Ulcer (ulcus) - granulating defect in the skin or mucous membranes, stubbornly not shown tendencies to heal.
Morphologically ulcers are very diverse. In form, depth, status edges, etc. allocate some typical types of ulcers: round (ulcus rotundum), slit-like or crack (see), callous (ulcus callosum), with saped edges (ulcus sinuosum). Ulcers in the form of narrow and deep festering course called granulating fistula (see).
Etiology. Ulceration is typical for a wide range of different nosological forms, as infectious diseases (syphilis, leishmaniasis, anthrax and other)and is not contagious (hospital disease stomach and duodenal ulcers, varicose veins of the lower limbs). However, there are ulcers that do not serve as a manifestation of any of these diseases.
The reasons for the formation of ulcers in all cases in General the same as necrosis, in particular gangrene (see). So sores on etiological grounds are classified as gangrene, discriminating first of all ulcers caused by local agents, and ulcers caused by the violation of the General condition of the organism. A more detailed classification distinguishes traumatic ulcers (mechanical, thermal, chemical, radiation, infectious, circulatory (ischemia, venous stasis, lymphostasis), neurotrophic, blastomycosis. Common disorders that cause ulceration may be: diabetes, beriberi (scurvy), anemia, malnutrition, trauma depletion, radiation sickness, just migrated or have not resulted in severe systemic infection and other conditions under which sharply reduces resilience and healing abilities of the body. Often plays the role of a combination of one locally acting factor with another or with a common disorders such as ulcers from the pressure of the heavy depleted patient (see Bedsore).
Pathogenesis. In the pathogenesis of ulcers initially involved inflammatory or necrotic process that caused the death of the tissue and the formation of the defect cover - significant or in the form of erosion (see). In other cases, the defect is formed as a result of damage - injury, burns, etc., the Transformation of this defect in the ulcer is listed under the influence of etiological factors, if they are not intensively, because otherwise develops rapidly progressing gangrene, and granulating defect in General is not formed. When less energetic, but the long-term effect of these factors reparative ability of affected tissues partially preserved, along with death and decay goes and regeneration: the defect granuliruth, but does not heal, becoming more or less stable ulcer. Necrotic process can sometimes prevail over reparative; in these cases, increases ulcer, spreading to the surrounding cover (corrosive ulcer - ulcus phagedenicum). Sometimes erosion occurs only in one direction and the other part of the ulcer pojivaet; then talk about creeping ulcer (ulcus serpiginosum). Ulcers may increase the depth of up to the destruction of the entire thickness of the affected part of the body or walls of the affected organ, such a plague called probcause (ulcus perforans). Ulcerative process can move on to another body, adjacent to the affected, spasica with him (penetrating ulcers - ulcus penetrans). In case of weakening, and then termination of the etiological factor comes gradual healing of the ulcer. But long-term for ulcers to the calling reason may join or even to replace it with a new etiological moment. So, around ulcers often formed massive scars, blocking the blood supply, and then to infectious or mechanical factor is added ischemic. More importantly, disorders of innervation, arising partly also due to the blocking of scars, but mainly due to the development of emerging neuritis and with changes in the Central nervous system, caused permanent pathological impulses from areas of ulcers. Thus, any long-existing ulcer, not having originally derived neurotrophic nature, with time acquires it. The most important danger in making ulcers in blastomata, i.e. malignant degeneration, especially possible with radiation ulcers.
Clinical picture, diagnosis and treatment of ulcers. Clinical course and symptoms sores are defined as its origin, and in most cases, its localization. This applies especially to the plagues of internal organs (stomach and duodenum). Diagnosis visible eye ulcer is no problem. However, the treatment of ulcers can be successful only if it takes into account the cause of ulcerative process, and is aimed at its elimination. Therefore, it should be differentiated depending on which group is given ethnological classification applies this plague. In some cases, and this question is not difficult to decide on clinical grounds.
Mechanical ulcers formed when granulating defect systematically subjected to friction, pressure or tension. They are often found in the mouth (crushing denture, primesyami or scratching the tooth) and, if not running, quickly healed after elimination traumatic moments.
The same applies to the plague of stump limbs, caused by ill-fitting denture. More complex treatment of ulcers caused by the tension that cannot be eliminated; these are the fissures, often require surgery, cracked lips, nipple and others In the practice of military surgery mechanical ulcers are found mainly in the lower limbs, often after injuries popliteal fossa or the area of the calf muscle and Achilles tendon. They are supported by stretching when walking, and their etiology usually easily detected because of motion in the joint significantly alter the shape of an ulcer, and muscle contraction causes a shift sannogo with her bottom ulcers. When ambiguities of these signs of mechanical nature of ulcers establish ex juvantibus; strict bed rest and immobilization plaster tire quickly and favourably affect the ulcer, and the resumption walk immediately negates the achieved effect.
