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ulcer

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ulcer /ul·cer/ (ul´ser) a local defect, or excavation of the surface, of an organ or tissue, produced by sloughing of necrotic inflammatory tissue.
corneal ulcer  ulcerative keratitis.
decubital ulcer , decubitus ulcer bedsore; an ulceration due to an arterial occlusion or prolonged pressure, as when a patient is confined to a bed or a wheelchair.
duodenal ulcer  a peptic ulcer situated in the duodenum.
gastric ulcer  an ulcer of the gastric mucosa.
Hunner's ulcer  one involving all layers of the bladder wall, occurring in chronic interstitial cystitis.
jejunal ulcer  an ulcer of the jejunum; such an ulcer following surgery is called a secondary jejunal u.
marginal ulcer  a gastric ulcer in the jejunal mucosa near the site of a gastrojejunostomy.
peptic ulcer  an ulceration of the mucous membrane of the esophagus, stomach, or duodenum, due to action of the acid gastric juice.
perforating ulcer  one involving the entire thickness of an organ or of the wall of an organ creating an opening on both surfaces.
phagedenic ulcer 
1. a necrotic lesion associated with prominent tissue destruction, due to secondary bacterial invasion of an existing cutaneous lesion or of intact skin in a person with impaired resistance as the result of systemic disease.
plantar ulcer  a deep neurotrophic ulcer of the sole of the foot, resulting from repeated injury because of lack of sensation in the part; seen with diseases such as diabetes mellitus and leprosy.
rodent ulcer  ulcerating basal cell carcinoma of the skin.
stercoraceous ulcer , stercoral ulcer one caused by pressure of impacted feces; also, a fistulous ulcer through which fecal matter escapes.
stress ulcer  peptic ulcer, usually gastric, resulting from stress.
trophic ulcer  one due to imperfect nutrition of the part.
tropical ulcer 
1. a lesion of cutaneous leishmaniasis.
tropical phagedenic ulcer  a chronic, painful, phagedenic ulcer of unknown cause, usually on the lower limbs of malnourished children in the tropics.
varicose ulcer  an ulcer due to varicose veins.
venereal ulcer  a nonspecific term referring to the formation of ulcers resembling chancre or chancroid about the external genitalia.

ul·cer (lsr)
n.
A lesion of the skin or of a mucous membrane, such as the one lining the stomach or duodenum, that is accompanied by formation of pus and necrosis of surrounding tissue, usually resulting from inflammation or ischemia.

Ulcer
A site of damage to the skin or mucous membrane that is characterized by the formation of pus, death of tissue, and is frequently accompanied by an inflammatory reaction.

ulcer
[ul′sər]
Etymology: L, ulcus, a sore
a circumscribed, craterlike lesion of the skin or mucous membrane resulting from necrosis that accompanies some inflammatory, infectious, or malignant processes. An ulcer may be shallow, involving only the epidermis, as in pemphigus, or deep, as in a rodent ulcer. Some kinds of ulcer are peptic ulcer, pressure ulcer, and serpent ulcer. ulcerate, v., ulcerative adj.

ulcer [ul´ser]
a local defect, or excavation of the surface of an organ or tissue, produced by sloughing of necrotic inflammatory tissue.
aphthous ulcer a small painful ulcer in the mouth, approximately 2 to 5 mm in diameter. It usually remains for five to seven days and heals within two weeks with no scarring.
chronic leg ulcer ulceration of the lower leg caused by peripheral vascular disease involving either arteries and arterioles or veins and venules of the affected limb. Arterial and venous ulcers are quite different and require different modes of treatment. Venous stasis ulcers occur as a result of venous insufficiency in the lower limb. The insufficiency is due to deep vein thrombosis and failure of the one-way valves that act during muscle contraction to prevent the backflow of blood. Chronic varicosities of the veins can also cause venous stasis.

