Ulcer
Question.1. Write note on nonhealing ulcer.
Answer. Non-healing ulcers classified under clinical classification of ulcers
Non-healing ulcer is also known as chronic ulcer depending on cause of ulcer.
- Chronic ulcer has no tendency to heal by itself.
- The bases of ulcer are indurated (hard).
- Floor of ulcer contain unhealthy granulation tissue and slough.
- Here edges depend on the cause, i.e. punched out, undermined, rolled out and beaded.
- Regional draining lymph nodes may be enlarged but non-tender.
Nonhealing Ulcer Causes of Chronic or Non-healing Ulcer
Nonhealing Ulcer Local Causes
- Recurrent infection
- Trauma, presence of foreign body or sequestrum
- Absence of rest and immobilization
- Poor blood supply, hypoxia
- Edema of the part
- Loss of sensation
- Periostitis or osteomyelitis of the underlying bone
- Fibrosis of the surrounding soft tissues
- Lymphatic diseases
Read And Learn More: General Surgery Question And Answers
Nonhealing Ulcer General/Specific Causes
- Anemia, hypoproteinemia
- Vitamin deficiencies
- Tuberculosis, leprosy
- Diabetes mellitus, hypertension
- Chronic liver or kidney diseases
- Steroid therapy locally or systemically
- Cytotoxic chemotherapy or radiotherapy
- Malignancy
For example
- Diabetic ulcer
- Malignant ulcer
- Carcinomatous ulcer
- Ulcer of squamous cell carcinoma
- Rodent ulcer.
Question.2. Write short note on differential diagnosis of ulcer on the lateral border of tongue.
Answer. The various types of ulcer on the lateral border of tongue are as follows:
- Aphthous ulcer
- Traumatic or dental ulcer
- Chronic non-specifi ulcer
- Post-pertussis ulcer
- Syphilitic ulcer
- Tuberculous ulcer
- Carcinomatous ulcer
- Herpetic ulcer
- Ulcer due to glossitis
Diagnosis Of Ulcer Aphthous ulcer
Minor aphthous ulcer:
- It is small painful ulcer seen on the tip, undersurface and side of the tongue.
- The ulcer is small, superfiial with white flor,yellowish border and surrounded by a hyperemic zone.
- It can occur at any age group, more common in females at the time of menstruation.
Major aphthous ulcer:
- When they are larger, deeper, painful, they are called major aphthous ulcer.
- They subside within a few days.
- Temporary relief can be obtained by applying salicylate gel.
Vitamin B complex is usually given.
Diagnosis Of Ulcer Traumatic or dental ulcer
- This ulcer occurs due to broken, sharp tooth, ill-fitng dentures, prostheses, etc.
- These ulcers occur at the lateral border or under surface of tongue.
- It often presents a slough at its base and surrounded by a zone of erythema and induration.
- This ulcer is quite painful.
Diagnosis Of Ulcer Chronic non-specific ulcers
- Usually occur in the anterior two-thirds of the tongue.
- Its etiology is unknown.
- It is moderately indurated and not very painful.
Diagnosis Of Ulcer Postpertussis ulcer
- Occurs only in children with whooping cough.
- Usually seen on the upper part of frenum lingulae and in the undersurface of tongue.
Diagnosis Of Ulcer Syphilitic ulcer
- Primaryulcer, i.e. chancre found onthe tip ofthe tongue.
- Mainly snail-track ulcers are seen in oral cavity in second stage of syphilis.
- In tertiary syphilis, the gummatous ulcers are found on the midline in the anterior two-thirds of the tongue
- The gumma found on the dorsum of tongue.
Diagnosis Of Ulcer Tuberculous ulcer:
- Young adults are usually involved.
- Such ulcers are shallow, often multiple and grayish yellow with slightly red undermining edges.
- These ulcers are seen at the margin (lateral border),tip or dorsum of tongue.
- These ulcers are very painful with enlargement of regional nodes.
Diagnosis Of Ulcer Carcinomatous ulcer:
- It usually occurs in elderly individual above the age of 50 year.
- Common site is the margins of tongue.
- It may occur at the dorsum of tongue.
- It is usually single, but may be multiple.
- It is usually painless to start.
- The ulcer is irregular in shape, has a raised and everted edges with indurated base.
- The flor of such ulcer is covered with necrotic debris.
- It bleeds on touch.
