eMentorSurgery

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An ulcer & Pressure sore

•        Def

An ulcer is any breach in an epithelial surface.

•         Formed from an open sore when inflamed tissueis shed .

•        Can occur on the skin or mucous membrane.

•         Have a fibrotic margin and a bed of granulation tissue -areas of slough (necrotic tissue).

 Aetiologies

•        Arterial or venous insufficiency

•        Lack of normal skin innervation

•        Healing process is delayed by infection,mechanical irritation, ischaemia or other metabolic factors

Classification

•        Nonspecific,

•        Specific (e.g. tuberculous orsyphilitic)

•         Malignant

Nonspecific ulcers

•        Due to infection of wounds,

•        Physical or chemical agents.

•        Local irritation, as in the case of a dental ulcer,

•        Interference with the circulation, e.g.varicose veins, are predisposing causes.

Trophic ulcers    [trophe (Greek) = nutrition]

•        Due to an impairment of the nutrition of the tissues-depends upon an adequate blood supply and a properly functioning nerve supply.

•        Ischaemia and anaesthesia - cause these ulcers.

•         In the arm, chronic vasospasm and syringomyelia will cause ulceration of the tipsof the fingers (respectively painful and painless).

•        In the leg, painful ischaemic ulcers occur around the ankle or on the dorsum of the foot.

•         Neuropathic ulcers due to anaesthesia (diabetic neuritis, spina bifida, tabes dorsalis,leprosy or a peripheral nerve injury) - called perforating ulcers

 The life history of an ulcer-3 Phases.

1.Extension

•        The floor is covered with exudate and sloughs, - the base is indurated. The discharge- purulent and blood stained.

2.Transition

•         Prepares for healing. The floor - cleaner, the sloughs separate, induration of the base diminishes and the discharge - more serous.

•        Small, reddish areas of granulation tissue appear on the floor .

 3.Repair

•        The transformation of granulation to fibrous tissue, which gradually contracts to form a scar.

•        The epithelium gradually extends - covers the floor (at a rate of 1 mm per day).

•        This healing edge consists of 3 zones

            a) an outer of epithelium, which appears white,

            b) a middle one, bluish in colour(where granulation tissue is covered by a few layers of epithelium),

           c) an inner reddish zone of granulation tissue covered by a single layer ofepithelial cells. The red colour of granulation tissue is due to the high density of new capillaries (neo-angiogenesis).

 Pain

Nonspecific ulcers in the extension and transition stages are painful (except for the anaesthetic trophic type).

Tuberculous ulcers vary, that of the tongue being verypainful.

Syphilitic ulcers are usually painless, but an anal chancre (of a homosexual) may be painful (cf. anal fissure).

 Clinical examination of an ulcer

 Site  -Rodentulcers - over  the upper part of the face.

           Carcinoma - the lower lip.

            Primary chancre of syphilis- on the upper lip.

Size - Relation to the length of history

            e.g. acarcinoma extends more rapidly

            than a  rodent ulcer, but more slowly than an  inflammatory ulcer.

Shape -e.g. a rodent ulcer is usually circular.

            A gummatous ulcer is typically circular,

            or serpiginous due to the fusion of multiple circles.

            An ulcer with a square area or straight edge is suggestive of dermatitis "artefacta" .

Edge             -A healing, nonspecific ulcer has a shelving edge.

                        -Pearly, rolled or rampant if a rodent ulcer.

                        -Raised and everted if an epithelioma,

                        -Under­mined and often bluish if tuberculous,

                        -Vertically punched out if syphilitic

Floor            -Seen by an observer. 

                        e.g. watery or apple-jelly granulations in tuberculous ulcer,

                        a wash-leather slough in a gummatous ulcer.

 Base             -Palpated by the surgeon.

                       -Indurated as in a carcinoma ,

                        Attached to deep structures,  e.g.a varicose ulcer to the tibia.

Discharge  -A purulent discharge indicates active infection.

                    -A blue-green coloration suggests infection with  Pseudomonas pyocyaneus.

                        -A watery discharge is typical of tuber­culosis.

                         -It is bloodstained in the extension phase of a nonspecific  ulcer.

                         -Use it for Bacteriological examination

Lymph nodes   -Not enlarged in the case of a rodentulcer, unless due to secondary infection.

    -In the case of carcinoma, may be enlarged,hard and even fixed.

   -The inguinalnodes draining a syphilitic chancre of the penis are  firm and‘shotty’,   but    contrarily  thesubmandibular nodes draining

        a chancre of   the lip are greatly enlarged.

General         examination.

Evidence of debility,

cardiac failure,

all types of anaemia, including sickle-cell anaemia, or

 diabetes must be sought.