Patient Care. Stasis ulcers are difficult to treat because impaired blood flow interferes with the normal healing process and prolongs repair. Patient care is concerned with preventing a superimposed infection in the ulcer, increasing blood flow in the deeper veins, and decreasing pressure within the superficial veins.
decubitus ulcer pressure ulcer.
duodenal ulcer an ulcer of the duodenum, one of the two most common types of peptic ulcer.
gastric ulcer an ulcer of the inner wall of the stomach, one of the two most common kinds of peptic ulcer.
Hunner's ulcer one involving all layers of the bladder wall, seen in interstitial cystitis.
hypertensive ischemic ulcer a manifestation of infarction of the skin due to arteriolar occlusion as part of a longstanding vascular disease, seen especially in women in late middle age, and presenting as a red painful plaque on the lower limb or ankle that later breaks down into a superficial ulcer surrounded by a zone of purpuric erythema.
marginal ulcer a peptic ulcer occurring at the margin of a surgical anastomosis of the stomach and small intestine or duodenum. Marginal ulcers are a frequent complication of surgical treatment for peptic ulcer; they are difficult to control medically and often require further surgery.
peptic ulcer see peptic ulcer.
perforating ulcer one that involves the entire thickness of an organ, creating an opening on both surfaces.
phagedenic ulcer
1. any of a group of conditions due to secondary bacterial invasion of a preexisting cutaneous lesion or the intact skin of an individual with impaired resistance as a result of a systemic disease, which is characterized by necrotic ulceration associated with prominent tissue destruction.
pressure ulcer see pressure ulcer.
rodent ulcer ulcerating basal cell carcinoma of the skin.
stasis ulcer ulceration on the ankle due to venous insufficiency and venous stasis.
stress ulcer a type of peptic ulcer, usually gastric, resulting from stress; possible predisposing factors include changes in the microcirculation of the gastric mucosa, increased permeability of the gastric mucosa barrier to H+, and impaired cell proliferation.
trophic ulcer one due to imperfect nutrition of the part.
tropical ulcer
1. a lesion of cutaneous leishmaniasis.
tropical phagedenic ulcer a chronic, painful phagedenic ulcer usually seen on the lower limbs of malnourished children in the tropics; the etiology is unknown, but spirochetes, fusiform bacilli, and other bacteria are often present in the developing lesion, and protein and vitamin deficiency with lowered resistance to infection may play a role in the etiology.
varicose ulcer an ulcer due to varicose veins.
venereal ulcer a nonspecific term referring to the formation of ulcers resembling chancre or chancroid about the external genitalia; there are both sexually transmitted and other types.

ulcer (ul´sur),
n a loss of covering epithelium from the skin or mucous membranes, causing gradual disintegration and necrosis of the tissues.
Enlarge picture
“Ugly duckling” stage of mixed dentition.
ulcer, aphthous
n an open, shallow lesion in the oral cavity that causes pain; commonly known as a
canker sore. The cause is unknown, and treatment is limited to alleviating the symptoms.
ulcer, aphthous, recurrent (RAU)
n periodic episodes of aphthous lesions on nonkeratinized oral tissues lasting from 1 week to several months. Trauma and immunologic factors are involved in the etiology. The single or multiple discrete or confluent ulcers have a well-defined marginal erythema and a central area of necrosis with sloughing. Also called
canker sore and
recurrent aphthae.
ulcer, autochthonous
n See chancre.
ulcer, decubitus
n 1. a bedsore.
2. older term for a traumatic ulcer of the oral mucosa. More commonly called
traumatic ulcer.
Enlarge picture
Decubitus ulcer.
ulcer, diabetic
n an ulcer, usually of the lower extremities, associated with diabetes mellitus.
ulcer, herpetic
n an ulcer on keratinized orofacial tissues that is secondary to the vesicle of herpes simplex after the intact surface is broken by trauma to the lesion; a shallow ulcer with an irregular, erythematous border and a yellow-gray base. Contagious through all stages of lesion. Can be treated by topical acyclovir. Also called a
cold sore.
ulcer, Mikulicz's
ulcer, pemphigoid aphthous,
n a lesion located on the gingiva or mucous membranes due to a chronic disease of the autoimmune system. It is indicated by a wound with a thick wall that ruptures within 24 to 48 hours and leaves an eroded and painful surface area. It heals through the formation of a scar.
ulcer, peptic
n an ulcer of the stomach or duodenum. Most ulcers are associated with
H. pylori, a spiral-shaped bacterium that lives in the acidic environment of the stomach. They can also be caused or worsened by drugs such as aspirin and other NSAIDs.
ulcer, pterygoid
ulcer, rodent,
ulcer, traumatic,
n an ulcer that is caused by trauma. It can be due to faulty oral hygiene, rough foods, oral habits, poor-fitting dentures, or inadvertent mastication or biting of oral tissues. The offending cause may need to be removed by the patient or clinician. After this treatment, it must heal within a 2-week period to rule out any oral cancer concerns. The older term in dentistry is
decubitus ulcer.

ulcer
a local defect, or excavation of the surface of an organ or tissue, produced by sloughing of necrotic inflammatory tissue. They occur in all organs and tissues and are to be found under those headings, e.g. abomasal, corneal, gastric.