- It is fied with underlying structures.
Question.3. Write short note on lesion on anterior 2/3rd of the tongue.
Answer. Lesions on the anterior 2/3rd of tongue are:
Lesion On Anterior 2/3rd of the tongue Ulcers
- Aphthous ulcer
- Tubercular ulcer
- Traumatic ulcer
- Carcinomatous ulcer
- Gummatous ulcer.
Question.4. Classify ulcers of tongue.
Answer. Classification of ulcers of tongue
Ulcers Of Tongue Non-Specific:
- Traumatic or dental ulcer due to sharp tooth or dentures
- Infective:
- Simple ulcer due to glossitis
- Herpetic ulcer
- Post-pertussis ulcer.
- Aphthous ulcer.
Ulcers Of Tongue Specific:
- Tubercular ulcer
- Syphilitic ulcer
- Malignant ulcer.
Question.5. Write short note on trophic ulcer.
Answer. It is also called as decubitus ulcer or pressure sore.
- Trophic ulcer is tissue necrosis and ulceration due to prolonged pressure.
- Blood flw to the skin stops once external pressure becomes more than 30 mm Hg and this causes tissue hypoxia, necrosis and ulceration.
- It is more prominent between bony prominence and an external surface.
Trophic Ulcer Etiology
It is due to:
- Impaired nutrition.
- Defective blood supply.
- Neurological defiit: Due to the presence of neurological defiit, 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 that extends down into the deeper plane up to the underlying bone as perforating ulcer.
Trophic Ulcer Sites
- Over ischial tuberosity
- Sacrum
- In the heel
- In relation to head of metatarsals
- Buttocks
- Over the shoulder
- Occiput
Trophic Ulcer Clinical Features
- It occurs in 5% of hospitalized patients.
- Ulcer is painless and is punched out.
- Ulcer is non-mobile and base ofthe ulcer is formed by bone.
Trophic Ulcer Management
- Cause should be treated.
- Nutritional supplementation is given.
- Rest, antibiotics, slough excision, regular dressings.
- Vacuum-assisted closure: It is the creation of intermittnt negative pressure of minus l25 mm Hg to promote formation of healthy granulation tissue.
- A perforated drain is kept over the foam dressing covered over the pressure sore. It is sealed with a transparent adhesive sheet.
- Drain is connected to required vacuum apparatus.
Once ulcer granulates well. Flap cover or skin grafting is done.
- Excision of the ulcer and skin grafting is done.
- Flaps: Local rotation or other flps (transposition flps).
- Proper care: Change in position once in 2 hours; lifting the limb upwards for l0 seconds once in l0 minutes; nutrition; use of water bed/air bed/air-flid floatation bed and pressure dispersion cushions to the affected area; urinary and fecal care; hygiene; psychological counseling.
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.
Question.6. Define and describe differentiating features of Curling ulcer and Cushing ulcer.
Answer.
Question.7. Write short note on ulcer.
Answer. An ulcer is the break in the continuity of the covering epithelium either skin or mucus membrane due to molecular death.
Classification of Ulcer
Classification I (Clinical) of Ulcer
- Spreading ulcer
- Healing ulcer
- Non-healing ulcer
- Callous ulcer
Classification II (Based on duration) of Ulcer
- Acute ulcer: Duration less than 2 weeks
- Chronic ulcer: Duration more than 2 weeks
Classification III (Pathological) of Ulcer
Specific ulcers:
- Tuberculous ulcer
- Syphilitic ulcer
- Actinomycosis
- Meleney’s ulcer
Malignant ulcers:
- Carcinomatous ulcer
- Rodent ulcer
- Melanotic ulcer
Non-specific ulcers:
- Traumatic ulcers
- Arterial ulcer
- Venous ulcer
- Trophic ulcer
- Infective ulcer
- Tropical ulcer
- Ulcers due to chilblain and frostbite
- Martorell’s hypertensive ulcer
- Bazin’s ulcer
- Diabetic ulcer
- Ulcers due to leukemia, polycythemia, jaundice,
collagen diseases, lymphoedema - Cortisol ulcers
Parts of an ulcer
Margin: It may be regular or irregular. It may be rounded or oval.
Edge: Edge is the one that connects floor of the ulcer to the margin. 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/firous tissue. Its middle part is blue due to epithelial proliferation
- Undermined edge is seen in a tuberculous ulcer. Disease process advances in deeper plane (in subcutaneous tissue) whereas (skin) epidermis proliferates inwards.
