ULCER

Issah J. kiswagala

(M.B.B.S)

DEFITION

ULCER

• An ulcer is a break in the continuity of the covering epithelium — skin or mucous membrane caused by either molecular death of the surface epithelium or its traumatic removal.

​

• In an ulcer, the primary tissue breakdown is internal, i.e. the lesion is caused by an underlying disease or other internal reasons and breakdown of the tissue will typically be gradual.
• In a wound, the primary tissue breakdown is caused by external force such as a bullet, a surgical incision or trauma and the breakdown of the tissue will typically be acute.
• Wound can be acute or chronic: A chronic wound is defined as one that has been in existence for more than 3 weeks or that has failed to proceed through an orderly and timely process to produce anatomic and functional integrity.
• For this reason, a chronic lession is sometimes referred to as an “ulcer.”

​

PARTS OF AN ULCER

1. Margin:
1. Is the junction between normal epithelium and the ulcer, so it is the boundary of the ulcer.
2. It may be regular or irregular. It may be rounded or oval.

2. Edge:
1. Is the area between the margin and the floor of the ulcer.
2. Edge is the one which connects floor of the ulcer to the margin.

​

TYPES OF EDGES

• Five common types of ulcer edge are seen in surgical practice;
• Sloping edge, Undermined edge, Punched out edge, Raised and beaded edge, Everted edge (rolled out edge).

UNDERMINED EDGE

SLOPPING EDGE

PUNCHED OUT

RAISED EDGE

EVERTED EDGE

3. Floor:
1. This is the exposed surface of the ulcer which is seen.
2. Floor may contain discharge, granulation tissue or slough.
3. When floor is covered with red granulation tissue, the ulcer seems to be healthy and healing.
4. Pale and smooth granulation tissue indicates a slowly healing ulcer.
5. Wash-leather slough (like wet chamois leather) on the floor of an ulcer is pathognomonic of gummatous ulcer.

4. Base:
1. Base is the one on which ulcer rests. It may be bone or soft tissue.
2. On palpation slight induration of the base is expected in any chronic ulcer but marked induration (hardness) of the base is an important feature of squamous-celled carcinoma and Hunterian chancre.

​

AETIOLOGY

• Traumatic causes
• Mechanical
• Physical – electrical, radiation etc.
• Chemical
• Vascular insufficiency
• Arterial
• Venous
• Metabolic diseases
• Diabetes mellitus

​

• Neoplastic conditions
• SCC
• BCC
• KS
• Malignant melanoma etc.
• Infective processes
• TB
• Syphilis
• Fungal infections

​

• Malnutrition
• Beriberi
• Tropical ulcer
• Inflammatory processes
• Cellulitis

​

CLASSIFICATION

• Two types of classification of ulcers are possible :— clinically and pathologically.

Classification I

• CLINICALLY, an ulcer may be either of 3 types.
• Spreading ulcer: Here edge is inflamed and oedematous. It is a painful ulcer.
• Healing ulcer: Edge is sloping with healthy pink/red granulation tissue with serous discharge.
• Callous (Chronic) ulcer: Floor contains pale unhealthy granulation tissue with indurated edge/base. It lasts for many months to years. Ulcer does not show any tendency to heal. It is due to callous attitude of the patient.

• Classification II
• PATHOLOGICALLY, the ulcers can be classified into 3:
• Specific ulcers: Tuberculous, syphilitic (It is punched out, deep, with “wash-leather” slough in the floor and with indurated base), soft sores, actinomycosis, Meleney’s ulcer.
• Malignant ulcers: Epithelioma, Marjolin's ulcer, rodent ulcer, Carcinomatous ulcer and malignant melanoma
• Non-specific ulcers:
• These ulcers can be further classified into the following categories
• Traumatic ulcer: It may be mechanical, physical, chemical-common.
• Arterial ulcer: as occurs in atherosclerosis, Buerger's disease, Raynaud's disease (primary and secondary)

3. Venous e.g. varicose ulcer in post-phlebitic limb.
4. Neurogenic (Trophic) ulcer/Pressure sore. e.g. bed sore and perforating ulcer.
5. Ulcers associated with malnutrition (Tropical ulcers): It occurs in tropical countries. It is callous type of ulcer, e.g. Vincent’s ulcer.
6. Ulcers may be associated with certain other diseases like gout, diabetes, anaemia, avitaminosis, erythrocyanosis frigida, rheumatoid arthritis etc.
7. Ulcers due to leukaemia, polycythemia, jaundice, collagen diseases, lymphoedema.
8. Certain other types of ulcers require special mention e.g. Bazin's ulcer, Martorell's ulcer etc. Bazin's ulcer is found in fatty adolescent girls particularly on the calves as purplish nodules followed by indolent ulcers. Martorell's or hypertensive ulcer is found in people suffering from hypertension.