button ulcer
see button ulcer.
callous ulcer
see set-fast (2).
collagenase ulcer
a rapidly expanding, erosive ('melting') corneal ulcer, seen particularly in brachycephalic breeds of dogs.
Curling's ulcer
acute ulceration of the stomach or duodenum seen after severe burns of the body in humans.
decubitus ulcer
see decubitus ulcer.
dendritic ulcer
linear, branching pattern of ulceration on the cornea; characteristic of herpesvirus infections. See also herpetic keratitis.
eosinophilic ulcer
see eosinophilic ulcer.
gastroduodenal ulcer
common in foals 1-3 months old. Many are asymptomatic. Clinical cases manifest by mild, intermittent colic. See also gastric ulcer, duodenal ulcer.
geographic ulcer
a large, superficial, irregularly shaped corneal ulcer, typically formed by the coalescence of several dendritic ulcers.
indolent ulcer
see eosinophilic ulcer, refractory ulcer (below).
infectious dermal ulcer
a systemic, fatal bacteremia of snakes manifested by multiple, small cutaneous ulcers. Called also scale rot.
intestinal ulcer
is rare in all species. When they do occur, intestinal ulcers usually cause signs of chronic enteritis. It is a common lesion in adenocarcinoma of the intestine. See also peptic ulcer.
lip ulcer
see eosinophilic ulcer.
lip and leg ulcer
see ulcerative dermatosis.
melting ulcer
see collagenase ulcer (above).
ulcer mound
a gastric ulcer viewed tangentially radiographically creates a mound in the otherwise smooth outline of radiopaque material in the stomach.
necrotic ulcer of swine
see ulcerative granuloma of swine.
perforating ulcer
one that involves the entire thickness of an organ, creating an opening on both surfaces. See also ulcer perforation.
phagedenic ulcer
a necrotizing lesion in which tissue destruction is prominent.
refractory ulcer
a chronic, superficial corneal ulceration in dogs, particularly common in Boxers, that extends into the superficial stroma, often undermining epithelium at the edges. The cause is unknown but abnormalities of the basal epithelial cells and anterior stroma have been noted. Response to the usual methods of treatment for corneal ulceration is characteristically very slow; superficial keratectomy is the treatment of choice. Called also superficial corneal erosion syndrome, Boxer ulcer.
rodent ulcer
see eosinophilic ulcer.
stress ulcer
superficial ulcerations or erosions of mucosa in the stomach, duodenum or colon. The possible predisposing factors include changes in the microcirculation of the gastric mucosa, increased permeability of the gastric mucosa barrier to H+, and impaired cell proliferation.
stromal ulcer
a corneal ulcer involving the stroma.
trophic ulcer
one due to imperfect nutrition of the part. In dogs, may develop in digital and metatarsal pads in association with tibial nerve injury.

ulcer 
A localized lesion of the skin or of a mucous layer in which the superficial epithelium is destroyed and deeper tissues are exposed. See abscess.
corneal ulcer A superficial loss of corneal tissue as a result of infection that has led to necrosis. It may be caused by a bacterium (e.g. Pseudomonas aeruginosa, Streptococcus pneumoniae), by a virus (e.g. herpesvirus), or by a fungus (e.g. Candida, Aspergillus, Penicillium). It causes pain and usually reduced visual acuity, especially if the ulcer occurs in the centre of the cornea. Corneal ulcers usually look dirty grey or white and are opaque areas of various sizes and a mucopurulent discharge may be present. If induced by contact lenses, especially extended wear lenses, patients must cease wearing their lenses immediately, and the appropriate therapy instituted: antibacterial, antifungal or antiviral agent. See corneal facet; herpes simplex keratitis; hypopyon keratitis; rosacea keratitis; ulcerative keratitis; keratocele; keratomycosis; leukoma.
dendritic ulcer See herpes simplex keratitis.
von Hippel's internal ulcer A depression noted in the posterior surface of the cornea. This lesion resembles posterior lenticonus, except that it is thought to be due to an infection or inflammation. The lesion can be differentiated from Peter's anomaly by the presence of endothelium and Descemet's membrane in the former. Due to its posterior location, the lesion does not usually disturb visual function. See Peter's anomaly.
marginal corneal ulcer Benign condition due to a hypersensitivity reaction to bacterial conjunctivitis, particularly staphylococcal blepharoconjunctivitis. It is characterized by infiltration of the peripheral cornea by white cells and by ocular irritation. The condition is usually self-limiting but painful. Treatment includes frequent cleaning of the eyelid margin with a cotton-tipped applicator or face cloth or cotton ball with baby shampoo, warm compresses, antibiotic ointment and occasionally topical corticosteroids.
Mooren's ulcer A rare, superficial ulcer of the cornea of unknown origin. It starts near the limbus as an overhanging advancing edge that in severe cases spreads over the entire cornea and may even invade the sclera. The patient complains of pain and blurred vision. There are two types: a self-limiting form, usually unilateral, affecting old people, and a progressive form, bilateral, affecting young people. The condition is difficult to treat and this may include topical and systemic steroids, immunosuppressants, or conjunctival excision. See peripheral ulcerative keratitis.
serpiginous ulcer See hypopyon keratitis.
shield ulcer A localized corneal ulcer noted in severe cases of vernal conjunctivitis. The lesion is usually oval or pentagonal resembling a warrior's shield. It is located in the upper portion of the cornea as a result of irritation from the large papillae on the palpebral surface of the overlying eyelid.

