Ulcer.pptx
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The document provides tips for using a PowerPoint presentation on ulcers, suggesting that the user can freely edit the presentation. It recommends showing blank slides on ulcer topics to students first to elicit their existing knowledge before presenting information, and repeating this process for active learning. The presentation also contains notes with bibliographic references and classifications and examinations of different types of ulcers.
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Ulcer.pptx
- 1. Tips on using my ppt. 1. You can freely download, edit, modify and put your name etc. 2. Don’t be concerned about number of slides. Half the slides are blanks except for the title. 3. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. 4. At the end rerun the show – show blank> ask questions > show next slide. 5. This will be an ACTIVE LEARNING SESSION x three revisions. 6. Good for self study also. 7. See notes for bibliography.
- 3. Ulcer:Definition • Discontinuity of epithelium
- 5. Types/Classifications • Clinical • Pathological • Wagner’s grading
- 6. Wagner’s Grading of ulcers
- 7. Wagner’s Grading of ulcers Grade 0 - Preulcerative lesion/healed ulcer Grade 1 - Superficial ulcer Grade 2 - Ulcer deeper to Subcutaneous tissue exposing soft tissue or bone Grade 3 - Abscess formation or osteomyelitis Grade 4 - Gangrene of part of tissues/limb/foot Grade 5 - Gangrene of entire one area/foot
- 8. A. Clinical
- 9. A. Clinical • Spreading : (Edge - Inflamed & Edematous) • Healing : (Edge is sloping with healthy red granulation tissue & serous discharge) • Callous : (Floor contains pale unhealthy granulation tissue with indurated edge)
- 10. B.Pathological
- 11. B.Pathological • 1. Nonspecific • 2. Specific • 3. Malignant
- 12. 1. Non specific
- 13. 1. Non specific • Traumatic Ulcer • Arterial Ulcer • Venous Ulcer • Neurogenic Ulcer • Infective Ulcer
- 14. 1. Non specific contd. • Diabetic Ulcer • Tropical Ulcer • Cryopathic Ulcer • Martorell’s Ulcer • Bazin’s Ulcer
- 15. Traumatic ulcer
- 16. Traumatic ulcer 1. Mechanical- Dental ulcer on tongue ( jagged tooth ) 2. Physical- Electrical burn 3. Chemical- Application of caustics • Acute, Superficial, Painful, Tender
- 17. Arterial Ulcer
- 18. Arterial Ulcer • Caused due to peripheral vascular disease • LL : Atherosclerosis & TAO • UL : Cervical Rib, Raynauds • Chief complaint : Severe Pain • Toes, Feet, Legs & UL Digits
- 19. Venous ulcers
- 20. Venous ulcers • Medial aspect of lower 3rd of lower limb • Ankle ( Gaiters Zone ) : Chronic Venous HTN • Ulcers are Painless • Varicose Veins or Post Phlebitic limb ( PTS )
- 21. Trophic Ulcer
- 22. Trophic Ulcer • Pressure Sore or Decubitus Ulcer • Painless. • Punched out edge with slough on the floor • Ex: Bed Sores & Perforating ulcers • Develop as a result of Prolonged Pressure • Sites : Ischial Tuberosity > Greater Trochanter > Sacrum > Heel > Malleolus > Occiput
- 23. Tropical ulcer • Tropical regions : Africa, India, S.America • Trauma or Insect Bite • Fusobacterium fusiformis & Borrelia vincentii • Abrasions, Redness, Papules & Pustules • Severe Pain
- 25. Diabetic foot Ulcer Due to • Diabetic Neuropathy • Diabetic Microangiopathy • Increased Glucose : Increased Infection • Foot ( Plantar ), Leg, Back, Scrotum, Perineum • Ischemia, Septicemia, Osteomyelitis,
- 26. Bazin’s Ulcer
- 27. Bazin’s Ulcer • Erythema induratum, also known as nodular vasculitis or Bazin disease, • Categorized as a tuberculid skin eruption, which is a group of skin conditions associated with an underlying or silent focus of tuberculosis • They are sequelae of immunologic reactions to hematogenously dispersed antigenic components of Mycobacterium tuberculosis
- 29. Martorell’s Ulcer •in middle-aged women. •a painful ulceration of the lower leg associated with diastolic arterial hypertension. •It is characterized by single or multiple small homogeneous, symmetrical ulcers most commonly located on the anterolateral aspect of the lower leg. •The pain associated to these lesions is often disproportionate to their size not relieved by rest or elevation.