Treatment only online. Apply excision sores and scars, the closure of the defect seams (late secondary seam) or displaced local cutaneous flap. If the scars in circumference are small, we can restrict carefully scraping of granulations and at the bottom of the defect to transplant free flap of skin; often prizyvaet. Attempts transplantation of epidermis in granulation are doomed to failure.
Thermal ulcers in the form of cracks occur almost exclusively when perniosis hands. With careful protection from re-cooling quickly heal spontaneously or under the influence of conservative treatment (warm bath, ointment dressing with weak antiseptics, for example Vishnevsky ointment).
Chemical ulcers occur as an occupational disease in the hands of sbolshakov (in the fishing industry, bacon production). Often acceding purulent infection is swelling and sharp redness around ulcers, usually multiple. In these cases, the exemption from work for a few days, antiseptic ointment dressing. Not complicated by the infection sores heal quickly, if hands are protected from the effects of brine rubber gloves. The latter are used and the means of prevention. Much harder chemical treatment of ulcers caused by the corrosive action of digestive juices, especially pancreatic, when external fistula pancreas and high intestinal fistulas. All the measures for protection of skin from maceration and digestion are often fruitless, and the plague is healed only after the liquidation of the fistula. The best preparation tool bruised skin before surgery over such fistula - permanent osushivaniya not closed bandage fistulous holes performed by patients with the help of gauze balls.
As a rarity can meet chemical ulcer, which the patient deliberately supports applications caustic soda ash (hysteria, mutilation l etc.).
Radiation ulcers - see Skin, radiation damage.
Infectious sores specific etiology - see Actinomycosis, Leishmaniasis, chancroid, anthrax, Syphilis, and Tuberculosis.
Nonspecific infection - purulent anaerobic, rotten - cause ulceration almost exclusively on the former wounds and mainly in the form of a fistula, supported by the deep pockets of infection - extensive purulent cavity, osteomyelitis, foreign matter, etc. Treatment consists in operation in respect of this center.
Much less the wound can become the plague, under the influence of vegetating on the granulation of pathogens - stafilo - or strep, especially diphtheria bacilli. In the past war, this microbe has repeatedly found in stubbornly persisting wounds in the absence of any characteristic manifestations of the wound diphtheria (see the Wounds, wounds). The nature of these infectious ulcers is recognized according to the bacteriological studies, and especially the elimination method is no evidence was found of ulcers of different origin. You should always be aware that persistent presence of a large number of pathogenic microbes on the granulation can be not the cause but the consequence of violations of healing. Treatment consists of local and General use of antibiotics and ultraviolet irradiation. Cracked lips, supported fungal infection (yeast), successfully treated with nystatin ointment.
Ulcers circulatory, ischemic - see Reynaud disease, obliterating Endarteritis; congestive - see Varicose veins; importations - see Elephantiasis.
A special form - circulatory ulcer caused strictly local ischemia of granulations caused by blocking the blood supply to the scars. Such ulcers occur on the site of the Russian Academy of Sciences with extensive defects of the skin, especially if the bottom of the wound formed tissue, poor blood vessels (e.g. wide fascia of the thigh, which were not cut in surgical treatment). Features: extensive massive scars in circumference, granulation poorly developed, flat, without normal grain or bumpy, swollen, but always pale, hardly bleed at the damage. Treatment: while the ulcer is not running (i.e. just decided termination epithelization from the edges and the deterioration of granulation), can give the effect of transplantation of epidermis in Yanovich - Chainsaw or Davis (see plastic surgery of the Skin). If the possibility of healing is already questionable, and the plague is very large, you should perform the test at peresadin on granulation 10-15 small grafts placed evenly on the surface of the defect; in the case of engraftment at least half of them, you can close all defects. If it fails and is clearly running slhca - wide excision sores and scars and transplantation of skin flap on the leg or stalked flap Filatov. As a rule, should not use local skin flaps: their cutting out and move may increase the insufficiency of blood supply.
