ULCERS
Abdallah
General Surgery
ttcih-Ifakara
Outline
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Definition
Aetiology
Classification
Pathophysiology
Clinical presentation
Workup
Treatment
Definition
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A break in the continuity of the covering epithelium
of the skin or mucous membrane
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It may either follow molecular death of the surface
epithelium or its traumatic removal
Aetiology
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Trauma
Vascular insufficiency
Neoplastic conditions
Metabolic diseases e.g. diabetis mellitus,
Infective processes eg TB, syphilis
Neurogenic
Classifications
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Clinical classification
Pathological classification
Clinical classification
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Spreading ulcer
Healing ulcer
Callous ulcer
Spreading ulcer
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Surrounding skin is inflammed
Floor is covered by slough
No evidence of granulation tissue
Purulent discharge
Healing ulcer
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Surrounding skin not inflamed
Floor covered with granulation tissue
Edges show bluish outline of the growing
epithelium
Slight serous discharge
Callous ulcer
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Pale granulation tissue in the floor
Considerable induration at the base, edge and
surrounding skin
Show no tendency towards healing
Pathological classification
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Non specific ulcers
Specific ulcers
Non specific ulcers
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Traumatic ulcers
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Arterial ulcers
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Mechanical
Physical – electrical, radiation etc
Chemical
Due to ischaemia eg following atherosclerosis,
Buergers disease
Venous ulcers
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Varicose ulcer
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Neurogenic ulcers (trophic ulcer)
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Ulcers associated with malnutrition
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eg tropical ulcer
Ulcers associated with other diseases
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eg bed sores, perforating ulcers
eg anemia, avitaminosis, gout, rheumatoid arthritis
Miscellaneous ulcer
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eg Bazin ulcer, martorell’s (hypertensive ulcer)
Specific ulcers
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Infective ulcers eg
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syphilitic ulcers,
tuberculous ulcer
Malignant ulcers eg
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Squamous cell carcinoma
Basal cell carcinoma ( rodent ulcer)
Malignant melanoma
Ulcerating adenocarcinoma
Pathophysiology
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The natural history of an ulcer consists of three phases:
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Extension phase
Transition phase
Repair phase
Extension phase
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The floor is covered with exudate and
sloughs
The base is indurated
The discharge is purulent or even blood
stained
Transition phase
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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
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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:
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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  density of new capillaries (neo-angiogenesis)
Clinical presentation I
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History; note the following:
Duration i.e. how long is the ulcer present?
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Mode of onset i.e. how has the ulcer developed?
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Acute: present for short time
Chronic: present for long time
Following trauma
Spontaneously eg following- swelling eg ulcerating LN in TB
or a scar of burn Marjolin ulcer
Pain i.e. is the ulcer painful?
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Painful: ulcers associated with inflammation
Slight painful: tuberculous
Painless eg syphilitic, neurogenic, malignnt ulcer
Clinical presentation II
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History (cont’d)
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Discharge: i.e does the ulcer discharge or not?
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Associated diseases which may lead to ulcer formation
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If YES: note the nature of discharge- pus, bloody, serous
E.g. TB, Syphilis, DM, nervous diseases
Physical examination
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General examination
Local examination
Systemic examination
Clinical presentation III
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PE (cont)
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General examination may be normal
Local examination
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Inspection
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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
Clinical presentation III
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Shape:
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Tuberculus ulcer- oval in shape
Syphilitic ulcer– circular in shape
Varicose ulcer – vertically oval in shape
Malignant – irregular in shape
Size:
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May determine the time of healing
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E.g. the smaller the ulcer the shorter the time it will take to heal
Clinical presentation IV
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Surrounding skin
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Floor/surface i.e. exposed part of the ulcer may give clue
to the diagnosis
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E.g. red and edematous- acute inflammation
Eg red granulation – healing ulcer
Black floor- malignant melanoma
Number
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Tuberculous ulcer
Gummatous ulcer
Varicose ulcer
may be more than one
Clinical presentation V
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Edge: five types:
Undermined edge
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Punched out edge
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Eg healing ulcer
Raised edge
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Eg. Gummatous ulcer, deep trophic ulcer
Sloping edge
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Eg; tuberculous ulcer-destroy subcutanous faster the skin
Rodent ulcer
Rolled out (everted)- eg SCC,
Clinical presentation V
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Discharge: the character of the discharge should be
noted e.g.
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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
Clinical presentation VI
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Palpation: note:
Tenderness:
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Edge and surrounding skin
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Tender- acutely inflamed ulcer
Slightly tender- tuberculous ulcer, syphilitic ulcer
Non-tender- malignant ulcer, chronic ulcer, neurogenic ulcer
Hard induration- malignant ulcer
Firm induration- chronic ulcer, syphilitic ulcer
Base (i.e. on which the ulcer rest)
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Slightly induration- syphilitic ulcer
Marked induration- malignant ulcer
Clinical presentation VII
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Depth:
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Bleeding;
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easy bleed on touch is a feature of malignant
Fixity to the deep structures
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eg trophic ulcer may be deep to reach the bones
Eg malignant ulcers are usually fixed to deep structures
Examination of lymph nodes
Examination of vascular insufficiency eg pulses
Examination of nervous system eg sensation
workup
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Lab studies
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Imaging studies
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Pus swab for- c/s
FBP +ESR
CXR : to detect primary focus in the lungs in case of
tuberculus ulcer
X-ray of the bone or joint if the ulcer is situated near a
bone or joint
Biopsy- to conform the diagnosis
Treatment
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Depends on the underlying cause
Generally:
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Dressing
Skin grafting
flaps