- 30. 2. Specific
- 31. 2. Specific • Tuberculosis • Syphilis • Actinomycosis • Meleney’s ulcer • Soft sore
- 32. 3. Malignant
- 33. 3. Malignant • Squamous cell ca • Basal cell ca • Malignant melanoma
- 37. Examination
- 38. Examination • Inspection • Palpation • Examination of lymph nodes • Vascular insufficiency • Nerve lesions
- 39. • INSPECTION Location, size, shape, floor, edge, discharge, surround- ing area. • PALPATION Tenderness, local rise of temperature, bleeding on touch, consistency of the ulcer, edge, surrounding area - oedema, mobility. Proe to bbone test • REGIONAL LYMPH NODES • SENSATIONS • PULSATIONS • FUNCTION OF THE JOINT • SYSTEMIC EXAMINATION
- 40. INSPECTION
- 41. INSPECTION • LOCATION OF THE ULCER • FLOOR OF THE ULCER • DISCHARGE FROM THE ULCER • EDGE • SURROUNDING AREA
- 42. LOCATION OF THE ULCER
- 43. LOCATION OF THE ULCER Arterial ulcer Tip of the toes, dorsum of the foot Long saphenous varicosity with ulcer Medial side of the leg. Short saphenous varicosity with ulcer Lateral side of the leg. Perforating ulcers Over the sole at pressure points. Nonhealing ulcer Over the shin
- 44. FLOOR OF THE ULCER
- 45. FLOOR OF THE ULCER DEF : This is the part of the ulcer which is exposed or seen. Red granulation tissue Healing ulcer Necrotic tissue, slough Spreading ulcer Pale, scanty granulation tissue Tuberculous ulcer Wash-leather slough Gummatous ulcer
- 46. FLOOR OF THE ULCER DEF : This is the part of the ulcer which is exposed or seen. Red granulation tissue Healing ulcer Necrotic tissue, slough Spreading ulcer Pale, scanty granulation tissue Tuberculous ulcer Wash-leather slough Gummatous ulcer
- 47. DISCHARGE FROM THE ULCER
- 48. DISCHARGE FROM THE ULCER Serous discharge Healing ulcer Purulent discharge Spreading ulcer Bloody discharge Malignant ulcer Discharge with bony spicules Osteomyelitis Greenish discharge Pseudomonas infection
- 49. EDGE
- 50. EDGE DEF: This is between the floor of the ulcer and the margin. The margin is the junction between the normal epithelium and the ulcer. These two parts represent areas of maximum activity. 3 STAGES • Stage of ex-tension. • Stage of transition. • Stage of repair.
- 51. A. Sloping edge All healing ulcers like traumatic ulcers, venous Ulcers
- 52. B. Punched out edge Gummatous ulcers and trophic ulcers.
- 54. D. Raised edge (beaded edge) Rodent ulcers or basal cell carcinoma .
- 56. SURROUNDING AREA
- 57. SURROUNDING AREA Thick and pigmented Varicose ulcer. Thin and dark Arterial ulcer. Red and oedematous Spreading ulcers like diabetic ulcer.
- 58. PALPATION
- 59. PALPATION • EDGE • BASE • MOBILITY • BLEEDING • SURROUNDING AREA • Probe to bone test.
- 60. EDGE
- 61. EDGE • Induration (hardness) of the edge is very characteristic of squamous cell carcinoma. • It is said to be a host defense mechanism. • Tenderness of the edge is characteristic of infected ulcers and arterial ulcers.