- 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 (basal cell carcinoma). Beads are due to proliferating active cells.
- Everted edge (rolledoutedge): Itis seenina carcinomatous ulcer due to spill of the proliferating malignant tissues over the normal skin.
- Floor: lt is the one which is seen. Floor may contain discharge, granulation tissue or slough.
- Base: Base is the one on which ulcer rests. It may be bone or soft tissue.
Induration of ulcer: It is the clinical palpatory sign which means a specific type of hardness in a diseased tissue. It is seen in carcinomatous ulcers.
Investigations For Ulcer
- Study of discharge: Culture and sensitivity, acid fast bacilli study and cytology.
- Edge 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. - X-ray of the part to look for periostitis/osteomyelitis.
- FNAC of the lymph node.
- Chest X-ray, Mantoux test in suspected case of tuberculous ulcer.
- Hemoglobin, ESR, total WBC count, serum protein estimation.
Management of an ulcer
- Cause should be found and treated
- Correct the defiiencies like anemia, protein and vitamins deficiencies
- Transfuse blood, if required
- Control the pain and infection
- Investigate properly
- Control the infection and give rest to the part
- Care of the ulcer by debridement, ulcer cleaning and dressing is done daily or twice daily.
- Remove the exuberant granulation tissue
- Topical antibiotics for infected ulcers only like, silver sulphadiazine, mupirocin.
- Antibiotics are not required once healthy granulation tissues, if are formed
- Once granulates, defect is closed with secondary suturingskin graft, flaps
Question.8. Describe briefly diabetic ulcer.
Answer. Diabetic ulcer is most common in foot. It can cause abscess, ulcer, osteomyelitis, gangrene, septicemia.
Initially, patient undergo toe amputation but later eventually land with below-knee or above-knee amputation.
Diabetic Ulcer Causes
- Increased glucose in the tissue precipitates infection.
- Diabetic microangiopathy which affects microcirculation.
- Increased glycosylated hemoglobin decreases the oxygen dissociation.
- Increased glycosylated tissue protein decreases the oxygen utilization.
- Diabetic neuropathy involving all sensory, motor and autonomous components.
- Associated atherosclerosis.
Diabetic Ulcer Sites
- Foot-plantar aspect is the most common site
- Leg
- Upper limb, back, scrotum, perineum
- Diabetic ulcer may be associated with ischemia
- Ulcer is usually spreading and deep
Diabetic Ulcer Investigations
- Blood sugar both random and fasting.
- Urine ketone bodies.
- Discharge for culture and sensitivity.
- X-ray of the part to see osteomyelitis.
- Arterial Doppler of the limb; glycosylated hemoglobin estimation.
Diabetic Ulcer Problems with diabetic ulcer
- Neuropathy, in foot clawing of toes, hammer toe (due to intrinsic muscle paralysis)
- Multiple deeper abscesses; osteomyelitis of deeper bones are common.
- Reduced leukocyte function; resistant infection; spreading cellulitis
- Arterial Insufficiency
- Septicemia; diabetic ketoacidosis
- Associated cardiac diseases like ischemic heart disease
Diabetic Ulcer Treatment
- Control of diabetes by using insulin.
- Proper antibiotics should be started after culture and sensitivity report
- Nutritional supplements.
- Regular cleaning, debridement, dressing.
- Once granulates, the ulcer is covered with skin graft or flip.
- Revascularization procedure is done by endarterectomy or thrombectomy or balloon angioplasty or arterial bypass graft. But if distal vessels are involved, then success rate is less.
- Toe foot/leg amputation.
- Microcellular rubber (MCR) shoes to prevent injuries; care of foot.
Question.9. Define ulcer. Describe different types of ulcer.
Answer. An ulcer is the break in the continuity of the covering epithelium either skin or mucus membrane due to molecular death.
Different Types Of Ulcer
Classification I (Clinical)
- Spreading ulcer: In this edge is inflmed, irregular and edematous.
- It is an acute painful ulcer, flor consists of profuse purulent discharge and slough.
- Surrounding area is red and edematous
- Healing ulcer: Edge is sloping with healthy pink/red granulation tissue with scanty/minimal serous discharge on the flor, slough is absent.
- Surrounding area does not show any signs of inflammation or induration.
