An ulcer is a non-traumatic disruption of continuity in epithelial surface of the skin or
mucous
membrane.
• It
may either follow molecular death of the surface epithelium or its traumatic
removal.
Characteristics
• Ulcers
are characterised by their shapes, margins or edges, floor, and base.
• Edge:
This gives clue to the diagnosis of an
ulcer and condition of an ulcer.
o
There are five common types of ulcer
edge:
Undermined edge: Mostly seen in ulcers caused by Mycobacterium (e.g.
mycobacterium
tuberculosis causing tuberculous ulcer or mycobacterium ulcerans
causing
buruli ulcer).
Punched out edge: Mostly seen in gummatous ulcers (syphilitic) or in deep
trophic
ulcer.
Sloping edge Mostly seen in healing traumatic or venous ulcer.
Raised and pearly white beaded
edge: A feature of basal cell carcinoma
(rodent
ulcer).
Rolled out everted edge: Is a characteristic feature of squamous cell carcinoma or
an
ulcerated adenocarcinoma.
• Floor
o
This is the exposed surface of the
ulcer.
o
Pale and smooth granulation indicates a
slowly healing ulcer.
o
A trophic ulcer penetrates down even to
the bones.
• Base
o
It is the site on which the ulcer
rests.
o
Hardness of the base is an important
feature of carcinomatous lessions.
Clinical Classification
• There
are two ways of classifying ulcers
o
Clinically
o
Pathologically
Clinical Classification of Ulcers
• Spreading
(acute phase)
o
Surrounding skin is inflamed and the
floor is covered with profuse offensive slough
without
any evidence of granulation tissues.
o
The ulcer is inflammed, oedematous and
ragged edges; it is a painful ulcer.
o
Draining lymphnodes are inflamed,
enlarged and tender and may be suppurated with
abscess
formation.
• Healing
o
The floor is covered with pinkish or
red healthy granulation tissue.
o
The edges are reddish with granulation,
while the margin is bluish with growing
epithelium
and the discharge is slight and serous.
• Callous
(chronic phase)
o
The ulcer shows no tendency towards
healing.
o
The floor is covered with pale
granulation tissue; sometimes shows typical washleather
slough
in gummatous.
o
Discharge is scanty or absent.
• Tropical
o
Common feature of this ulcer is
callousness and they develop through three stages
Stage
One: A pustule, or neglected cut, containing microorganisms (typically
penicillin-sensitive).
Rolled
out (everted) edge
Raised
and pearly-white beaded edge
Sloping
edge
Stage
Two: Progression of the cut or pustule to form an acutely painful ulcer with
a
raised, thickened, and slightly undermined edge.
This
ulcer grows rapidly for several weeks.
A
bloody discharge covers the grey slough on its floor, the skin around it is
dark
and
swollen, and muscle, bone, and tendon occasionally lie exposed in its base.
After
about a month, the pain, swelling, and discharge improve, and it either heals,
or
it goes on to the next stage.
Stage
Three: It becomes chronic, and resembles any other
long-standing indolent ulcer.
Pathological Classification
• Pathologically
an ulcer may be:
o
Nonspecific
o
Specific (tuberculous or syphilitic)
Non-Specific Ulcers
• Traumatic
o
Mechanical: e.g. Dental ulcers of the
tongue from jagged tooth, from pressure of a
splint
o
Physical: From electrical or X-ray burn
o
Chemical: From application of caustics
o
These types of ulcers heal quickly and
do not become chronic unless supervened by
infection
or ischaemia.
• Trophic
Ulcers
o
Arterial (ischaemic), as in
Atherosclerosis (hardening & narrowing of the vessels)
o
Venous
-Typically
situated on the medial aspect of the lower third (1/3) of the lower limb
often
associated with varicose veins in upper third (1/3) of the lower limb
-Occur
as a complication of Deep Venous Thrombosis (DVT)
-Presents
with eczema and pigmentation around ulcers, slightly painful in the
beginning,
but gradually the pain settles down
o
Associated with other diseases
Gout
Diabetic
Mellitus- may be precipitated by ischeamia due to diabetic
atherosclerosis,
infection or diabetic peripheral neuropathy; toes and feet are
commonly
affected
-Anaemia
-Avitaminosis
-Rheumatoid
arthritis
o
Neurogenic trophic
-Trophic
ulcers are due to impairment of nutrition of the tissues, which depends
upon
an adequate blood supply and a properly functioning nerve supply
-Ischaemia
and loss of sensation do cause these ulcer
-In
the leg, painful ischaemic ulcers occur around the ankle or on the dorsum of
the
foot
-These
ulcers have punched out edge with slough in the floor thus resembling
gummatous
ulcer
-Bed
sores and perforating ulcers are typical examples of trophic ulcers
Specific Ulcers
• Tuberculous:
Caused by mycobacteria tuberculosis
• Buruli
ulcer: Caused by mycobacteria ulcerans
• Syphilitic
ulcer: There are primary, secondary, tertiary stages in syphilis
o
In primary- a hard chancre or hunterian
chancre is seen.
