CMT0509: Surgery

Session 16: Ulcers

1
 Learning Objectives
By the end of this session, students are expected
to be able to:
• Define the term ulcer
• Describe characteristic of ulcers
• Classify ulcers
• Describe the management of ulcers
 Activity: Brainstorming
• What is an ulcer?
 Definition of an ulcer
• 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 of an Ulcer
An ulcer is characterized by there;
• Margin: It may be regular or irregular. It
may be rounded or oval.
• Edge: Edge is the one which connects floor
of the ulcer to the margin.
• Floor: It is the one which is seen.
• Base: Base is the one on which ulcer rests.
Characteristics of an Ulcer cont..
 Activities: Brainstorming
• Mention five (5) types of ulcer edges
Characteristics of an Ulcer cont…..
• There are five types of ulcer edges
 Classification of an ulcer
There are three ways of classifying ulcers
• Clinically
• Based on duration
• Pathologically
 Clinical classification of an ulcer
Healing ulcer:
• Edge is sloping with healthy pink/red
healthy granulation tissue with
scanty/minimal serous discharge in the floor;
• Slough is absent;
• Lymph nodes may or may not be enlarged
but when enlarged always non-tender.
Healing ulcer
Clinical Classification of Ulcers cont…
Spreading (acute phase)
• It is a painful ulcer.
• Surrounding skin is inflamed and the floor is
covered with profuse offensive slough
• Draining lymphnodes are inflamed, enlarged
and tender and may be suppurated with
abscess formation.
Spreading ulcers
Clinical Classification of Ulcers cont…

Callous (stationary) ulcer:

• It is also a chronic non-healing
• Ulcer; floor contains pale unhealthy, flabby,
whitish yellow granulation tissue and thin
scanty rous discharge or often with copious
serosanguinous discharge, indurated
nontender edge
• Base is indurated, nontender and often fixed
Callous (stationary) ulcer
Clinical Classification of Ulcers cont…
Tropical
Common feature is callousness that develop
through three stages
• Stage One: A pustule, or neglected cut,
containing microorganisms
• Stage Two: Progression of the cut or pustule to
form an acutely painful ulcer
• Stage Three: It becomes chronic, and resembles
any other long-standing indolent ulcer.
Tropical ulcers
 Classification II (Based on Duration)

An ulcer may be Classification as;

• Acute ulcer—duration is less than 2 weeks.
• Chronic ulcer—duration is more than 2 weeks
(long).
 Pathological Classification
Pathologically an ulcer may be classified as:
• Non-specific
• Specific (tuberculous or syphilitic)
 Non-specific
• Traumatic ulcer: It may be mechanical,
physical, chemical
• Associated with other diseases; ulcer may be
associated with Gout, Diabetic Mellitus
• Neurogenic trophic; it may be secondary to
ischaemia and loss of sensation do cause
these ulcer
 Non-specific cont..
• Trophic Ulcers; may be due to;
o Arterial (ischaemic), as in Atherosclerosis
o Venous- varicose veinsAssociated with
other diseases
 Specific Ulcers
• Tuberculous: Caused by mycobacteria
tuberculosis
• Buruli ulcer: Caused by mycobacteria
ulcerans
• Syphilitic ulcer: There are primary,
secondary, tertiary stages in syphilis
• Malignant Ulcers; Epithelioma, Malignant
melanoma
 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.

• During history taking note the following:-

o Duration i.e. how long is the ulcer
present?
Acute: present for short time
Chronic: present for long time
Principles of Management cont…
o Mode of onset i.e. how has the ulcer
developed?
Following trauma
Spontaneously eg following- swelling eg
ulcerating LN in TB or a scar of burn
Marjolin ulcer
Principles of Management cont…
o Pain i.e. is the ulcer painful?
Painful: ulcers associated with
inflammation
Slight painful: tuberculous
Painless eg syphilitic, neurogenic,
malignnt ulcer
Principles of Management cont…
o Discharge: i.e does the ulcer discharge or
not?
If YES: note the nature of discharge-
pus, bloody, serous