ulcer
Dermatology A defect in a mucocutaneous surface See Bairnesdale ulcer, Buruli ulcer, Esophageal ulcer, Kissing ulcer, Pressure ulcer, Rodent ulcer ENT Mouth ulcer, see there See Aphthous ulcer GI disease Duodenal ulcer, see there. Cf Cushing's ulcer, Dieulafoy ulcer, Peptic ulcer, Stercoral ulcer, Stress ulcer Ophthalmology A defect on the epithelium of the eye. See Corneal ulcer, Corneal neurotrophic ulcer, Geographic ulcer, Peptic ulcer, Serpiginous ulcer.

ul·cer (ŭl'sĕr),
A lesion through the skin or a mucous membrane resulting from loss of tissue, usually with inflammation. See: erosion.
Synonym(s): ulcus
[L. ulcus (ulcer-), a sore, ulcer]

ul·cer (ŭl'sĕr)
An erosive or penetrating lesion on a cutaneous or mucosal surface, usually with inflammation.
Compare: erosion
Synonym(s): ulcus.
[L. ulcus (ulcer-), a sore, ulcer]

ul·cer (ŭl'sĕr)
Lesion through skin or mucous membrane resulting from loss of tissue, usually with inflammation.
See: erosion
[L. ulcus (ulcer-), a sore, ulcer]

ulcer non-healing, chronic wound showing concomitant tissue repair and tissue breakdown, chronic inflammation and deposition of fibrous tissue in surrounding/underlying soft tissues, and threat of secondary infection; caused by loss of/breakdown/infection of epidermal/dermal tissues, with subcuticular tissue and deeper structure involvement; characterized by pain (unless in neuropathic tissues), chronic inflammation, fibrosis of underlying and local peripheral tissue, fluid exudation and proneness to infection predisposing factors include arterial, venous, lymphatic, neurological and immune compromise (see Table 1); presence of foreign body (including necrotic material) within the wound, repeated microtrauma, and concurrent systemic disease and drug regimes contribute to non-healing; normal healing events (i.e. healing by secondary intention [inflammation, epithelialization, wound contraction, connective tissue maturation]) are prolonged, disrupted and often non-sequential (Table 2); healing is promoted by addressing the cause of tissue breakdown and concomitant factors that interrupt normal healing, together with measures to promote systemic wellness (Table 3; see Table 4), including rest (e.g. use of a full contact cast to allow non-weight-bearing ambulation), regular wound care (and dressings appropriate to phase of healing to optimize wound environment; see Table 5 and Box 1), antibiotics (to control infection Table 6), pressure bandaging and/or diuretics (to control or reduce foot/limb oedema), vascular surgery (to improve arterial supply/venous return) and tight glycaemic control (see Table 7, Table 8 and Table 9 and Box 2)
  • complicated ulcer secondarily infected chronic wound penetrating to and involving deeper structures; possibly complicated by osteomyelitis

  • decubitus ulcer; pressure sore ulcer formation at pressure point (e.g. posterior/plantar margin of heels, sacrum, elbows) in bed-bound patients, caused by compromised local blood supply and reduced tissue viability, relative immobility and general patient debility

  • gastric ulcer erosion of gastric mucosa due to chronic ingestion of non-steroidal anti-inflammatory drugs or infection with Helicobacter pylori

  • Marjolin's ulcer neoplastic deterioration of pre-existing long-standing ulcer

  • mixed-pathology ulcer chronic wound caused by mixed pathology, e.g. secondary bone infection within a neuroischaemic ulcer

  • neuroischaemic ulcer ulcer development in neuropathic ischaemic tissue

  • neuropathic ulcer plantar ulcer induced by relatively minor trauma, in an insensitive foot (see trophic ulcer)

  • perforating ulcer ulcer whose base penetrates to involve subcuticular structures, e.g. tendon/bone (which may be visible within the lesion base)

  • rodent ulcer see basal cell carcinoma

  • trophic ulcer deep plantar ulcer (prone to both aerobic and anaerobic infections) induced by relatively minor trauma and/or tissue stress (e.g. pressure/friction) in a neuropathic (anaesthetic) foot, e.g. in diabetes or leprosy; skin surrounding the ulcer tends to exuberant callous formation (see Box 3 and Table 10)

  • varicose ulcer; venous ulcer wide, shallow ulcer most commonly found at lower medial one-third of leg in association with poor and prolonged compromised venous return and/or venous stasis; develops within area of oedematous tissue characterized by signs of compromised venous function (e.g. varicose eczema, haemosiderosis, woody tissue fibrosis, scars of healed earlier ulceration, atrophy blanche and varicose veins)

