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ulcer ug class.pptx
- 1. ULC ER DR.Masoom P 6th semPG DEPT.OF GEN.SURGERY 12- 10-2020
- 2. Definitio n • An ulceris a break in the continuity of the covering epithelium, either skin or mucous membrane due to molecular death. Parts of an Ulcer a.Margin: It may be regular or irregular. It may be rounded or oval. b.Edge: Edge is the one which connects floor of the ulcer to the margin.
- 3. Different edges are: •Sloping edge. It is seen in a healing ulcer. • Its inner part is red because of red, healthy granulation tissue. • Its outer part is white due to scar/fibrous tissue. • Its middle part is blue due to epithelial proliferation.
- 4. • Undermined edgeis seen in a tuberculous ulcer • Punched out edge is seen in a gummatous (syphilitic) ulcer and trophic ulcer. It is due to endarteritis. • Raised and beaded edge (pearly white) is seen in a rodent ulcer (BCC). Beads are due to proliferating active cells. • Everted edge (rolled out edge): It is seen in a carcinomatous ulcer due to spill of the proliferating malignant tissues over the normal skin.
- 5. c. Floor: • Itis the one which is seen. Floor may contain discharge, granulation tissue or slough. d. Base: Base is the one on which ulcer rests. It may be bone or soft tissue.
- 8. Induration of an Ulcer •Induration is a clinical palpatory sign which means a specific type of hardness in the diseased tissue. • It is obvious in well-differentiated carcinomas. • It is better felt in squamous cell carcinoma. • It is also observed in long standing ulcer with underlying fibrosis • Brawny induration is a feature of an abscess.
- 9. • Induration isfelt at edge, base and surrounding area of an ulcer. • Induration at surrounding area signifies the extent of disease (tumour). • Outermost part of the indurated area is taken as the point from where clearance of wide excision is planned.
- 10. Classificati ons Classification I (Clinical) 1.Spreading ulcer: • Here edge is inflamed, irregular and oedematous. • It is an acute painful ulcer; floor does not contain healthy granulation tissue (or granulation tissue is absent) but with profuse purulent discharge and slough; surrounding area is red and edematous.
- 12. 2. Healing ulcer • Edgeis sloping with healthy pink/red healthy granulation tissue with scanty/minimal serous discharge in the floor; • slough is absent; • regional lymph nodes may or may not be enlarged but when enlarged always non- tender. • Surrounding area does not show any signs of inflammation or induration; base is not indurated.
- 13. Three zones areobserved in healing ulcer. • Innermost red zone of healthy granulation tissue; • middle bluish zone of growing epithelium; • outer whitish zone of fibrosis and scar formation.
- 15. 3. Non-healing ulcer • Itmay be a chronic ulcer depending on the cause of the ulcer; here edge will be depending on the cause—punched out (trophic), undermined (tuberculous), rolled out (carcinomatous ulcer), beaded (rodent ulcer); • floor contains unhealthy granulation tissue and slough, and serosanguineous/purulent/bloody discharge; • Regional draining lymph nodes may be enlarged but non-tender.
- 17. 4. Callous (stationary) ulcer •It is also a chronic non-healing ulcer; floor contains pale unhealthy, flabby, whitish yellow granulation tissue and thin scanty serous discharge or often with copious serosanguinous discharge, with indurated nontender edge; base is indurated, nontender and often fixed. • Ulcer does not show any tendency to heal. • It lasts for many months to years. • Tissue destruction is more with absence of or only minimal regeneration.
- 18. • Induration andpigmentation may be seen in the surrounding area. • There is no/less discharge. • Regional lymph nodes may be enlarged; are firm/ hard and nontender. • It is callousness towards healing; word callous means—hard skinned.
- 20. Classification II (Basedon Duration) 1. Acute ulcer duration is less than 2 weeks. 2. Chronic ulcer duration is more than 2 weeks (long).
- 21. Classification III (Pathological) 1. Specificulcers: • Tuberculous ulcer. • Syphilitic ulcer: It is punched out, deep, with “wash- leather” slough in the floor and with indurated base. • Meleney’s ulcer-postoperative gangrenous wounds
- 22. 2. Malignant ulcers: •Carcinomatous ulcer • Rodent ulcer. • Melanotic ulcer. 3. Non-specific ulcers: • Traumatic ulcer: It may be mechanical, physical, chemical— common. • Arterial ulcer: Atherosclerosis, TAO
- 23. • Venous ulcer:Gravitational ulcer, post-phlebitic ulcer. • Trophic ulcer/Pressure sore. • Infective ulcers: Pyogenic ulcer. • Tropical ulcers: It occurs in tropical countries. It is callous type of ulcer, e.g. Vincent’s ulcer. • Ulcers due to chilblains and frostbite (cryopathic ulcer). • Martorell’s hypertensive ulcer.
