د .علي كاظم الحيدر

Ulcers : An ulcer is a break in the continuity of an epithelial surface . It's characterised by progressive destruction of the surface epithelium and a granulating base . Ulcers are classified as ( non specific , specific and malignant ulcers ) . Non specific ulcers are due to infection of wounds or physical or chemical agents . Local irritation , interference with circulation and sensation are predisposing factors .

Classifications of common types of ulcers : Non-specific : peptic ulcers , pressure sores , Ischemic ulcers venous insufficiency , traumatic ulcers , secondary infective Neuropathic ulcers ( DM , leprosy , tabes , dorsalis ) . Iareogenic , Aphthaus ulceration , Demnatitis artefacta . Specific : Primary infective-herpes simplex , T.B. , fungal , syphilis . Malignant : G.I.T and skin ( ulcerative gastric ca , basal cell ca. , squamous cell ca . ) .

Clinical features : An ulcer may be acutely inflamed surrounded by area of cellulitis , or it chronically inflamed with adherent slough weak ulcers are covered ny granulation tissue . Clinical examination of an ulcers : includes Local exam . Reginal exam .

Local exam : A. Inspection : Site : e.g. 95% of rodent ulcers occurs on the upper part of the face , while carcinoma affect the lower lip . Size : Shape . e.g. rodent ulcer is usually circular . Edges : - slopping Healing . Inflammatory . - Punched – our edge syphilis - undermined Tuberculosis . - Rolled edge Basal cell carcinoma - Everted edge epithelioma S.C.carc.

Floor : that which is seen , contain - infected granulation tissue ( yellow ) - clean granulation tissue ( pink ) - sloughs or dead tissue . Base : that which can be palpated indurated – carcinoma Discharge : - Purulent : infective - blue green : infection with pseudomonas - watery – in T.B.

Reginal exam : 1. Reginal lymph nodes . Rodent ulcer not enlarged S.C.C enlarged . 2. Pulse : above and below ulcerated area . 3. Tenderness : viral ulcer ( e.g. ) 4. Sensory exam and reflexes . 5. Muscle power . General exam : anemia , debility , cardiac failure , jumdice and D.M. Pathological exam : biopsy will confirm ca.   Marjolin's ulcer : Carcinomatous change occurring at the edge of a chronic venous ulcer and long standing benign ulcer .

Trophic ( Ischemic ) ulcer : Occur's in In Ambulent patient , pressure areas ( heel of the feets , tips of toes ) . In bed ridden patients , pressure areas e.g. Back of the heel lateral side of the feet . Causes of trophic ulcers : Obliteration of large arteries ( atherosclerosis , embolism ) Obliteration of small arteries ( Raynaud's , Burger's dis D.M. Physical agents : pressure necrosis , Trauma radiation .

Neuropathic ulcers : Peripheral lesions ( DM , injury , leprosy ) Neuropathic ulcers : Peripheral lesions ( DM , injury , leprosy ) . Spinal lesions ( spina bifeda , tabes dorsalis ) Chronic ulcers : Due to infections , Trauma , ischemia , oederna , denervation .

Basic requirements of the ideal ulcer dressing . Management of ulcers : Principles : Determine etiology and comorbid factors ( e.g. anemia ) could be infection , venous or arterial insufficiency or D.M should be treated . Accurate assessment of ulcer , adequate drainage and desloughing essential for healing . removal ( excision ) of dead Tissue . Identify and correct comorbid factors . Antibiotics not used in healthy granulating wounds but used when ulcer is infected and surrounded by cellulites . Avoid adherent dressings and antiseptic solutions that impair capillary circulation . Basic requirements of the ideal ulcer dressing . - Maintain high humidity between wound and dressing . - Absorbent , removes excess exudate - Non adherent , allowing easy removal without trauma at dressing . - Safe and acceptable to patient ( non-allergic ) - Permit gaseous exchange but impermeable to micro-organisms . - Cost-effective .