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ULCERS
Dr Phillipo Leo Chalya M.D. ; M.Med (Surg)Consultant Surgeon & Senior Lecturer
CUHAS-BUGANDO
Leaning objectives Definition Etiology Classification Pathophysiology Clinical presentation Work up Treatment
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
ETIOLOGY
Traumatic causes Mechanical Physical – electrical, radiation etc Chemical
Vascular insufficiency Arterial Venous
Neoplastic conditions SCC BCC KS Malignant melanoma etc
ETIOLOGY…….. Metabolic diseases
diabetes mellitus Malnutrition
Beriberi Tropical ulcer
Inflammatory processes cellulitis
Infective processes TB Syphilis Fungal infections
ETIOLOGY……… Neurogenic causes
Bed sores Perforating ulcers Cord Lesions Peripheral Neuropathies
Other causes Bazin ulcer Martorell’s (hypertensive ulcer
CLASSIFICATION
Etiological classification Clinical classification Pathological classification
Etiological classification Traumatic ulcers Vascular ulcers Neoplastic ulcers Metabolic ulcers Ulcers due to malnutrition Inflammatory ulcers Infective ulcers Miscellaneous ulcer
Clinical classification
Spreading ulcer Healing ulcer Callous ulcer
Spreading ulcer
Surrounding skin is inflamed Floor is covered by slough No evidence of granulation tissue Purulent discharge
Healing ulcer
Surrounding skin not inflamed Floor covered with granulation
tissue Edges show bluish outline of the
growing epithelium Slight serous discharge
Callous ulcer
Pale granulation tissue in the floor Considerable induration at the base,
edge and surrounding skin Show no tendency towards healing
Pathological classification
Non-specific ulcers Specific ulcers Malignant ulcers
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
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)
Malignant ulcers
These include:- Squamous cell carcinoma Basal cell carcinoma ( rodent ulcer) Malignant melanoma Ulcerating adenocarcinoma etc
PATHOPHYSIOLOGY
The natural history of an ulcer consists of three phases:-
Extension phase Transition phase Repair phase
Extension phase
The floor is covered with exudates and sloughs
The base is indurated The discharge is purulent or even
blood stained
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
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)
CLINICAL PRESENTATION
History Physical examination
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
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
Physical examination
General examination Local examination Systemic examination
General examination
Usual normal
Local examination
Inspection Palpation Examination of lymph node Examination of vascular
insufficiency
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
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
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
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
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
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
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
Examination of lymph node
Depends on the site of an ulcer
Examination of vascular insufficiency
Depends on the site of an ulcer
WORK UP
Laboratory Imaging Histopathology
Laboratory investigations Haematological
FBP & ESR Haemoglobin levels
Microbiological Gram staining Culture and sensitivity
Biochemical Serum glucose
Imaging investigations
Plain X-rays CXR X-ray of the affected limb
Doppler US CT Scan MRI
Histopathology
To confirm diagnosis
TREATMENT
Depends on the cause Generally treat the cause
Conservative treatment Surgical treatment
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
Surgical treatment
Surgical debridement Sloughectomy Skin grafting Flaps Limb amputation
COMPLICATIONS
Limb amputation Chronic osteomyelitis Malignant change Septicemia Septic emboli