   Pathologicalexaminations.

   e.g. biopsy,will confirm carcinoma.

  The serologicaland Mantoux tests may be of value for syphilis and tuberculosis, respectively.

 Treatment

Local (topical) treatment of nonspecific ulcers

•        Underlying cause is treated,

        e.g. varicose veins , diabetes,arterial disease.

     Many lotions and non adhesive applications.

     To aid the separation of sloughs, hasten granulation

         stimulate   epithelialisation.

 The basic requirements of an ideal dressing

 Maintain a high humidity between the wound and  the dressing;

      -Removeexcess exudate and toxic compounds;

      -Permitgaseous exchange of oxygen, carbon dioxide

               and water vapour;

      -Providethermal insulation to the wound surface

               and be impermeable to microorganisms;

      - Be free from particles and toxic wound contaminants

      -Allow easy removal with no trauma at dressing change;

      -Be safe touse and be acceptable to the patient;

      - Be cost-effective.

 Antiseptics and topical antibiotics

 -More harm than good, when used inappropriately.

-Interfere with the normal healing process, are toxic to fibroblasts and may permit  

         more    virulent organisms to dominate.

-The routine use of antiseptic and   hypochlorite solutions should be avoided.

-If a wound needs cleaning, this can be achieved safely and more economically

        with normal saline warmed to body  temperature prior to use.

-If a topical antiseptic is necessary, aqueous chlorhexidine

    1 in 5000solution is effective against a wide range of Gram-positive and -negativeorganisms and some fungi, but not spores.

-Povidone iodine has a broad spectrum of activity but its antibacterial effect is reduced by contact with pus or exudate.

-Not be used on patients who are sensitive to iodine.

-Topical antibiotics are not recommended routinelyas   resistance and sensitisation following application may arise.

-Flamazine is a hydrophilic cream containing

     Silversulphadiazine 1% which is a broad-spectrum antibacterial agent and very effective against Pseudomonas, useful for the prevention of Gram-negative sepsis in patients with severe burns.

Wound dressings

 1.Hydrocolloid dressings such as Granuflex or Comfeelconsist of a thin polyurethane foam sheet bonded on to a semipermeable polyurethane film-impermeable to exudate and microorganisms

   -The treatment of leg ulcers, pressure sores, minor burn

   -Small wounds containing dry slough or necrosis

2.Hydrogel (Intrasite gel) is a pale yellow/colourles transparent aqueous gel

    - The treatment of leg ulcers, pressure sores, surgical wounds and granulating tissue

Alginates (Kaltostat) consist of an absorbent fibrousfleece composed of the mixed sodium and calcium salts of alginic acid.

•        Lyofoam is a low-adherent conformable polyurethane foam sheet.

   -With the skin has been heat treated to render it hydrophilic, whilst the outer surfaceremains hydrophobic.

•        Tegaderm consists of a thinpolyurethane membrane coated with a layer of an acrylic adhesive.

•         Alleyvn cavity wound dressing is a highlycomfortable absorbent dressing consisting of a soft, polymeric outer membrane with a three-dimensional honeycomb-like structure containing a mass of hydrophilic polyurethane chips.

 Oriental sore(syn. Delhi boil, Baghdad sore.)

•        Due to infection by a protozoal parasite, Leishmania tropica,

•          A common condition in Eastern countries

An indurated papule appears on an exposed surface,usually the face.

      If untreated,this breaks down to form an indolent ulcer.

      Eventually leaves an ugly, pigmented scar.

      Responds to intravenous injections of antimony tartrate.

      Small lesions- by carbon dioxide snow, and also curettage.

•        Bazin’s disease (syn. erythemainduratum)

•        Due to localised areas of fat necrosis.

•        -Affects adolescent girls.

      Symmetrical purplish nodules appear, especially on the calves, gradually break down to form indolent ulcers.

     Leave in their wake pigmented scars.

     Tuberculosis may be a cause.

Pressure sores

•        Chronic wounds following tissuenecrosis from pressure. - over bony prominences.

                     Pathogenesis

Unrelieved pressure in the soft tissues overlying bone-exceeds capillary perfusion pressure and ischaemic necrosis occurs.

•        Occur in paraplegic.

•        As hypotension and peripheralvascular disease. Sacral and trochanteric sores occur in bed-bound patients

Prevention is better than cure.

Pressure Ulcer Prediction and Prevention

•        Turning or lifting the patient,

•        Pressure-relieving mattresses and beds,

•        Special seating and cushions,and

•        Educating the patient and their carers .

 Management of Pressure Sore

•        Manage Nutrition

•        Manage Moisture

•        Manage Friction & Shear

•        Specialty  Beds and Prevention