o
This chancre usually develops at site
of entry of tryponema in about three or four
weeks
after exposure.
o
Sites of the ulcers are the genitalia,
lip, tongue, nipple, and perianal region.
o
These types of ulcer are single, usually
painless and have a characteristic indurated
base
which feels like a button.
o
In secondary- ulcers may develop in
form of mucous patches, snail track ulcers –these
are
multiple small, round and superficial erosions which coalesce to form narrow,
curved
shallow ulcers.
o
They are mostly found in the mouth.
Condylomalata are fleshy wart like growths
which
are seen in the angles of the mouth anus, vulva.
o
In tertiary- gummatous ulcers occur in
(late stage) syphilis.
o
It is a result of obliterative
endarteritis, necrosis and fibrosis, usually seen over the
bones
(e.g. tibia, sternum, ulna and skull), in the scrotum in relation to the
testis,
upper
part of the leg etc.
-The
most characteristic feature is punched-out indolent edge and yellowish grey
gummatous
tissue in the floor.
Pain
and tenderness are absent.
-Lymphnodes
are seldom involved unless secondarily infected.
• Malignant
Ulcers
o
Squamous cell carcinoma (Marjolin’s
ulcer)
-A
squamous cell carcinoma (SCC) arising from a long standing benign ulcer or
scar.
-The
most common ulcer to become malignant is a longstanding venous ulcer.
-The
scar which may show malignant change is an old burn scar.
-It’s
a slow growing and less malignant SCC.
-Edges
are not raised and everted as do the typical SCC ulcers.
o
Epithelioma (squamous cell carcinoma or
basal cell carcinoma)
-Arises
from layer of the skin, so can arise anywhere in the body.
-Commonly
seen on the lips, cheek, hands, penis, vulva and old scars.
-Mostly
seen after 40 yrs as a small nodule, enlarges and gradually the centre
becomes
necrotic and sloughs out to develop an ulcer.
-In
early stages it’s mobile, but later on becomes fixed to the deeper structure.
o
Malignant melanoma
-A
malignancy of pigment producing cells (melanocytes) located predominantly in
the
skin, but also found in eyes, ears, GIT, leptomeninges, oral and genital mucous
membranes.
-Clinically
it presents like a mole which increases in size and changes colour but in
some
cases the colour does not change.
-Lesions
that do not change colour are known as amelanotic melanoma.
-Ulceration
of the mole can lead to bleeding.
-Enlarged
regional lymph nodes indicate that there is metastasis.
-Malignant
melanoma is not painful, although it often itches.
o
Basal Cell Carcinoma
-Common
in the trunk in black population
-Presents
with raised rolled out edges
-Regional
lymphadenopathy indicate metastasis (rare)
Principles of Management of Ulcers
• Identification
of the exact aetiology of the ulcer is important so as to have a successful
treatment
of the ulcer.
o
History and clinical physical findings
are important.
o
Biopsy of the lesion is extremely
important to determine the exact nature of the ulcer.
o
A clear ulcer with healthy granulation
tissue exuding serous discharge should be
dressed
once a day, and if there is copious discharge more frequent dressings are
needed.
o
Ulcers can be cleaned safely with
normal saline solution.
o
The ideal dressing should be one that
is soft, absorbent, non-adherent, and nonallergenic.
o
Topical antibacterials may be
administered, e.g. Povidone Iodine, Metronidazole
cream.
o
Systemic antibiotics are prescribed to
manage specific bacterial infection.
o
Management of melanoma is complicated;
it is mainly by surgical excision of the
lesion
and later regional lymphnodes excision depending on the site of the melanotic
lesion.
o
Management of squamous cell carcinoma
ulcers is surgical by wide excision of the
ulcer
followed by skin graft which is done at the district hospital.
o
Finally the patient should be referred
for radiotherapy.
References
• Bickley
S. (2003). Guide to Physical Examination
and History Taking (8th ed.). USA:
Lippincott
Williams and Wilkins.
• Das
S. (2008). Concise Textbook of Surgery (5th ed.).
India: Dr. Das.
CMT
05210 Surgery NTA Level 5 Semester 2 Student Manual
Session
4: Ulcers 24
• Russell
R.C.G., Norman S.W. & Bulstrode C.J.K. (2004). Bailey and Love’s Short
Practice of Surgery (24th ed.).
London: Edward Arnold.
• WHO.
(2003). Surgical
Care at District Hospital.
Malta.
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