Common surgical infectionsboil, abscess, ulcer, cellulitis, carbuncle, gangrene, sinus and fistula

Professor Panna Lal SahaProfessor of Surgery & Head

Department of Surgery

BGC Trust Medical College Chittagong

Infection

• Invasion of the body tissues by bacteria or other tiny organisms that cause illness.

Or• Invasion and multiplication of micro

organisms in body tissues, which may be in apparent or characterized by cellular injury.

Boils (furuncle)

• It is an infection of a hair follicle.

It is caused by staphylococcus.

It may be associated with perifolliculitis, which may proceed to suppuration.

Boils (furuncle)

• Furuncle of the external auditory meatus is very painful as the skin is more or less attached to the underlying cartilage and there hardly remain any space for the swelling to develop, so a great tension develops which leads to pain.

• Perianal boils when rupture may lead to a sinus.

Complications of boils

• Cellulitis – may develop in a person whose immunity is compromised.

• It may also lead to infection of the neighboring hair follicles where the number of hair follicles are too many (e.g. axilla)

• Lymph adenitis of draining area

Boil

Abscess

• An abscess is a localized collection of pus in a cavity lined by pyogenic membrane (usually caused by bacteria or parasites).

• It is a defensive reaction of the tissue to prevent the spread of infectious materials to the other parts of the body.

abscess

Pus

• Pyogenic membrane - a layer of pus cells lining an abscess cavity that have not yet autolyzed.

• Pus - A thick yellowish-white fluid which results from the accumulation of white blood cells (WBCs), dead micro organisms, liquefied tissue and cellular debris. Pus is commonly a site of infection or foreign material in the body.

Abscess

• Bacteria enters into the abscess area

– Direct infection from without

– Local extension from some adjacent focus

– Blood-stream or lymphatic vessel

Types of abscess

• Pyogenic abscess – This is the commonest variety of abscess and may result from cellulitis or acute lymph adenitis. At first the infected part becomes red hot and quite tender. When pus develops, the pain takes typical character of throbbing in nature. There will be brawny induration and oedema (demonstrable by pitting on pressure). Fluctuation may or may not be present (as in parotid abscess).

Types of abscess

• Pyaemic abscess – they are generally multiple in number, either develop simultaneously or a number of them crop up in succession only after one of them incised.

• This condition results when infective emboli circulating in the blood lodge in different parts of the body and gives rise to multiple abscesses.

• Sometimes they are non reacting i.e. acute features are absent but constitutional symptoms are tremendous with high fever, rigor and toxaemia.

Types of abscess

• Cold abscess – as the name suggests, this abscess is cold and non-reacting in nature. It does not produce hot and painful abscess as seen in pyogenic abscess. Brawny induration, oedema and tenderness are conspicuous by their absence. Cold abscess is almost always a sequel of tubercular infection anywhere in the body commonly in the lymph nodes and bone. Caseation of the lymph node forms the cold abscess.

Types of abscess

• The commonest sites are the neck and axilla. Sometimes cold abscesses are seen at the loin, at the back or at the side of the chest wall. These are sequel of tuberculous affection of the spine, ribs and posterior mediastinal group of lymph nodes. Cold abscesses may also originates from the ends of the bones and joints and gradually comes to the surface through the fascial planes

Diagnosis

• History

• Clinical examination

• Investigations – • Blood CBC

• Blood sugar

• Needling

• Ultrasonography

• Others

Impetigo

Definition• A bacterial skin infection caused by the

staphylococcus or, more rarely, streptococcus bacteria.

• The first sign of impetigo is a patch of red, itchy skin. Pustules develop on this area, soon forming crusty, yellow-brown sores that can spread to cover entire areas of the face, arms, and other body parts. Most patients are children.

• Treatment is by antibiotics.

Impetigo

Cellulitis

• Cellulitis is a spreading infection of the skin and deep subcutaneous tissue.

• Cellulitis can be caused by normal skin flora or by exogenous bacteria, and often occurs where the skin has previously been broken: cracks in the skin, cuts, blister, burns, insect bites, surgical wounds, or sites of intravenous catheter insertion.

CELLULITIS

Erysipelas

• Erysipelas is the term used for a more superficial infection of the dermis and upper subcutaneous layer that presents clinically with a well defined edge. Erysipelas and cellulitis often coexist, so it is often difficult to make a distinction between the two.

Erysipelas

Carbuncle

A necrotizing infection of skin and subcutaneous tissue composed of a group of furuncles (boils).

A carbuncle is a deep infection of a group of contiguous pilosebaceous follicles with Staphylococcus aureus.

Pathologically a similar process to that seen in a furuncle, carbuncles are much larger and considerably more symptomatic.

Carbuncle

Carbuncle

Ulcer -Definition

• An ulcer is a break in the continuity of an epithelial surface. It is characterized by progressive destruction of surface epithelium and a granulating base.

Healing of an ulcer

TB ULCER

TB ULCERTONGUE

Trophic ulcer

Basal cell carcinoma

SQ CELLCARCINOMA

SQ CELLCARCINOMA

Ulcer - Classification • Specific –

– TB, Syphilis, fungal, herpes simplex

• Non specific – Peptic, – Pressure sores (decubitus ulcers) and ischaemic ulcers– Gravitational ulcers – venous insufficiency– Secondary infective – wound infection and abscess– Neuropathic ulcers – diabetes, tabes dorsalis, leprosy– Iatrogenic – intravenous fluid extravasation– Misc – traumatic, dermatitis artefacta (self mutilation),

aphthous

• Malignant

ULCER STAGING

Stage-I Non blanchable erythema of intact skin heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration or hardness may be indicators.

ULCER STAGING

Stage II• A breakage in the skin occurs, including the

top layer of the skin (epidermis) and/or the layer under the epidermis (dermis).

• The skin is broken, cracked, blistered, and mottled in color. It may look like a shallow crater, an abrasion, or blister.

• The ulcer remains superficial.

ULCER STAGING

Stage - III• Full damage to the skin and tissue under the skin

that may extend down to, but not through, underlying fascia.

• The ulcer may present itself as a deep crater. Undermining or tunneling may be present. Undermining or tunneling occurs when the ulcer continues past the wound edge under the skin.

ULCER STAGING

Stage - IV• Extensive damage to or death (necrosis) of

subcutaneous tissue, muscle, bone, joints, tendons, or any supporting structures.

• The ulcer may include undermining. (See Stage III for a definition of undermining.)

• It is important to emphasize that a Stage IV ulcer extends anywhere past the fascia, but does not have to involve the bone. When the bone is involved it is most serious.

Clinical features

• May be acutely inflamed

• Chronically inflamed

• Specific infection and vascular insufficiency causes delayed healing

Clinical examination

• Site • Size• Shape• Edge• Floor• Base

• Discharges• Lymph nodes• Pain • General examinations• Pathological examination• Marjolin’s ulcer

Investigations

• Blood examination: routine, blood sugar, other investigation to exclude specific diseases

• Urine – routine to exclude diabetes• Bacteriological examination of discharges• Skin tests• X-ray examination and other imaging• Histopathology

Treatment

• According to aetiology of disease