- 24. • Bazin’s ulcer(Erythrocyanoid ulcer) –exclusive disease of young women,seen in women with thick ankles • Diabetic ulcer. • Ulcers due to leucaemia, polycythemia, jaundice, collagen diseases, lymphoedema. • Cortisol ulcers are due to long-time application of cortisol (steroid) creams to certain skin diseases. • These ulcers are callous ulcers last for long time and require excision and skin grafting.
- 26. GRANULATION TISSUE • It isproliferation of new capillaries and fibroblasts intermingled with red blood cells and white blood cells with thin fibrin cover over it.
- 28. Unhealthy granulation tissue • Itis pale with purulent discharge. • Its floor is covered with slough. • Its edge is inflamed and oedematous. • It is a spreading ulcer. • Unhealthy, pale, flat granulation tissue: It is seen in chronic nonhealing ulcer (callous ulcer).
- 29. Exuberant granulation tissue(Proud flesh) • It occurs in a sinus or ulcer wherein granulation tissue protrudes out of the sinus opening or ulcer bed like a proliferating mass. • It is commonly associated with a retained foreign body in the sinus cavity.
- 31. INVESTIGATIONS FOR AN ULCER Studyof discharge: • Culture and sensitivity, AFB study, • cytology. Wedge biopsy: • Biopsy is taken from the edge because edge contains multiplying cells. • Usually two biopsies are taken. • Biopsy taken from the centre may be inadequate because of central necrosis
- 32. • X-ray ofthe part to look for periostitis/osteomyelitis. • FNAC of the lymph node. • Chest X-ray, Mantoux test in suspected case of tuberculous ulcer. • Haemoglobin, ESR, total WBC count, serum protein estimation (albumin).
- 34. MANAGEMENT OF AN ULCER •Cause should be found and treated. • Correction of the anaemia, deficiencies like of protein and vitamins. • Proper investigation as needed. • Transfusion of the blood if required. Control the pain and infection. • Rest, immobilization, elevation, avoidance of repeated trauma.
- 35. • Care ofthe ulcer by debridement, ulcer cleaning and dressing. • Desloughing is done either mechanically or chemically. Mechanically it is done using scissor by excising the slough. • Hydrogen peroxide which releases nascent oxygen is used as chemical agent. • Acriflavine is antiseptic and irritant and so desloughs the area and promotes granulation tissue formation.
- 36. • Eusol (EdinburghUniversity Solution) which contains sodium hypochlorite releases nascent chlorine which forms a water soluble complex with slough to dissolve it. • Use of povidone iodine in ulcer cleaning is controversial (open wound is not suitable; it is mainly for cleaning the surgical field prior to incision).
- 37. • Maggots ifpresent in the wound will cause crawling sensation and are removed using turpentine solution. • Removal of the exuberant granulation tissue is also required when present. • Ulcer cleaning and dressing is done daily or twice daily or once in 2–3 days depending on the type of ulcer and type of dressing used.
- 38. • Normal salineis ideal for ulcer cleaning. • Various dressings are available. • Films (opsite/semipermeable polyurethane), hydrocolloids (duoderm), hydrogels (polyethylene oxide with water), hydroactives (nonpectin-based polyurethane matrix), foams.
- 42. EUSOL bath. • DiluteEUSOL solution in a basin is used wherein ulcer foot is dipped and kept in place for 20–30 minutes. • EUSOL removes the slough and cleans the ulcer bed. • Hydrogen peroxide releases nascent oxygen and helps in removing necrotic material. • Povidone iodine is not used for open wound; it is only a surface antiseptic
- 43. Vacuum assisted closure(VAC) therapy • It is by creation of negative pressure (25–200 mmHg), continuous or intermittent over the wound surface; it causes reduced fluid in the interstitial space, reduces oedema, increases the cell proliferation and protein matrix synthesis, promotes formation of healthy granulation tissue. • Sterile foam is placed over the ulcer bed covering widely; tube drain with multiple holes is kept within it and end of the tube comes out significantly away; foam is sealed airtight using a sterile adhesive film.