- 62. BASE
- 63. BASE • It is the area on which ulcer rests. • Marked induration at the base is diagnostic of squamous cell carcinoma. • Probe to bone Test
- 64. INDURATION
- 65. INDURATION • The edge, base and the surrounding area should be examined for induration. Maximum induration Squamous cell carcinoma Minimal induration Malignant melanoma. Brawny induration Abscess. Cyanotic induration Chronic venous congestion as in varicose ulcer.
- 66. MOBILITY
- 67. MOBILITY • Gentle attempt is made to move the ulcer to know its fixity to the underlying tissues. • Malignant ulcers are usually fixed, benign ulcers are not.
- 68. BLEEDING
- 69. BLEEDING • Malignant ulcer is friable like a cauliflower. On gentle palpation, it bleeds. • Granulation tissue as in a healing ulcer also causes bleeding.
- 70. SURROUNDING AREA
- 71. SURROUNDING AREA • Thickening and induration is found in squamous cell carcinoma. • Tenderness and pitting on pressure indicates spreading inflammation surrounding the ulcer.
- 73. RELEVANT CLINICAL EXAMINATION • REGIONAL LYMPH NODES Tender and enlarged Acute secondary infection. Non-tender and enlarged Chronic infection. Non-tender and hard Squamous cell carcinoma. Non-tender, large, firm, multiple Malignant melanoma.
- 74. Investigations
- 75. Investigations 1) Complete blood picture: Hb%, TC, DC, ESR, PS 2) Urine and blood examination to rule out diabetes 3) Chest X-ray - PA. view to rule out Koch’s 4) Pus for culture/sensitivity 5) Lower limb angiography in cases of arterial diseases. 6) X-ray of the part to see for Osteomyelitis 7) Doppler study of LL. Vessels. 8) Biopsy: Non-healing/malignant ulcers
- 76. Treatment
- 77. Treatment • Address cause • Correct deficiencies • Control pain, infection • Debridement, dressing • Closure of defect
- 78. TREATMENT OF THE ULCERS
- 79. TREATMENT OF THE ULCERS • Treatment of Diabetic foot Ulcers • Treatment of Spreading Ulcers • Treatment of Healing Ulcers • Treatment of Chronic Ulcers • Treatment of The Underlying Disease
- 80. TREATMENT OF DIABETIC FOOT ULCERS
- 81. TREATMENT OF DIABETIC FOOT ULCERS • Control of DM with insulin. • Debridement • Prevention.
- 82. TREATMENT OF SPREADING ULCERS
- 83. TREATMENT OF SPREADING ULCERS • Pus Culture/Sensitivity report, • Appropriate Antibiotics • Solutions to treat the Slough : H₂O₂ & EUSOL - Edinburgh University Solution (Hypochlorite solution) • Excessive Granulation Tissue (Proud Flesh) : Excision or Application of Copper Sulphate or Silver Nitrate • Repeated Dressings,
- 84. TREATMENT OF HEALING Ulcer ULCER
- 85. TREATMENT OF HEALING Ulcer ULCER • Regular dressings are done for a few days • Culture swab is taken to rule out Streptococcus Haemolyticus ( contraindication for skin grafting ) • Ulcer is small - Heals by itself ( Epithelialization ) Large - Free Split Skin Graft applied
- 86. TREATMENT OF CHRONIC ULCERS • These do not respond to conventional methods of treatment. The following are tried: • Infrared radiation, short-wave therapy, ultraviolet rays decrease the size of the ulcer. • Amnion helps in epithelialization. • Chorion helps in granulation tissue. • These ulcers ultimately may require skin grafting./flaps
- 89. Disturbances in Wound Healing • Local Factors • Systemic Factors
- 90. Local Factors
- 91. Local Factors • Immobility- Pressure sore/bed sore/decubitus ulcer • Ischemia • Venous congestion. • Lymphedema • Infection: impairs healing. • Smoking: increased platelet adhesiveness, decreased O2 carrying capacity of blood, abnormal collagen. • Radiation:
- 92. Wound Infection A positive wound culture does not confirm a wound infection.