Table 1: Phases in the progression of an ulcer to healing
Ulcer phaseCharacteristicsComment
Active phaseWound dimensions increase (undermined wound edges)
Exudation
Formation of slough
Periwound oedema and induration of edges
Dissolution and degradation of devitalized tissue ± infection
Macrophage and enzyme activity
Accumulation of degraded tissue and dead macrophages
Chronic, non-resolving inflammation ± collagen deposition
Proliferative phaseWound begins to infill (wound dimensions reduce)
Epithelialization (saucerization) of margins
Formation of granulation tissue
Recruitment of fibroblasts; collagen formation
Epidermal cells at margins mitose and spread out to begin to close wound
Maturation phaseWound contraction
Wound closure
Scar formation
Myofibrils within fibroblasts contract
Epithelialization is complete
Devascularization of fibrotic tissue that forms scar
Table 2: Examples of ulcer classification systems
Classification systemDetailsComments
WagnerGrade 0: local deformity or callosity but no open lesions
Grade 1: partial or full skin thickness, superficial ulcer
Grade 2: deep ulcer without osteomyelitis, but extending to ligament, tendon, bone, joint capsule or deep fascia
Grade 3: deep ulcer with associated cellulitis, abscess formation and/or osteomyelitis and/or joint sepsis
Grade 4: gangrene localized to the forefoot or heel
Grade 5: extensive gangrene
Widely recognized and used system
Rather generalist and non-specific
Ignores neuropathy and lesion size, and thus their effects of choice of treatment/lesion management
S SADS = size of lesion (area; depth)
S = sepsis (presence/absence)
A = arteriopathy (ischaemia)
D = denervation (sensory/autonomic/motor neuropathy)
Builds on from the Wagner system (above), introducing additional categories, each awarded 0 (normal), 1 (mild change), 2 (moderate change), 3 (severe change) subclassification
RYBR = red wound (pale pink-beefy red ulcer base, proliferating/inflammatory ulcer)
Y = yellow wound (moist, exudating ivory/ green/brownish sloughy wound)
B = black wound (dry wound with black/ brown/tan hard eschar)
Wound assigned colour grading
A limited classification that focuses solely on wound appearance and ignores other factors (e.g. distal sensory neuropathy, peripheral ischaemia, cellulitis, size/depth of lesion, phase of progression of lesion)
PEDISP = perfusion of limb/foot
E = extent of wound (size of lesion)
D = depth of lesion/tissue loss
I = infection
S = sensation (perception of light touch, vibration, contact of 10g monofilament, hot/cold discrimination)
Each subcategory is graded 1-4, where 1 = normal/absence and 4 = severe
Useful research tool allowing indepth assessment of lesion progression over time, and comparison of lesions subjected to varying treatment modalities
DEPAD = depth of lesion
E = extent of bacterial colonization
P = phase of ulcer (Table 11)
A = associated aetiology (e.g. trauma, neuropathy, ischaemia, infection, diabetes mellitus)
DEPA <6 = low-grade wound (i.e. local debridement, oral antibiosis as necessary, glycaemic control measures)
DEPA 7-9 = moderate-grade wound (i.e. debridement, parenteral antibiosis, insulin therapy, wound-healing promotion agents, pressure relief)
DEPA 10-12 = high-grade wounds (i.e. parenteral antibiosis, insulin therapy, wound-healing promotion agents, vascular reconstruction)
Each subcategorization is graded 1-3 to reflect increasing levels of severity
Validated system
Score 6 = wound likely to heal in time
Score 10: great difficulty in healing
Score 11-12 (especially heel wounds): prognostic of lower-limb amputation
University of Texas systemTier 1
Wound graded 0-3 according to wound depth/tissue involvement:
0 = pre-/postulcer with intact epithelium
1 = superficial ulcer not involving bone/tendon
2 = ulcer penetrates to tendon/joint capsule
3 = ulcer penetrates to bone/joint
Tier 2
Wound graded A-D according to wound burden/tissue status
A = non-infected/non-ischaemic
B = infected/non-ischaemic
C = non-infected/ischaemic
D = infected/ischaemic
Multisite validated system
Two-tier wound classification (tier 1 = ulcer; tier 2 = wound burden/tissue status, e.g. 1C = no current ulcer; ischaemic foot) gives risk assessment
Useful wound management 'road map'
Should be used in conjunction with other markers of limb status (e.g. degree of sensory neuropathy, autonomic function; ankle-brachial pressure index, Buerger's test, presence of critical ischaemia, skin condition, local foot/toes deformity, subtalar joint range of motion)
Table 3: Phases in the progression of an ulcer to healing
Ulcer phaseCharacteristicsComment
Active phaseWound dimensions increase (undermined wound edges)
Exudation
Formation of slough
Periwound oedema and induration of edges
Dissolution and degradation of devitalized tissue ± infection
Macrophage and enzyme activity
