Ulcer

An ulcer is a deep defect of the skin or mucous membrane and underlying tissues, the healing processes of which (development of granulation tissue, epithelialization) are reduced or significantly impaired and are accompanied by prolonged healing. Superficial processes in the skin are related to dermatitis, eczema or dermatoses under the influence of professional factors.

What causes ulcers?

The causes that cause ulcer formation are very diverse. They can be divided into two groups: the site of the damaging action (endogenous and exogenous) and the general damaging action (most often, neurotrophic disorders). In most cases, there is a combination of both causes.

What types of ulcers are there?

Clinically and according to the etiological factor, the following types of ulcers are distinguished.

Traumatic ulcers formed by direct damaging effects of high and low temperatures, electricity, radiation energy, exposure to certain chemicals, and wounds. Unlike sluggishly regenerating acute manifestations of these effects, the ulcer is characterized by a long course (more than two months), granulations in the ulcer are pale, covered with fibrin, pathogenic microflora is absent in most cases, and pain syndrome is not expressed.

Trophic ulcers are formed due to circulatory disorders (circulatory type), mainly venous and lymphatic blood flow in: post-thrombophlebitic syndrome, varicose veins, and are a manifestation of venous insufficiency; lymphedema, diabetes mellitus (diabetic foot), obliterating diseases of the vessels of the extremities, with the rejection of bedsores. Trophic ulcers most often form on the shin and foot, have a round, oval or irregular shape, their sizes vary, sometimes they can be giant or cover the entire shin circularly, the edges are edematous, compacted, with progression more often loose and undermined, the skin around the ulcer is atrophic or, conversely, dense with infiltration, can be cyanotic or have a brown color; the bottom is filled with flaccid, pale granulations covered with detritus; in the absence of purulent infection, the discharge may be serous, serous-hemorrhagic, sometimes there are erosive bleedings; the pain syndrome is weakly expressed, with the exception of obliterating diseases of the extremities. When an infection is added, tropical ulcers are defined as infected: pain, hyperemia and edema around the ulcer, increased skin temperature, characteristic purulent discharge appear (Pseudomonas aeruginosa is most common - discharge is blue or greenish, Proteus - with an unpleasant "rag" smell, Staphylococcus - with an ichorous smell of discharge).

Allergic and neurotrophic ulcers are classified as the most difficult to treat, as they themselves are multifaceted in pathogenesis, in addition, they are often combined with viral, fungal and purulent infections. Usually loose, flat, the edges are raised above the skin in the form of a ridge, the skin is thinned, cyanotic hyperemic, there may be blisters filled with serous or serous-hemorrhagic contents, there are almost no granulations, the ulcers are wet, accompanied by skin itching, there is a connection with an allergen, most often an industrial one.

Specific ulcers have characteristic features depending on the microflora that caused their formation. Tuberculous ulcers often form together with a fistula, are characterized by slow development, painlessness, pale granulation, bridges are formed, which, as they regenerate, form rough deforming scars: Syphilitic ulcers form after the gumma opens with fistulas with a creamy discharge; the ulcer is accompanied by characteristic night pain; can be of different sizes, usually of a regular round shape, with steep dense, scalloped edges of a ridge-like shape, usually sharply outlined by a pigmented border of atrophic skin, often has bridges of different sizes and colors; ulcers tend to deepen, causing disfigurement and even loss of some organs (nose, eyes, testicles, etc.); heal either with delicate scars of varying depth and color (“mosaic scar”), or with a rough, dense, retracted scar; the border of pigmented and atrophic skin around the healed ulcer is preserved in both cases.

Blastomatous ulcers are formed as a result of the decay of the primary tumor or, less often, metastases, and have an unpleasant ichorous odor. Callosity (callous ulcer) of the edges of a chronic ulcer is highly suspicious of malignancy, which must be confirmed or rejected by a biopsy of tissues taken from three points - the edge, wall, and bottom of the ulcer. In general, in all cases, it is necessary to take smears-imprints of the bottom of the ulcer for cytology, which often allows one to establish the cause of a persistent ulcer.

Ulcerative processes on the mucous membranes even form separate diseases: gastric ulcer and duodenal ulcer, nonspecific ulcerative colitis, blepharitis, bronchiectasis, etc. All these ulcerative processes are multifaceted in etiology and pathogenesis. For example, gastric ulcer and duodenal ulcer can form both under the influence of spirochetes and under the influence of neurohumoral factors; under the influence of hypoxia (hypoxic ulcer); stress (stress ulcer); disorders of gastric juice secretion (peptic ulcer), under the influence of some drugs - steroid hormones, salicylates, etc., symptomatic ulcers.

Complications of ulcers include: gross cicatricial deformation of surrounding tissues, which can cause not only a cosmetic defect, but also dysfunction of the limb or cause stenosis of the outlet of the stomach; deepening of the ulcer and erosion of the vessels can cause bleeding, even profuse, although veins are mainly affected. Ulcers of the stomach and intestines are threatened by perforation, penetration into adjacent organs and tissues, malignancy.

How is an ulcer treated?

Ulcer treatment should mainly be aimed at the underlying disease, so the tactics are chosen individually in each case. The surgeon's competence is the treatment of trophic ulcers and complicated gastric ulcer.