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Uploaded byBipul Thakur
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Ulcer presentation

Ulcer is a break in the skin or mucous membrane. There are several types of ulcers including acute, chronic, spreading, and non-healing ulcers. Ulcers can be caused by infection, trauma, poor circulation, or underlying conditions like diabetes. The key parts of an ulcer include the margin, edge, floor, and base. Evaluation of an ulcer involves examining these parts and considering characteristics like appearance, drainage, surrounding skin, and tenderness. Investigation and management depends on the identified cause, with goals of cleaning the ulcer, promoting healing, treating underlying issues, and closing the wound.

Health & Medicine◦
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ULCER DR. BIPUL THAKUR
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
Parts of Ulcer  Margin : Junction b/w Normal epithelium & Ulcer  Edge: one which connects floor of ulcer with the margin  Floor : Exposed surface of ulcer may contain discharge, granulation tissue or slough  Base : on which ulcer rests may be bone or soft tissue Parts of Ulcer
- - Acute < 2 wks - Chronic > 2 wks -- Healing -- Non healing --Spreading Infection: Pypgenic ulcer Traumatic:physical/ chemical agents,mechanical Interference with circulation - arterial / venous Cryopathic, Bazin’s, Martorells Diabetic, Cortisol, Tropical TB Syphilis Meleney’s ucer Sq. cell carcinoma Melanoma basal cell CA ( rodent) Pathological Duration Clinical Non specific specific Malignancy
Spreading ulcer  Edge : Inflammed, irregular and oedematous Acute painful ulcer  Floor: No healthy granulation tissue profuse purulent discharge and slough + surrounding area red & oedematous  Regional LN s: Enlarged & tender Fig: Spreading ulcer with copious and purulent discharge
Healing Ulcer  Edge: Sloping  Floor : Healthy pink granulation tissue with scanty/minimal serous discharge  Regional LNs: May/maynot be enlarged but when enlarged always non-tender  Surrounding area: No signs of inflammation Fig: Healing Ulcer with healthy granulation tissue in floor
3 zones in Healing Ulcer  Innermost :Red zone of healthy granulation tissue  Middle :Bluish zone of growing epithelium  Outer :Whitish zone of fibrosis & scar formation
Non-healing Ulcer  Floor : Unhealthy granulation tissue and slough Serosanguinous/purulent/bloody discharge  Regional LNs: may be enlarged but non-tender Fig: Non-healing ulcer with pale unhealthy granulation tissue with slough
STAGES OF ULCER HEALING   Extension phase  Transition phase  Repair phase
Extension phase  The floor is covered with exudates and sloughs    The base is indurated  Inflammed edge and margin  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)
Life history of Ulcer Floor Base Discharge Granulation Pain  Extension Transition Repair Covered with slough and exudate Indurated Purulent / even blood stained absent +++ clearer Induration decreases more serous small areas appear & spread ++ granulation tissue transforms to fibrous tissue . further decreases. serous epithelisation from surrounding area growth rate 1 mm/d 3 layers +ve -- ve
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 contd  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  
Physical examination  Local examination  General examination  Systemic examination
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 Eg red granulation – healing ulcer  Black floor- malignant melanoma  Wash leather slough: pathognomonic of Gummatous ulcer  Number: more than one  Tuberculous ulcer  Gummatous ulcer  Varicose ulcer
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: 
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  enlarged , tender: infected  enlarged , stony hard , fixed: CA  firm & shotty: hunterian chancre  Not affected: Rodent ulcer
Examination of vascular insufficiency  When located in lower part of leg: Look for varicose vein in Upper part of leg or thigh  If no varicose found, look for arterial condition proximal to ulcer.  Causes of Ulcer from poor circulation: Atherosclerosis Buerger’s Dz Raynoud’s Dz
Neurological Examination  Sensory  Motor  Reflexes
General Examination  Look for Malnutrition, Anemia , Diabetes
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
Management of Ulcer  Cause found and treated.  Correction of Anaemia, protein & vitamin deficiency  Blood transfusion if required  Control of pain & infection  Rest, immobilization, elevation & avoidance of repeated trauma  Debridement  Ulcer cleaning & dressing: NS – Ideal for ulcer cleaning
 Topical Antibiotics: Silver sulphadiazine, Mupirocin, Framycetin  Vaccum Assisted Closure  Once ulcer degranulates, defect is closed with secondary suturing, skin grafting or flaps.
Ulcer -- treatment local applications ( lotions / ointments ) -- to separate slough -- hasten granulation -- stimulate epithelisation -- treatment of cause -- correct Aneamia -- treat metabolic disorders. -- Antibiotics -- treatment of DM Na hypochlorite 0.5% AgNo3 Zinc Sulphate early phase 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
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