Ulcer.pptx

1. Tips on using my ppt. 1. You can freely download, edit, modify and put your name etc. 2. Don’t be concerned about number of slides. Half the slides are blanks except for the title. 3. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. 4. At the end rerun the show – show blank> ask questions > show next slide. 5. This will be an ACTIVE LEARNING SESSION x three revisions. 6. Good for self study also. 7. See notes for bibliography.

2. Ulcer:Definition

3. Ulcer:Definition • Discontinuity of epithelium

4. Types/Classifications

5. Types/Classifications • Clinical • Pathological • Wagner’s grading

6. Wagner’s Grading of ulcers

7. Wagner’s Grading of ulcers Grade 0 - Preulcerative lesion/healed ulcer Grade 1 - Superficial ulcer Grade 2 - Ulcer deeper to Subcutaneous tissue exposing soft tissue or bone Grade 3 - Abscess formation or osteomyelitis Grade 4 - Gangrene of part of tissues/limb/foot Grade 5 - Gangrene of entire one area/foot

8. A. Clinical

9. A. Clinical • Spreading : (Edge - Inflamed & Edematous) • Healing : (Edge is sloping with healthy red granulation tissue & serous discharge) • Callous : (Floor contains pale unhealthy granulation tissue with indurated edge)

10. B.Pathological

11. B.Pathological • 1. Nonspecific • 2. Specific • 3. Malignant

12. 1. Non specific

13. 1. Non specific • Traumatic Ulcer • Arterial Ulcer • Venous Ulcer • Neurogenic Ulcer • Infective Ulcer

14. 1. Non specific contd. • Diabetic Ulcer • Tropical Ulcer • Cryopathic Ulcer • Martorell’s Ulcer • Bazin’s Ulcer

15. Traumatic ulcer

16. Traumatic ulcer 1. Mechanical- Dental ulcer on tongue ( jagged tooth ) 2. Physical- Electrical burn 3. Chemical- Application of caustics • Acute, Superficial, Painful, Tender

17. Arterial Ulcer

18. Arterial Ulcer • Caused due to peripheral vascular disease • LL : Atherosclerosis & TAO • UL : Cervical Rib, Raynauds • Chief complaint : Severe Pain • Toes, Feet, Legs & UL Digits

19. Venous ulcers

20. Venous ulcers • Medial aspect of lower 3rd of lower limb • Ankle ( Gaiters Zone ) : Chronic Venous HTN • Ulcers are Painless • Varicose Veins or Post Phlebitic limb ( PTS )

21. Trophic Ulcer

22. Trophic Ulcer • Pressure Sore or Decubitus Ulcer • Painless. • Punched out edge with slough on the floor • Ex: Bed Sores & Perforating ulcers • Develop as a result of Prolonged Pressure • Sites : Ischial Tuberosity > Greater Trochanter > Sacrum > Heel > Malleolus > Occiput

23. Tropical ulcer • Tropical regions : Africa, India, S.America • Trauma or Insect Bite • Fusobacterium fusiformis & Borrelia vincentii • Abrasions, Redness, Papules & Pustules • Severe Pain

24. Diabetic foot Ulcer

25. Diabetic foot Ulcer Due to • Diabetic Neuropathy • Diabetic Microangiopathy • Increased Glucose : Increased Infection • Foot ( Plantar ), Leg, Back, Scrotum, Perineum • Ischemia, Septicemia, Osteomyelitis,

26. Bazin’s Ulcer

27. Bazin’s Ulcer • Erythema induratum, also known as nodular vasculitis or Bazin disease, • Categorized as a tuberculid skin eruption, which is a group of skin conditions associated with an underlying or silent focus of tuberculosis • They are sequelae of immunologic reactions to hematogenously dispersed antigenic components of Mycobacterium tuberculosis

28. Martorell’s Ulcer

29. Martorell’s Ulcer •in middle-aged women. •a painful ulceration of the lower leg associated with diastolic arterial hypertension. •It is characterized by single or multiple small homogeneous, symmetrical ulcers most commonly located on the anterolateral aspect of the lower leg. •The pain associated to these lesions is often disproportionate to their size not relieved by rest or elevation.

30. 2. Specific

31. 2. Specific • Tuberculosis • Syphilis • Actinomycosis • Meleney’s ulcer • Soft sore

32. 3. Malignant

33. 3. Malignant • Squamous cell ca • Basal cell ca • Malignant melanoma

34. Examination

35. Examination • Inspection • Palpation • Examination of lymph nodes • Vascular insufficiency • Nerve lesions

36. • INSPECTION Location, size, shape, floor, edge, discharge, surrounding area. • PALPATION Tenderness, local rise of temperature, bleeding on touch, consistency of the ulcer, edge, surrounding area - oedema, mobility. Proe to bbone test • REGIONAL LYMPH NODES • SENSATIONS • PULSATIONS • FUNCTION OF THE JOINT • SYSTEMIC EXAMINATION

