ; lack of nutrition ) occur due to the
impairment of tissue nutrition as a result of either ischemia or anesthesia .
E.g. In the arm -- chronic vasospasm ( painful )
-- syringomyelia .( painless ) ulcer on fingertips .
in the leg -- ischemic ulcers ( painful ) around ankle/ dorsum of foot .
Neuropathic ulcer ( anesthesia )
Perforating ulcer seen in – Diabetes
-- Spina bifida
-- Tabes dorsalis
-- Leprosy
-- peripheral nerve injury
It starts as acorn / bunion penetrate foot suppuration Bone / joint /along fascial
planes of calf .
7. Ulcer - few concepts
Modes of Onset of Ulcer
• Traumatic
• Spontaneous-
• Secondary changes on a Swelling-Tuberculous lymphadenopathy
• From a Previous Scar-Marjolin’s Ulcer
8. Life history of Ulcer
Extension Transition Repair
Covered with slough clearer granulation tissue
and exudate transforms to fibrous
tissue .
Indurated Induration decreases further decreases.
Purulent / even blood more serous serous
stained
absent small areas appear & epithelisation from
spread surrounding area
growth rate 1 mm/d
3 layers +ve
+++ ++ -- ve
Floor
Base
Discharge
Granulation
Pain
9. Ulcer – clinical features
Site : Rodent ulcer (95%) on upper part of face .
CA affects lower lip while primary ulcer of syphilis occur
on upper lip .
Arterial ulcers occur at finger tips / toe .
Venous ulcers occurs around ankle .
Size: Variable , depends on length of history .
inflammation > CA > Rodent .
Shape: Irregular -- Infective / CA .
Circular -- Rodent / Gummatous
Sq area / straight edge -- dermatitis artefacta .
12. Ulcer – clinical features ( cont. )
Floor ( area seen by the observer )
Granulation -- non specific healing
Slough -- infected
Watery / Apple jelly Appearance -- tuberculus
Wash leather appearance -- gummatous
Base ( part of an ulcer which is palpated )
Indurated -- malignancy
Attached to deep structures -- venous ulcer
13. Ulcer – clinical features ( con’t )
Discharge : Purulent -- active infection
watery -- tuberculosis
blue – green -- pseudomonas
Blood stained -- extension phase of ulcer
Lymph nodes : enlarged , tender -- infected
enlarged , hard , fixed -- CA
firm & shotty -- syphilitic chancre
enlarged submandibular LN – chancre on lip
not enlarged -- rodent ulcer
14. Ulcer – clinical features ( cont. )
Pain
non sp ulcer in ext & ulcer in phase of repair
transition phase
Tuberculous ulcer on Tuberculous ulcer
tongue
Syphilitic Ulcer on anal Syphilitic ulcer
canal
Apthos ulcer
present absent
15. Ulcer – Regional examination
Examination of draining LNs
Tender & enlarged – secondary infection
Enlarged hard fixed – malignant ulcer
Enlarged , firm , matted – tuberculous ulcer
Enlarged and shotty – syphilis
Examination for impaired circulation
look for absent pulse/ weak pulse,
trophic changes – thin limb, shiny skin, loss of hairs, brittle nails
Look for varicose veins
Neurological examination
Sensation, motor power, reflexes
16. Ulcer – general examination
Look for -- Aneamia , Malnutrition , Diabetes .
Rule out -- Cardiac Failure .
17. Ulcer -- Investigations
Haematological
LFT / Protein
Blood sugar -- fasting & post prandial
Montoux test
Serological tests for Syphilis
Biopsy ( wedge/ Excision ) / scraping – histopath
Swab -- culture / sensitivity
Discharge – gm. staining, ZN staining for AFB, PCR for Koch.
FNAC of enlarged LNs
X-ray of affected part
18. Ulcer - principles of management
Determine aetiology
Accurate assessment of ulcer
Identify and correct comorbid factors .
Treat underlying cause
Adequate drainage and desloughing .
Avoid adherent dressings .
19. Ulcer -- treatment
local applications ( lotions / ointments ) -- treatment of cause
-- to separate slough -- correct Aneamia
-- hasten granulation -- treat metabolic
-- stimulate epithelisation disorders.
Na hypochlorite -- Antibiotics
0.5% AgNo3 early phase -- treatment of DM
Zinc Sulphate
Ointments ( mupirocin, soframycin , povidon iodine )
Vinegar ( 1: 6 ) for pseudomonas
Amnion ( fresh & cleaned with sodium hypochlorite
stored at 4*C
Silver Foil / SWD / Infra red
Hydrocolloids , Alginates ,Tegaderm
Recombinant epidermal growth factor
treatment
generallocal
20. Ulcer treatment - points to remember
Determining exact aetiology is important - note the site & local characteristics
- thorough history & physical assessment
Detect & treat comorbid factors
Biopsy of the lesion may be necessary sometimes for exact cause.
Treat the underlying cause -- infection /DM / venous or arterial insufficiency .
Adequate drainage & desloughing required – surgical excision is cost effective.
Antibiotic treatment is required for – infected ulcer / ulcer due to sp cause e.g. TB
Clean ulcer should be dressed twice /day or more if copious discharge.
Avoid adherent dressings .
Wounds can be cleaned safely with normal saline solution.
21. Ulcer treatment – basic requirement of ideal dressing
Maintain high humidity between wound & dressings.
Absorbent , removes excess exudate.
Non- adherent , allowing easy removal without trauma at changing
Safe & acceptable to patients ( non allergic )
Permit gaseous exchange but impermeable to micro- organisms .
Cost - effective
22. Ulcer treatment ( Loco + Gen )
Healing
excision & curettage
AgN03 application
swab to r/o staph
coagulase + organism
pseudomonas
beta- hemo. Strepto .
clean with tetracycline treatment & confirm with swab
Loco + gen Treatment
Small ulcer Large ulcer
granulation Excessive granulation
(proud flesh )
Large area but granulation ++
+ ve- ve
SSG
26. References
Bailey & love’s Short Practice of surgery 22nd & 24th edition
Short cases in surgery - Bhattacharya
Text book of surgery for dental students- Dr. Sanjay Marwah
Clinical surgery – Hamilton Bailey
Text book of Clinical Surgery – S Das