​

​

9. 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.
10. Infective ulcers: Pyogenic ulcer

​

CLINICAL PRESENTATION

• History taking
• Physical examination

​

HISTORY

• The following points are particularly noted in the history of a case of an ulcer:
• Duration (i.e. how long is the ulcer present?).e.g. The patient complaints of painful ulcer on the right ankle joint for 6 months. (acute/chronic).
• 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
• Pain (i.e. is the ulcer painful? Then amplify pain - DONPARA)
• Painful: ulcers associated with inflammation
• Slight painful: tuberculous ulcer
• Painless e.g. syphilitic, neurogenic, malignant ulcers

​

​

4. Discharge (i.e. does the ulcer discharge or not?)
• If YES: note the nature of discharge- pus, bloody, serous
5. Associated diseases which may lead to ulcer formation
• e.g. Tuberculosis , Syphilis, Diabetes Mellitus, nervous diseases - tabes dorsalis, syringomyelia, transverse myelitis and peripheral neuritis may result an ulcer (trophic or perforating ulcer).

​

PHYSICAL EXAMINATION

• General examination
• Local examination
• Systemic examination

​

GENERAL EXAMINATION

• In case of ulcer, one should not give all attention to the ulcer only. Ulcer may well be a sequel of malnutrition, general atherosclerosis, syphilis, tuberculosis etc.
• Thus, head-to-toe examination is required; hair (malnutrion), paleness (anaemia), Jaundice, lymph nodes. etc
• If the ulcer appears to be tuberculous, all the lymph nodes in the body should be examined along with other examination such as the chest, the neck, the abdomen etc.
• When the ulcer is suspected to be syphilitic, a thorough search should be made for presence of other syphilitic stigmas in the body.
• When the ulcer is a trophic (perforating) one general examination must be made to know the type of nervous disease present with this condition.

• If the ulcer seems to be due to atherosclerotic or Buerger's disease (ischaemic), the whole body must be examined for presence of atherosclerosis or its complication anywhere in the body. Moreover Buerger's disease is a bilateral condition and the other limb should always be examined.

LOCAL EXAMINATION

• Inspection
• Palpation
• Examination of lymph node
• Examination of vascular insufficiency

​

INSPECTION

1. Site: This is very important and often by itself gives a clue to the diagnosis
• Varicose ulcer - lower limb on the medial malleolus
• Rodent ulcer - face
• Tuberculous ulcer – neck and axilla or groin
• Trophic ulcer – heal
• Malignant ulcer- anywhere but commonly seen on the lips, tongue, breast, penis and anus.
• Hunterian chancre and soft sores - found over the external genitalia
• Gummatous ulcers - seen over the subcutaneous bones such as tibia , sternum, skull etc
2. Number:- Tuberculous, gummatous, varicose ulcers and soft chancres may be more than one in number. (so, state the numbers e.g. three ulcers on the face)

3. Shape:
• Tuberculus ulcer- oval in shape
• Syphilitic ulcer– circular or semilunar 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
• To record exactly the size and shape of an ulcer, a sterile gauge may be pressed on to the ulcer to get its measurements.

5. Surrounding skin
• E.g. red and edematous- acute inflammation
• Eczematous and pigmented - varicose ulcer
• A scar or a wrinkling – an old case of tuberculosis.