- 44. • Tube isconnected to suction system. • Suction is maintained initially continuously later intermittently. • Redressing is done only after 4–7 days. • Therapy using infrared/short wave/ultraviolet rays to decrease the ulcer size is often used but their benefits are not proved.
- 46. Maggot debridement therapy • Itis used as biotherapy (but not commonly) by placing cultured live disinfected maggots. • Maggots are larvae of the green bottle fly, also known as the green blowfly (Lucilia sericata). • They act by dissolving and engulfing dead necrotic tissues; they may reduce the bacterial content in the wound. • They can inhibit many bacteria including MRSA (methicillin resistant bacteria), anaerobic and aerobic bacteria.
- 47. • They secreteproteolytic enzymes to have mechanical effects; secretion of ammonia alters the pH in the ulcer bed which inhibits bacterial growth. • They increase the granulation tissue formation also. • Once ulcer granulates, defect is closed with secondary suturing, skin graft or flaps
- 48. TRAUMATIC ULCER • Such ulceroccurs after trauma. It may be mechanical—dental ulcer along the margin of the tongue due to tooth injury; physical like by electrical burn; chemical like by alkali injury. • Such ulcer is acute, superficial, painful and tender. • Secondary infection or poor blood supply of the area make it chronic and deep.
- 49. • Footballer’s ulceris a traumatic ulcer occurring over the shin of males due to direct knocks on the shin. It is staphylococcal infection with a chronic and deep ulcer. • Traumatic ulcers can occur anywhere in the body due to trauma
- 51. • Trauma causesinfection, necrosis, fasciitis, crush injury, endarteritis of the skin leading into formation of large/deep nonhealing ulcer. • Treatment depends on size and extent of ulcer. • Regular dressing, • later skin grafting .
- 52. TROPHIC ULCER (PRESSURE SORE/DECUBITUS ULCER) •Pressure sore is tissue necrosis and ulceration due to prolonged pressure. • Blood flow to the skin stops once external pressure becomes more than 30 mmHg (more than capillary occlusive pressure) and this causes tissue hypoxia, necrosis and ulceration. • It is more prominent between bony prominence and an external surface.
- 55. It is dueto: • Impaired nutrition. • Defective blood supply. • Neurological deficit.
- 56. Site s • Over theischial tuberosity. • Sacrum. • In the heel. • In relation to heads of metatarsals. • Buttocks. • Over the shoulder. • Occiput.
- 57. • Due tothe presence of neurological deficit, trophic ulcer is also called as neurogenic ulcer/neuropathic ulcer. • Initially it begins as callosity due to repeated trauma and pressure, under which suppuration occurs and gives way through a central hole which extends down into the deeper plane up to the underlying bone as perforating ulcer (penetrating ulcer). • Bedsores are trophic ulcers.
- 60. Clinical Features • Occurs in5% of all hospitalised patients. • Painless ulcer which is punched out. • Ulcer is non-mobile with base formed by bone.
- 61. Investigatio ns • Study ofdischarge, blood sugar, biopsy from the edge, X-ray of the part, X-ray spine
- 62. Treatme nt • Cause shouldbe treated. • Nutritional supplementation. • Rest, antibiotics, slough excision, regular dressings. • Vacuum-assisted closure (VAC): It is the creation of intermittent negative pressure of minus 125 mmHg to promote formation of healthy granulation tissue.
- 63. • Negative pressurereduces tissue oedema, clears the interstitial fluid and improves the perfusion, increases the cell proliferation and so promotes the healing. • A perforated drain is kept over the foam dressing covered over the pressure sore. • It is sealed with a transparent adhesive sheet.
- 64. • Drain isconnected to required vacuum apparatus. • Once ulcer granulates well, flap cover or skin grafting is done. • Excision of the ulcer and skin grafting. • Flaps—local rotation or other flaps (transposition flaps). • Cultured muscle interposition.
- 65. • Proper care:Change in position once in 2 hours; lifting the limb upwards for 10 seconds once in 10 minutes; nutrition; use of water bed/air bed/air-fluid floatation bed and pressure dispersion cushions to the affected area; urinary and faecal care; hygiene; psychological counselling. • Regular skin observation; keeping skin clean and dry (using regular use of talcum powder); oil massaging of the skin and soft tissues using clean, absorbent porous clothing; control and prevention of sepsis helps in the management.
- 66. ULCER DUE TO FROSTBITE •It is due to exposure of a part to wet cold below the freezing point (cold wind). • There is arteriolar spasm, denaturation of proteins and cell destruction. • It leads to gangrene of the part. • Ulcers here are always deep.
- 82.