Accumulation of degraded tissue and dead macrophages
Chronic, non-resolving inflammation ± collagen deposition
Proliferative phaseWound begins to infill (wound dimensions reduce)
Epithelialization (saucerization) of margins
Formation of granulation tissue
Recruitment of fibroblasts; collagen formation
Epidermal cells at margins mitose and spread out to begin to close wound
Maturation phaseWound contraction
Wound closure
Scar formation
Myofibrils within fibroblasts contract
Epithelialization is complete
Devascularization of fibrotic tissue that forms scar
Table 4: Features of chronic wounds (ulcers) as an aid to diagnosis
FeatureNeuropathicIschaemicInfectedHealing
BaseSloughyAdherent sloughDeep and sloughyGranulation and epithelialization
WallsUnderminedVerticalUnderminedSaucerized
DepthDeepRelatively shallowDeep and penetratingShallow
ExudateModerate/copious thickModerate serousHeavy, pus-y, bloody, malodorousScant, serous
Surrounding tissuesHeavy callosityCold, cyanoticCelluliticMild inflammation
PrognosisExtendingStatic, non-healingExtending and spreadingReducing
Table 5: Examination of chronic wounds (ulcers): appearance of the wound
Point of noteFeatures to be recorded
SiteThe exact anatomical location of the wound
SizeThe dimensions of the wound, in millimetres:
• Width (medial-lateral distance)
• Length (longitudinal distance)
• Depth
AppearanceThe appearance of the wound and the surrounding tissues:
• Callosity
• Maceration
• Signs of local infection
• Signs of spread of infection (cellulitis, lymphangitis, lymphadenitis)
SidesThe orientation of the walls of the wound in relation to the skin surface:
• Undermined (extending wound)
• Vertical (static wound)
• Saucer-shaped (healing wound)
BaseThe nature of the wound floor:
• Sloughy (infected, non-healing)
• Granulating (healing)
• Hypergranulating (non-healing or traumatized wound)
• Deep structures, such as joint capsule/tendon/bone, visible through wound base (extending wound)
DischargeA deep swab of the discharge should be sent for pathology laboratory culture and sensitivity
The amount and type of discharge should be noted (the amount can be inferred by the state of the dressing in relation to how long it has been in situ):
• Colour - yellow/green (extending wound or infection); red/brown (blood or infection); turquoise green (Pseudomonas infection); clear (joint fluid or healing wound)
• Texture - thick (staphylococcal infection or extending wound); thin (streptococcal infection or healing wound)
• Amount - copious (infection); plentiful (extending or non-healing wound); scarce (healing wound)
• Odour - very smelly (necrotic, infected); sweet (healing)
Table 6: Types of wound dressings and indications for their use
Dressing TypeFeaturesIndicated Use
Primary Wound-Dressing Films
Semi-permeable adhesive filmNon-absorbent
Non-adherent to wound surface
Gas and water vapour permeable, but impermeable to water
Non-shedding
Transparent, allowing observation of wound
Low exudating wounds
Perforated film, absorbentLow adherence (absorbent pad covered by perforated film)
Low exudating wounds
Low-adherent Wound Contact Layers
Unmedicated viscoseNon-absorbent; non-sheddingNon-adherent primary dressing
Medicated tulleLow-adherent polyethylene glycol or paraffin impregnated tulle incorporating an antiseptic (e.g.: chlorhexidine gluconate; iodine)Topical antisepsis
Semi-permeable hydrogelsHydrophilic polymers in either sheet or amorphous formulations
Highly absorbent
Gas permeable, but impermeable to water
Dressing surface may dry out, and thus requires rehydration with saline
Removal of slough
Rehydration of dry, necrotic tissue to allow its later sharp debridement
Absorption of heavy exudation
Carrier of topical antimicrobials (e.g.: metronidazole)
HydrocolloidsInteractive (form a gel when in contact with wound surface)
Usually formulated with an occlusive, water-repellent backing
Promote an acidic and hypoxic wound environment, and facilitates neoangiogenesis
Not suitable for infected wounds
Maintain a moist, temperature controlled wound environment
AlginatesSeaweed derivatives which form a hydrophilic gel in contact with the wound surface
Require irrigation to remove from wound surface
Absorption of exudation
Moisten with saline before application
Polyurethane foamsSmooth low-adherent wound contact layer backed with hydrophobic foam
Highly gas-permeable
Maintain a moist wound environment and good thermal insulation
Absorption of moderate exudation
Outer layer prevents 'strike through'
Silver agentsSilver ions impregnated into dressing
Antibacterial action
Topical antisepsis, including resistant forms
Box 1: Properties of an 'ideal' wound dressing
  • Removal and absorption of exudate to prevent maceration of tissues and growth of wound contaminants and microorganisms, and prevent 'strike-through'