- 93. Wound Infection: Systemic features
- 94. Wound Infection: Systemic features • Tachycardia • Malaise • Fever • Chills • Leukocytosis • elevated erythrocyte sedimentation rate
- 95. Wound Infection: Local features
- 96. Wound Infection: Local features • Foul-smelling drainage • spontaneously bleeding wound bed • flimsy friable tissue • increased levels of wound exudates • increasing pain • surrounding - – cellulitis – Crepitus – necrosis, – Fasciitis – regional lymphadenopathy
- 97. Wound Infection: Local features Osteomyelitis • Fevers, malaise, chronic fatigue, and limited range of motion of the affected extremity, • patients often present with only a nonhealing wound or a chronic draining sinus tract overlying a bone or joint. • Probe to bone test. • Plain radiographs, CT scans, radionuclide bone scans, and MRI • Osteomyelitis is treated with surgical curettage and appropriate systemic antibiotics.
- 98. Systemic Factors
- 99. Systemic Factors • Malnutrition • Cancer • Old Age • Diabetes- impaired neutrophil chemotaxis, phagocytosis. • Steroids and immunosuppression suppresses macrophage migration, fibroblast proliferation, collagen accumulation, and angiogenesis. Reversed by Vitamin A 25,000 IU per day. • Superstitions
- 100. Wound Management
- 101. Wound Management • Systemic measures. • Local measures
- 102. Wound Management Local measures- “The golden hour” • Haemostasis • Anaesthesia • Decontamination • Repair and closure • Delayed closure- • Late presentation • Heavy contamination • Lot of dead and devitalized tissue.
- 103. Wound Management Local measures- “The golden hour” • Haemostasis • Anaesthesia • Decontamination • Repair and closure • Delayed closure- • Late presentation • Heavy contamination • Lot of dead and devitalized tissue.
- 104. Wound Management • Local measures- • Surgically debride nonvitalized tissue and with appropriate irrigation • Dressing changes require clean but not necessarily sterile technique. • Remove foreign bodies • Pat the wound surface with soft moist gauze; do not disrupt viable granulation tissue.
- 105. Wound Management Pressure sores • Mobilise • Appropriate turning and positioning • Use of offloading support surface • Appropriate wound care • Appropriate management of incontinence • Appropriate nutritional management
- 106. Wound Management • Pressure sores •
- 107. Wound Management Venous Ulcers • Appropriate wound care • Compression dressings.
- 108. Wound Management Diabetic foot ulcers • Appropriate wound care • Liberal debridement • Maintain euglycemia with insulin. • Antibiotics only if evidence of infection. • Reperfusion.
- 109. Wound Management Surgical Care • Skin grafting • Cadaveric allografting • Application of bioengineered skin substitutes • Use of flap closures
- 111. Future and Controversies • Human cell–conditioned media developed in embryologiclike conditions • transforming growth factor (TGF)–β3 • Hyperbaric oxygen has also been used to promote healing. • Agents such as platelet-rich plasma (PRP) and erythropoietin (EPO • Engineered tissue matrices • Stem Cells
- 112. Take home messages • Early closure of clean wounds. • Delayed closure of dirty / infected wounds. • Antibiotics are generally not indicated in abrassions, contusions. • For open wounds give three dosage of antibiotic. • Further antibiotics only if evidence of infection. • Spirit, Betadine,Savlon, Hydrogen peroxide Sumag should not be applied on wounds.
- 113. Get this ppt in mobile 1. Download Microsoft PowerPoint from play store. 2. Open Google assistant 3. Open Google lens. 4. Scan qr code from next slide.
- 114. Get this ppt in mobile
- 115. Get my ppt collection • https://www.slideshare.net/drpradeeppande/ edit_my_uploads • https://www.dropbox.com/sh/x600md3cvj8 5woy/AACVMHuQtvHvl_K8ehc3ltkEa?dl =0 • https://www.facebook.com/doctorpradeeppa nde/?ref=pages_you_manage