37. INSPECTION

38. INSPECTION • LOCATION OF THE ULCER • FLOOR OF THE ULCER • DISCHARGE FROM THE ULCER • EDGE • SURROUNDING AREA

39. LOCATION OF THE ULCER

40. LOCATION OF THE ULCER Arterial ulcer Tip of the toes, dorsum of the foot Long saphenous varicosity with ulcer Medial side of the leg. Short saphenous varicosity with ulcer Lateral side of the leg. Perforating ulcers Over the sole at pressure points. Nonhealing ulcer Over the shin

41. FLOOR OF THE ULCER

42. FLOOR OF THE ULCER DEF : This is the part of the ulcer which is exposed or seen. Red granulation tissue Healing ulcer Necrotic tissue, slough Spreading ulcer Pale, scanty granulation tissue Tuberculous ulcer Wash-leather slough Gummatous ulcer

43. FLOOR OF THE ULCER DEF : This is the part of the ulcer which is exposed or seen. Red granulation tissue Healing ulcer Necrotic tissue, slough Spreading ulcer Pale, scanty granulation tissue Tuberculous ulcer Wash-leather slough Gummatous ulcer

44. DISCHARGE FROM THE ULCER

45. DISCHARGE FROM THE ULCER Serous discharge Healing ulcer Purulent discharge Spreading ulcer Bloody discharge Malignant ulcer Discharge with bony spicules Osteomyelitis Greenish discharge Pseudomonas infection

46. EDGE

47. EDGE DEF: This is between the floor of the ulcer and the margin. The margin is the junction between the normal epithelium and the ulcer. These two parts represent areas of maximum activity. 3 STAGES • Stage of ex-tension. • Stage of transition. • Stage of repair.

48. A. Sloping edge All healing ulcers like traumatic ulcers, venous Ulcers

49. B. Punched out edge Gummatous ulcers and trophic ulcers.

50. C. Undermined edge Tuberculous ulcers

51. D. Raised edge (beaded edge) Rodent ulcers or basal cell carcinoma .

52. E. Everted edge (Rolled out) Squamous cell carcinoma.

53. SURROUNDING AREA

54. SURROUNDING AREA Thick and pigmented Varicose ulcer. Thin and dark Arterial ulcer. Red and oedematous Spreading ulcers like diabetic ulcer.

55. PALPATION

56. PALPATION • EDGE • BASE • MOBILITY • BLEEDING • SURROUNDING AREA • Probe to bone test.

57. EDGE

58. EDGE • Induration (hardness) of the edge is very characteristic of squamous cell carcinoma. • It is said to be a host defense mechanism. • Tenderness of the edge is characteristic of infected ulcers and arterial ulcers.

59. BASE

60. BASE • It is the area on which ulcer rests. • Marked induration at the base is diagnostic of squamous cell carcinoma. • Probe to bone Test

61. INDURATION

62. INDURATION • The edge, base and the surrounding area should be examined for induration. Maximum induration Squamous cell carcinoma Minimal induration Malignant melanoma. Brawny induration Abscess. Cyanotic induration Chronic venous congestion as in varicose ulcer.

63. MOBILITY

64. MOBILITY • Gentle attempt is made to move the ulcer to know its fixity to the underlying tissues. • Malignant ulcers are usually fixed, benign ulcers are not.

65. BLEEDING

66. BLEEDING • Malignant ulcer is friable like a cauliflower. On gentle palpation, it bleeds. • Granulation tissue as in a healing ulcer also causes bleeding.

67. SURROUNDING AREA

68. SURROUNDING AREA • Thickening and induration is found in squamous cell carcinoma. • Tenderness and pitting on pressure indicates spreading inflammation surrounding the ulcer.

69. RELEVANT CLINICAL EXAMINATION

70. RELEVANT CLINICAL EXAMINATION • REGIONAL LYMPH NODES Tender and enlarged Acute secondary infection. Non-tender and enlarged Chronic infection. Non-tender and hard Squamous cell carcinoma. Non-tender, large, firm, multiple Malignant melanoma.

71. Investigations

72. Investigations 1) Complete blood picture: Hb%, TC, DC, ESR, PS 2) Urine and blood examination to rule out diabetes 3) Chest X-ray - PA. view to rule out Koch’s 4) Pus for culture/sensitivity 5) Lower limb angiography in cases of arterial diseases. 6) X-ray of the part to see for Osteomyelitis 7) Doppler study of LL. Vessels. 8) Biopsy: Non-healing/malignant ulcers

73. Treatment

74. Treatment • Address cause • Correct deficiencies • Control pain, infection • Debridement, dressing • Closure of defect

75. TREATMENT OF THE ULCERS

76. TREATMENT OF THE ULCERS • Treatment of Diabetic foot Ulcers • Treatment of Spreading Ulcers • Treatment of Healing Ulcers • Treatment of Chronic Ulcers • Treatment of The Underlying Disease