  • Maintenance of correct levels of humidity at the wound surface in order to encourage keratinocyte migration across the wound surface

  • Gaseous permeability to allow correct oxygen levels within the wound; high oxygen levels promote keratinocyte function; relative hypoxia promotes neoangiogenesis and macrophage function, and reduces pain

  • Impermeable to microorganisms, by the prevention of 'strike-through'

  • Maintenance of the correct tissue pH; oxygen dissociates from haemoglobin, and neoangiogenesis is stimulated at acidic (i.e. <7.4) pH levels

  • Maintenance of the correct temperature, in order to promote fibroblast and keratinocyte division, and thereby promote healing; the wound takes up to 3 hours to regain its pre-dressing rate of cell mitosis, and a 10°C fall in wound temperature reduces oxygen dissociation from oxyhaemoglobin

  • Low adherence, so that newly formed tissues are not disrupted during dressing changes; 'wet to dry' dressings cause considerable tissue damage when the dressing is changed

  • Non-contaminating, in order to prevent shedding of the dressing fibres into the wound; shed fibres can cause foreign-body and toxic reactions

  • Ease of application

  • Comfortable in situ, and well conforming to the wound site

Table 7: Indicative antibiotic/antimicrobial regimes
Infection siteIndicative antibiotic regime
Skin
ImpetigoLocalized infection: topical fusidic acid (or mupirocin if MRSA+ve); dicloxacillin; azithromycin
Widespread infection: oral flucloxacillin or erythromycin (if penicillin-sensitive)
ErysipelasPhenoxymethylpenicillin or erythromycin
CellulitisBenzylpenicillin and flucloxacillin (or erythromycin if penicillin-sensitive); co-amoxiclav
Infected ulcerTopical antibiotics: mupirocin, fusidic acid
Topical antiseptics: povidone-iodine
Infected burns (e.g. caustic burns)Silver sulfadiazine
Animal/human bitesCo-amoxiclav (doxycyline + metronidazole if penicillin-sensitive)
OsteomyelitisFlucloxacillin (clindamycin if penicillin-sensitive)
Vancomycin if MRSA+ve or Staphylococcus epidermidis -+ve
Sodium fusidate (has good bone penetration)
Septic arthritisFlucloxacillin + fusidic acid (clindamycin if penicillin-sensitive)
Vancomycin if MRSA+ve or Staphylococcus epidermidis -+ve
Prevention of infection in orthopaedic surgerySingle dose of intravenous cefuroxime or intravenous flucloxacillin
Staphylococcus speciesSystemic flucloxacillin; fusidic acid (erythromycin if penicillin-sensitive)
Streptococcus speciesSystemic penicillin, erythromycin, clindamycin, phenyloxymethylpenicillin
Beta-haemolytic streptococciSystemic phenyloxymethylpenicillin
Pseudomonas aeruginosa Systemic ciprofloxacin; ticarcillin + clavulanic acid; azlocillin; piperacillin
Anaerobic infectionSystemic metronidazole (also as topical beads in the treatment of anaerobe-infected ulcers)

Note: Swab of the wound/exudate is taken to ensure the most effective antibiotic is prescribed; the patient is started on a broad-spectrum antimicrobial and the medication modified as necessary once the laboratory results confirm the regime of choice.

MRSA, meticillin-resistant Staphylococcus aureus .

Table 8: Examination of chronic wounds (ulcers): history of the wound
Points of noteQuestions that should be asked
DurationHow long has the wound been present?
SizeHas the wound changed (got bigger/smaller; altered its appearance)?
NumberIs there an increase/decrease in the number of wounds?
Previous woundsHave similar wounds occurred in the past? If so, when?
Sensory changesHas the patient noted any changes of sensation in the affected foot (increased sensitivity; decreased sensitivity; paraesthesia)?
Tissue changesHave the surrounding tissues altered in appearance (swelling; limb/foot oedema; colour changes; dryness of skin)?
CauseWhat does the patient think caused the wound in the first place?
Table 9: Examination of chronic wounds (ulcers): appearance of the wound
Point of noteFeatures to be recorded
SiteThe exact anatomical location of the wound
SizeThe dimensions of the wound, in millimetres:
• Width (medial-lateral distance)
• Length (longitudinal distance)
• Depth
AppearanceThe appearance of the wound and the surrounding tissues:
• Callosity
• Maceration
• Signs of local infection
• Signs of spread of infection (cellulitis, lymphangitis, lymphadenitis)
SidesThe orientation of the walls of the wound in relation to the skin surface:
• Undermined (extending wound)
• Vertical (static wound)
• Saucer-shaped (healing wound)
BaseThe nature of the wound floor:
• Sloughy (infected, non-healing)
• Granulating (healing)
• Hypergranulating (non-healing or traumatized wound)
• Deep structures, such as joint capsule/tendon/bone, visible through wound base (extending wound)
DischargeA deep swab of the discharge should be sent for pathology laboratory culture and sensitivity
The amount and type of discharge should be noted (the amount can be inferred by the state of the dressing in relation to how long it has been in situ):
• Colour - yellow/green (extending wound or infection); red/brown (blood or infection); turquoise green (Pseudomonas infection); clear (joint fluid or healing wound)
• Texture - thick (staphylococcal infection or extending wound); thin (streptococcal infection or healing wound)
• Amount - copious (infection); plentiful (extending or non-healing wound); scarce (healing wound)
• Odour - very smelly (necrotic, infected); sweet (healing)
Table 10: Antibiotic regimes for the treatment of infection in plantar neuropathic ulceration
Identified microorganismExample of antimicrobial drug
StreptococciOral amoxicillin 500mg tds (or IV amoxicillin 500mg 8-hourly)
StaphylococciOral flucloxacillin 500mg qds (or IV flucloxacillin 500mg 6-hourly)
AnaerobesOral metronidazole 400mg tds (or IV metronidazole 500mg 8-hourly)
Gram-negativesOral ciprofloxacin 500mg bd (or IV ceftazidime 1g 6-hourly)

IV, intravenous.