​

• Floor/surface i.e. exposed part of the ulcer may give clue to the diagnosis
• E.g red granulation – healing ulcer
• Black floor- malignant melanoma

​

7. 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

​

8. Discharge: the character of the discharge should be noted, its amount and smell. E.g.
• Healing ulcer - scant serous discharge
• Spreading ulcer - purulent discharge
• Tuberculous ulcer - serosanguinous
• Malignant ulcer - bloody discharge

​

PALPATION

1. Tenderness
• Tender- acutely inflamed ulcer
• Slightly tender- tuberculous ulcer, syphilitic ulcer
• Non-tender- malignant ulcer, chronic ulcer, neurogenic ulcer
2. Edge and surrounding skin
• Hard induration- malignant ulcer e.g. a squamous-celled carcinoma or adenocarcinoma.
• Firm induration- chronic ulcer, syphilitic ulcer
3. Base (i.e. on which the ulcer rest)
• Slightly induration- syphilitic ulcer
• Marked induration- malignant ulcer e.g. SCC and Hunterian chancre.

​

4. Depth
• It can be recorded in the examination sheet in millimetres.
• e.g. trophic ulcer may be deep to reach the bones
5. Bleeding
• Easy bleed on touch is a feature of malignant
6. Fixity to the deep structures
• The ulcer is made to move over the deeper structures to know whether it is fixed to any of these structures
• e.g. malignant ulcers are usually fixed to deep structures

​

7. Surrounding skin
• Skin around the ulcer must be palpated and examined.
• E.g. increased temperature and tenderness indicates the ulcer to be of acute inflammatory origin
• The mobility of the surrounding skin is examined
• E.g. Fixity to deeper structures indicates the malignant nature of the lesion

EXAMINATION OF LYMPH NODE

• This part of the examination is very important;
• In acutely inflamed ulcers - the regional lymph nodes become enlarged, tender and show the signs of acute lymphadenitis
• In tuberculous ulcer - the lymph nodes become enlarged, matted and slightly tender.
• Hunterian chancre - the regional lymph nodes remain discrete, firm and shotty.
• In gummatous and rodent ulcer - lymph nodes are not usually involved and not affected
• In malignant ulcer - the nodes are stony hard and may be fixed to the neighbouring structures in late stages.
• The lymph nodes may be enlarged because of secondary infection rather than anything else.

EXAMINATION OF VASCULAR INSUFFICIENCY

• Examine the condition of the arteries proximal to the ulcer
• Atherosclerosis, Buerger's disease, Raynaud’s disease etc. may be the cause of the ulcer from poor circulation.

DIFFERENTIAL DIAGNOSIS

• It depends with the aetiological causes such;
• Traumatic ulcers
• Vascular ulcers
• Neoplastic ulcers
• Metabolic ulcers
• Ulcers due to malnutrition
• Inflammatory ulcers
• Infective ulcers

​

INVESTIGATIONS

• Laboratory
• Imaging
• Histopathology

​

LABORATORY INVESTIGATIONS

• Haematological
• FBP & ESR
• RBG.
• Microbiological examination of the discharge of the ulcer
• Gram staining
• Culture and sensitivity
• Biochemical
• Serum glucose to exclude diabetes

​

IMAGING INVESTIGATIONS

1. Plain X-rays
• CXR is important in tuberculous ulcers to detect any primary focus in the lung
• X-ray of the affected limb
2. Doppler US
3. CT Scan
4. MRI

​

​

HISTOPATHOLOGY

• Biopsy
• In malignant ulcers, is very important To confirm diagnosis
• The biopsy is generally taken from the edge of the ulcer taking a portion of surrounding healthy tissue.

TREATMENT

• Depends on the cause
• Generally → treat the cause
• Conservative treatment
• Surgical treatment

​

CONSERVATIVE TREATMENT

• Wound Dressing: Normal saline, Povidone Iodine, Sterile gauzes
• Treat infections
• Bacteria, fungal, syphilis, TB etc.
• Topical antimicrobial agents such as silver sulfadiazine, Mupirocin
• Nutritional support
• Control blood glucose in DM patients
• Compression bandage
• Limb elevation

​

​

​

SURGICAL TREATMENT

• Surgical debridement
• Sloughectomy
• Skin grafting
• Flaps
• Limb amputation

​

PROGNOSIS

• Depends on the type of ulcer and its management

FOLLOW-UP

• Follow-up should be performed daily for the first month. The interval may then be increased depending with the types of an ulcer.
• Early issues include daily dressing, sloughectomy, suture removal, drain removal or secondary suturing and when to allow the patient to exercise or sit up.

COMPLICATIONS

• Limb amputation
• Chronic osteomyelitis
• Malignant change
• Septicemia
• Septic emboli

​