77. TREATMENT OF DIABETIC FOOT ULCERS

78. TREATMENT OF DIABETIC FOOT ULCERS • Control of DM with insulin. • Debridement • Prevention.

79. TREATMENT OF SPREADING ULCERS

80. TREATMENT OF SPREADING ULCERS • Pus Culture/Sensitivity report, • Appropriate Antibiotics • Solutions to treat the Slough : H₂O₂ & EUSOL - Edinburgh University Solution (Hypochlorite solution) • Excessive Granulation Tissue (Proud Flesh) : Excision or Application of Copper Sulphate or Silver Nitrate • Repeated Dressings,

81. TREATMENT OF HEALING Ulcer ULCER

82. TREATMENT OF HEALING Ulcer ULCER • Regular dressings are done for a few days • Culture swab is taken to rule out Streptococcus Haemolyticus ( contraindication for skin grafting ) • Ulcer is small - Heals by itself ( Epithelialization ) Large - Free Split Skin Graft applied

83. TREATMENT OF CHRONIC ULCERS • These do not respond to conventional methods of treatment. The following are tried: • Infrared radiation, short-wave therapy, ultraviolet rays decrease the size of the ulcer. • Amnion helps in epithelialization. • Chorion helps in granulation tissue. • These ulcers ultimately may require skin grafting./flaps

84. Disturbances in Wound Healing

85. Disturbances in Wound Healing • Local Factors • Systemic Factors

86. Local Factors

87. Local Factors • Immobility- Pressure sore/bed sore/decubitus ulcer • Ischemia • Venous congestion. • Lymphedema • Infection: impairs healing. • Smoking: increased platelet adhesiveness, decreased O2 carrying capacity of blood, abnormal collagen. • Radiation:

88. Wound Infection A positive wound culture does not confirm a wound infection.

89. Wound Infection: Systemic features

90. Wound Infection: Systemic features • Tachycardia • Malaise • Fever • Chills • Leukocytosis • elevated erythrocyte sedimentation rate

91. Wound Infection: Local features

92. Wound Infection: Local features • Foul-smelling drainage • spontaneously bleeding wound bed • flimsy friable tissue • increased levels of wound exudates • increasing pain • surrounding - – cellulitis – Crepitus – necrosis, – Fasciitis – regional lymphadenopathy

93. Wound Infection: Local features Osteomyelitis • Fevers, malaise, chronic fatigue, and limited range of motion of the affected extremity, • patients often present with only a nonhealing wound or a chronic draining sinus tract overlying a bone or joint. • Probe to bone test. • Plain radiographs, CT scans, radionuclide bone scans, and MRI • Osteomyelitis is treated with surgical curettage and appropriate systemic antibiotics.

94. Systemic Factors

95. Systemic Factors • Malnutrition • Cancer • Old Age • Diabetes- impaired neutrophil chemotaxis, phagocytosis. • Steroids and immunosuppression suppresses macrophage migration, fibroblast proliferation, collagen accumulation, and angiogenesis. Reversed by Vitamin A 25,000 IU per day. • Superstitions

96. Wound Management

97. Wound Management • Systemic measures. • Local measures

98. Wound Management Local measures- “The golden hour” • Haemostasis • Anaesthesia • Decontamination • Repair and closure • Delayed closure- • Late presentation • Heavy contamination • Lot of dead and devitalized tissue.

99. Wound Management Local measures- “The golden hour” • Haemostasis • Anaesthesia • Decontamination • Repair and closure • Delayed closure- • Late presentation • Heavy contamination • Lot of dead and devitalized tissue.

100. Wound Management • Local measures- • Surgically debride nonvitalized tissue and with appropriate irrigation • Dressing changes require clean but not necessarily sterile technique. • Remove foreign bodies • Pat the wound surface with soft moist gauze; do not disrupt viable granulation tissue.

101. Wound Management Pressure sores • Mobilise • Appropriate turning and positioning • Use of offloading support surface • Appropriate wound care • Appropriate management of incontinence • Appropriate nutritional management

102. Wound Management • Pressure sores •

103. Wound Management Venous Ulcers • Appropriate wound care • Compression dressings.

104. Wound Management Diabetic foot ulcers • Appropriate wound care • Liberal debridement • Maintain euglycemia with insulin. • Antibiotics only if evidence of infection. • Reperfusion.

105. Wound Management Surgical Care • Skin grafting • Cadaveric allografting • Application of bioengineered skin substitutes • Use of flap closures

106. Future and Controversies

107. Future and Controversies • Human cell–conditioned media developed in embryologiclike conditions • transforming growth factor (TGF)–β3 • Hyperbaric oxygen has also been used to promote healing. • Agents such as platelet-rich plasma (PRP) and erythropoietin (EPO • Engineered tissue matrices • Stem Cells

108. Take home messages • Early closure of clean wounds. • Delayed closure of dirty / infected wounds. • Antibiotics are generally not indicated in abrassions, contusions. • For open wounds give three dosage of antibiotic. • Further antibiotics only if evidence of infection. • Spirit, Betadine,Savlon, Hydrogen peroxide Sumag should not be applied on wounds.

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