Box 2: Algorithm for the treatment of plantar neuropathic ulceration
  • Debride the skin surrounding and overlying ulcer of all callosity

  • Take a deep bacteriological swab of the ulcer base

  • Initiate broad-spectrum antibiotic therapy if infection is suspected (tailor the antibiotic once the swab has been cultured and the microorganism sensitivity identified; severe infections/cellulitis may require treatment as an inpatient with intravenous antibiotic drugs)

  • Cut back all unsupported tissue at the periphery of the ulcer and necrotic tissue to healthy bleeding tissue (if an entire digit is necrotic, a ray excision amputation may be required)

  • Cleanse the ulcer using normal saline (Normasol) at 37°C delivered under pressure from a disposable needleless syringe

  • Dry the ulcer area with non-shedding sterile gauze

  • Dress the ulcer (exudating wounds require absorbent dressings that wick the exudates away and prevent tissue maceration)

  • Reduce plantar pressures (with padding, triple-layer bespoke insoles in bespoke shoes, removable or full-contact casts)

  • Review weekly; maintain antibiosis and non-weight-bearing regime until the ulcer has healed

Box 3: Algorithm for the treatment of plantar neuropathic ulceration
  • Debride the skin surrounding and overlying ulcer of all callosity

  • Take a deep bacteriological swab of the ulcer base

  • Initiate broad-spectrum antibiotic therapy if infection is suspected (tailor the antibiotic once the swab has been cultured and the microorganism sensitivity identified; severe infections/cellulitis may require treatment as an inpatient with intravenous antibiotic drugs)

  • Cut back all unsupported tissue at the periphery of the ulcer and necrotic tissue to healthy bleeding tissue (if an entire digit is necrotic, a ray excision amputation may be required)

  • Cleanse the ulcer using normal saline (Normasol) at 37°C delivered under pressure from a disposable needleless syringe

  • Dry the ulcer area with non-shedding sterile gauze

  • Dress the ulcer (exudating wounds require absorbent dressings that wick the exudates away and prevent tissue maceration)

  • Reduce plantar pressures (with padding, triple-layer bespoke insoles in bespoke shoes, removable or full-contact casts)

  • Review weekly; maintain antibiosis and non-weight-bearing regime until the ulcer has healed

Table 11: Antibiotic regimes for the treatment of infection in plantar neuropathic ulceration
Identified microorganismExample of antimicrobial drug
StreptococciOral amoxicillin 500mg tds (or IV amoxicillin 500mg 8-hourly)
StaphylococciOral flucloxacillin 500mg qds (or IV flucloxacillin 500mg 6-hourly)
AnaerobesOral metronidazole 400mg tds (or IV metronidazole 500mg 8-hourly)
Gram-negativesOral ciprofloxacin 500mg bd (or IV ceftazidime 1g 6-hourly)

IV, intravenous.


Patient discussion about ulcer.

Q. Is it an ulcer? I am worried! Hi friend, I'm 35 year old male and recently I started to suffer from some strange symptoms I have never experienced. The first symptom was sharp pain in my upper abdomen that starts two of three hours after eating. In the beginning I thought it could be connected with some food intolerance but then I started to get this pain early in the morning, before any eating what so ever and all this was accompanied with nausea, frequent burping and weight loss. I have read some stuff about stomach ulcer and I could say that I poses almost every major symptom. Is there any way for me to be sure that I have developed disease of ulcer?

A. There is nothing you could do to check do you have ulcer or not by your self. Anyone who thinks he may have an ulcer needs to see a doctor because over time, untreated ulcers grow larger and deeper and can lead to other problems. So go now to the doctor.
http://www.youtube.com/watch?v=YrcrG-dcIXA

Q. What are the symptoms of Ulcerative Colitis? I am 40 years old and suffer from a lot of stomach aches and diarrhea. Do I have Ulcerative Colitis? What are its symptoms?

A. Here's a pretty good article that covers symptoms of UC:

http://www.wearecrohns.org/ucers/articles/319

Q. What is the difference between duodenal ulcer and stomach ulcer? I was diagnosed recently with duodenal ulcer. I heard the term stomach ulcer but not duodenal. What causes duodenal and what cause stomach ulcer? And how do they treat duodenal ulcer?

A. The duodenum is right after the stomach. They are both (as published a few years back) caused 90% of the time from a bacteria named helicobacter pylori. Hence the treatment for it is probably antibiotics. But I guess that should be your doctor’s call. Good luck!

Read more or ask a question about ulcer


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