- Base is not indurated. Three zones are seen innermost red zone of healthy granulation tissue, middle bluish zone of growing epithelium, outer white zone of firosis and scar formation.
- Non-healing ulcer: In this ulcer, edge of the ulcer depend on the cause punched out (trophic), undermined (tuberculosis), rolled out (carcinomatous ulcer), beaded (rodent ulcer); flor consists of unhealthy granulation tissue and slough, and serosanguineous/purulent/bloody discharge, regional draining lymph nodes are enlarged but nontender.
- Callous ulcer: This is a chronic non healing ulcer, flor consists of pale, unhealthy, flbby, whitish yellow granulation tissue and thin scanty serous discharge or rarely with copious serosanguinous discharge, with indurated non tender edge, base in indurated, nontender and is often fied.
- Ulcer does not show any tendency to heal. It lasts for months to years.
- Induration and pigmentation can be seen.
Classification II (Based on duration)
- Acute ulcer: Duration less than 2 weeks
- Chronic ulcer: Duration more than 2 weeks
Classification III (Pathological)
Specific ulcers:
- Tuberculous ulcer: Ulcer can be single or multiple;oval or rounded with undermined edge, painless with caseous material on the flor. Ulcer is not deep
- Syphilitic ulcer: It has punched-out edge, deep with wash leather slough in the flor and indurated base.
- Actinomycosis: In this initially an induration develops.
It softens and bursts via skin as sinuses which discharge pus and have sulfur granules. - Meleney’s ulcer: It is seen in postoperative wounds in abdomen and chest wall. This is an acute rapidly spreading ulcer with destruction and deep burrowing of subcutaneous tissues.
Malignant ulcers:
- Carcinomatous ulcer: This ulcer arises from prickle cell layer of skin.
- It has rolled out/everted edge.
- Floor consists of necrotic content, unhealthy granulation tissue and blood.
- Ulcer bleeds on touch and is vascular or friable. Induration is felt at base and edge.
- It is circular or irregular in shape.
- Rodent ulcer: It is seen in basal cell carcinoma. Ulcer shows central area of dry scab with peripheral, raised active and beaded edge.
- Often flor is pigmented. It erodes in deeper planes such as soft tissue, cartilage and bones
- Melanotic ulcer: It is the ulcerative form of melanoma.
- Ulcer is pigmented often with halo around. Ulcer is rapidly growing often with satellite nodules.
Non-specific ulcers:
- Traumatic ulcers: It occurs after trauma. Ulcer is superfiial, painful and tender.
- Arterial ulcer: This ulcer occurs after trauma and soon become nonhealing.
- Ulcer is usually deep,destruct deep fascia, exposing tendons, muscles and underlying bone.
- Ulcer is very painful, tender and often hyperaesthetic
- Venous ulcer: It is common around ankle due to ambulatory chronic venous hypertension.
- Ulcer is initially painful but once it become chronic, it is painless.
- It is vertically oval in shape. Floor is covered with pale or often without any granulation tissue.
- Edge is sloping. Induration and tenderness is seen often at base of an ulcer.
- Trophic ulcer: It is the ulcer due to prolonged pressure.
- Blood flow to skin stops once external pressure becomes more than 30mm of Hg and this leads to tissue hypoxia, necrosis and ulceration.
- Infective ulcer
- Tropical ulcer: It is an acute ulcerative lesion of skin seen in tropical countries.
- Pustule formation occur which bursts in three days with necrobiosis and phagedena causing spreading painful ulcer with an undermined edge, brownish floor and serosanguineous discharge
- Ulcers due to chilblain and frostbite: This is due to exposure of a part to wet cold below freezing point.
Ulcers here are deep - Martorell’shypertensiveulcer: Itisseeninhypertensive patients often with atherosclerosis.
In this necrosis of calf skin occur with sloughing away and formation of deep, punched out ulcers extending to deep fascia. - Bazin’s ulcer
- Diabetic ulcer: Diabetic ulcer is most common in foot.
- It can cause abscess, ulcer, osteomyelitis, gangrene,septicemia.
- Initially, patient undergo toe amputation but later eventually land with below knee or above knee amputation.
- Ulcers due to leukemia, polycythemia, jaundice,collagen diseases, lymphoedema
- Cortisol ulcers: They are due to long time application of cortisol creams to certain skin diseases.
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