Ulcers Notes

Ulcers

“A breach in an epithelial surface”

Can be classified

• Vascular

  • 85% venous

  • 15% arterial

• Neoplastic

  • BCC, SCC (chronic ulcers can also become neoplastic)

• Neuropathic

  • Diabetes

• Traumatic

  • Burns, cold, polycythemia, pressure sores

Features to look for on examination

Site

• Legs and feet = vascular, neck/groin/axilla = TB anywhere = malignant

Surface

• Usually depressed – look for vascular granulations

Size

• Is it large compared to history? Fast growing = pyoderma gangrenosum

Shape

• Circular, straight edges, irregular

Edges

• Eroded = spreading

• Shelved = healing

• Punched out = Syphillitic

• Rolled or everted = malignant

Base

• Fixed to structures underneath, mobile, penetrating

Discharge

• Purulent = infected

• Watery = TB, transudate

• Bleeding = malignancy/granulation

Pain

• Suggests ischaemia, infection and growth

Progress

• Short history = pyogenic

• Long history = vascular

Lymph nodes

• Near ulcer = secondary infection or malignancy

Arterial ulcers (ischaemic ulcers)

Pathogenesis

Chronic arterial insufficiency produces ulceration because of skin ischaemia at areas of pressure

Site

(Ulcers are distal)

• Lateral malleolus

• Lateral foot

• Outer edges and between toes (especially little and great toes – pressure)

• Also at the heel

Clinical features

• Pain, especially rest pain and night pain

• ‘Punched out’ appearance

• Deep – can extend to tendons

Associated features

• Intermittent claudication

• Absent pulses

• Shiny, hairless skin

• “Blue toe” – micro-emboli

• Smoker/ex smoker

Investigations

• Arterial circulation assessed using Doppler

• ABPI

• Angiography – used for severe disease (e.g APBI < 0.8)

• Xray to rule out osteomyelitis

Management

(Same as critical limb ischaemia)

• Lifestyle modification

  • Stop smoking, lose weight, exercise (increase collateral flow)

• Medical

  • Aspirin, glycaemic control, statin, antibiotics for infection

• Interventional/surgical

  • Angioplasty to improve perfusion

  • By-pass grafting

  • Amputation

Gangrene

• Ischaemic tissue necrosis

• Sign of critical ischaemia

Aetiology

• Thrombosis

• Emoblus (atherosclerotic emboli)

• Extrinsic compression (e.g fracture, tourniquet, organ torsion)

Clinical features

• Dry gangrene “no infection”

  • Affected limb/organ/digit is black (haemoglobin breakdown)

  • Is dry and shriveled

  • Doesn’t spread

  • Zone of demarcation between dead and living tissue

• Wet gangrene “tissue death + infection”

  • Arteries and veins are blocked

  • Pain ++ initially then less pain as patient becomes more septic

  • Always associated infection

  • Skin blisters

  • Broad zone of ulceration

  • Proximal spread septicaemia death

• Gas gangrene

  • Gangrene complicated by infection of gas-producing anaerobic bacteria

    • Clostridium perfringes

  • Leads to surgical emphysema + crepitus

Investigations

• Bloods

  • FBC, U+E, CRP, glucose, lipids, cultures, group and save for sugery

• ECG

  • Cause of embolism

• Imaging

  • Assess arterial insufficiency

  • Angioplasty – reperfusion

Management

• Conservative

  • If dry gangrene and non-vital organs

  • Aim is to let affected areas spontaneously separate

• Surgical

  • Amputation

  • Resecting back to bleeding healthy tissue (radical debridement)

• Systemic

  • Analgesia (IV morphine 5-10mg)

  • Fluids

  • Antibiotics – broad spectrum (liaise with microbiology)

    • Metronidazole for clostridium

Necrotising faciitis

• “Flesh eating bacteria”

• Infection of deep tissue layers

• Fast spreading

Diabetic Foot

Spectrum of disorders from ulceration to gangrene that occur in people with diabetes

As a result of neuropathy or ischaemia or both

(Patients often have both vascular and neuropathic problems)

Diabetics are prone to ulcers and infection

• 3 distinct processes lead to diabetic foot problems

  • Ischaemia

    • Micro

    • Macro

  • Neuropathy

    • Sensory

    • Motor

    • Autonomic

  • Sepsis

    • Glucose rich tissue promotes bacterial growth

Ischaemia in diabetic foot

• Diabetics are at increased risk of getting arterial...

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