o Associated diseases which may lead to

ulcer formation
E.g. TB, Syphilis, DM, nervous
diseases
 Physical examination
– General examination may be normal
– Local examination
oInspection
Number, Site, Shape, Size
Surrounding skin, floor, edge
Discharge, whole limb
 Physical examination cont…
• During Palpation, note:-
o Tenderness
o Edge and surrounding skin
o Base (i.e. on which the ulcer rest)
o Depth
o Bleeding
o Fixity to the deep structures
 Physical examination cont…
• Examination of lymph nodes
o Especially the immediate draining lymphnode
• Examination of vascular insufficiency eg
pulses
• Examination of nervous system eg sensation
Wagner’s Grading/Classification of Ulcer

• Grade 0 – Pre-ulcerative lesion/healed ulcer

• Grade 1 – Superficial ulcer
• Grade 2 – Ulcer deeper to subcutaneous tissue
exposing soft tissues or bone
 Wagner’s Grading/Classification of Ulcer
cont..
• Grade 3 – Abscess formation
underneath/osteomyelitis
• Grade 4 – Gangrene of part of the
tissues/limb/foot
• Grade 5 – Gangrene of entire one area/foot
 Activity: Brainstorming
• What are the investigations to be ordered for a
patient with an ulcer?
 Investigations
The following are investigation to a patient
with ulcer;
• Culture and sensitivity, AFB study, cytology.
• Biopsy
• X-ray of the part to look for
periostitis/osteomyelitis.
• FNAC of the lymph node.
 Investigations cont..
• Chest X-ray, Mantoux test in suspected case of
tuberculous ulcer.
• Total WBC count, ESR serum protein
estimation (albumin).
• Biopsy- to conform the diagnosis
 Treatment
For a successful treatment of an ulcer;
• Cause should be found and treated .
• Correction of the anaemia, deficiencies like of
protein and vitamins.
• Proper investigation is needed.
• Transfusion of the blood if required
 Treatment cont…
• Control the pain and infection.
• Rest, immobilization, elevation, avoidance of
repeated trauma.
• Care of the ulcer by debridement, ulcer
cleaning and dressing.
• Once ulcer granulates, defect is closed with
secondary suturing, skin graft or flaps
 Treatment cont…
• Ulcers can be cleaned safely with normal
saline solution and dressed.
o The ideal dressing; soft, absorbent, non-
adherent, and nonallergenic.
• Topical antibacterial may be administered, e.g.
framycetin, silver sulphadiazine, mupirocin
and Metronidazole cream.

• Systemic antibiotics (specific bacterial

infection).
 Treatment cont…
• In case of Malignant Melanoma: ulcer excision
and regional lymphnode excision.

• For Squamous cell carcinoma, wide local

excision followed by skin graft.

• Finally the patient should be referred for

radiotherapy.
 Complications of an ulcer
The following are complications of an ulcer;
• Limb amputation
• Chronic osteomyelitis
• Malignant change
• Septicemia
• Septic emboli
 Key points
• An ulcer is a non-traumatic disruption of
continuity in epithelial surface of the skin or
mucous membrane
• An ulcer is characterized by its Margin, edges.
Floor and base
• Ulcer can be classified clinically, Pathologically
or Based od duration
• Management of an ulcer will depend on the
cause and the stage of the ulcer
 Evaluation questions
• Mention three (3) characteristics of healing
ulcer.

• Describe Wagner’s Grading of an ulcer.

• What are the complications of ulcer?

 Reference
• F.Charles Brunkardi (2019) Schwartz’s principles of
surgery (11th edition). McGraw-Hill Education

• Siram Bhat M (2015) SRB’s Manual of surgery( 5 th

edition). Prakash Rao Thangam venghese Joshua.

• Russell R.C.G., Norman S.W. & Bulstrode C.J.K.

(2006). Bailey and Love’s Short Practice of Surgery
(25th edition.). London: Hodder Arnold.

• Somen Das (2008) concise textbook of Surgery (5 th

edition). Kolkata-Dr Somen Das.