Neurotrophic ulcers (sores) are developed in the areas with impaired innervation, diseases and injuries to the spinal cord, larger peripheral nerve. These are Provadiya foot ulcer (malum perforans pedis) with the defeat of the sciatic nerve (Fig. 3), the ulcer in place bedsores with lesions of the spinal cord, etc. These ulcers are the primary neurotrophic origin, formed on the area affected by the mortification - "spontaneous or induced insignificant external cause. Ulcero-necrotic process is usually progresses rapidly. So, Provadiya foot ulcer, beginning with necrosis of the skin on the soles in the field of the metatarsal heads, deepens to the rear of the foot, which also destroys the skin, forming a through hole. The nature of these ulcers can be easily detected on the history and the presence of other signs of a sharp disorders of innervation - rough sensitive and movement disorders. Sometimes these disorders play an important role in the formation of ulcers; loss of sensation does not allow the patient to avoid hazardous external influences (corneal injury - with the defeat of the first branch of the trigeminal nerve, re-burn - with those of syringomyelia), and paresis can create a vicious position of the limbs, contributing to its permanent injury. Ulcer at the ends of the toes when the paralytic flexion contracture can have purely mechanical, and not neurotrophic origin. Treatment of primary neurotrophic ulcers can be successful if it is possible to restore the damaged innervation online (neurosis, seam nerve decompression of the spinal cord and others) or conservative measures. When you do this task ulcer no cure and may lead to amputation, if it is localized on a limb and damage of nerve trunks. When you break the spinal cord, not led to the death of the patient, vegetative innervation with years to recover; then the plague of pressure sores heal spontaneously. Treatment in these cases is to protect a ulcers from infection (local administration of sulfonamides, antibiotics, weak antiseptics).
Less demonstrative symptoms of an ulcer, which acquired neurotrophic nature secondary owing to its large ago. Most often it varicose ulcers of the lower leg (Fig. 1 and 2), then ischemic ulcers, supported blocking scars, and radiation ulcers (Fig. 4), less all the rest. Ulcer thus retains its original characteristics and its changing nature only show a vegetative disorders in the circle: hyperhidrosis or excessive dryness of the skin, its atroficski, hypertrichosis or poverty and brittle hair, compared with symmetric region. Only sometimes there are some changes in the sensitivity around the ulcer. All these signs should be sought when any of circulatory, mechanical or other plague, the existing more than 3-4 months. It should also be noted that if the injuries (especially firearms) prolonged for wounds caused her severe infection or the General weakening of the body, can lead to secondary impaired trophic before features wound defect will make it possible to qualify it as an ulcer. In this case, the secondary neurotrophic disorders are often the only reason for the subsequent transformations of the wound in a stomach ulcer, so that the symptoms last there are no signs pointing to a different origin.
Treatment should resolve to support the ulcer, pathological impulsaciu - centripetal and centrifugal. With this purpose recommend long-term oil and balsamic dressing (see) in the form of a warm compress, iontophoresis with novocaine, short or circular blockade, spirtovodochniy blockade (see Blockade procaine), neurotomy relevant cutaneous nerves on Molotkov (all this without guarantee of success). Failure is inevitable if these methods are applied at an ulcer, supported, in addition to secondary violations of trophism, etiological factor that originally caused ulcerative process: infection (foreign body, osteomyelitis), ischemia (massive scars), and so on Elimination of this factor (for example, excision ischemic ulcers and blocking scars with plastic substitution of the defect) when the ongoing neurotrophic disorders will also be fruitless: the flap will not prizivat or syatwinda. To succeed in such cases, you can expect when combined plastic surgery with blockages or neurotopia, but it is not always effective.
Thus, even if an exact knowledge of the complex etiology of these ulcers treatment remains very difficult. More importantly, their prevention, which is to achieve healing of mechanical, or other circulatory the plague before it will cause secondary changes of nervous trophism. Therefore, you should never hesitate no surgical intervention regarding existing ulcer, nor with accelerates healing of operations with extensive granulating wounds.
Ulcers that are associated with public disorders (diabetes, scurvy and other diseases listed above). With modern possibilities of recognition and treatment of these diseases, they rarely cause "spontaneous", without external causes ulceration, but can serve as an important cause of the development of ulcers in the wound or burn. Of the common infections should be noted syphilis, which, in addition to specific infectious sores, can cause and the transformation of wounds in nonspecific ulcer (by reducing reparative abilities of the organism). In wartime, the most important is the combination of deficiencies with marasmus and blood loss; in besieged Leningrad it drastically impaired wound healing, and led to the transformation of these ulcers.
Every plague, and especially in cases when its origin is not clear, should be studied in detail the General condition of the patient (in the first turn the symptoms of hypovitaminosis, determination of sugar in the urine, General blood analysis, serologic test for syphilis), and the results taken into account in the treatment.
High-calorie, rich in vitamins nutrition shows and ulcers that are not related to violations of the General condition of the patient.

Ulcer - long-term healing a granulating tissue defect resulting from ossification them, in the absence or weak intensity of the processes of regeneration (healing). Ulcers should be distinguished from erosion (see)that will kill only the surface layer of tissue, and the deeper underlying layers are not affected.
The origin of ulcers play the role of many reasons. To ulcers, due to common diseases associated with metabolic disorders include ulcers with scurvy, diabetes, radiation sickness, sharp depletion, etc. depending on the nature of the causes ulceration, there are ulcers: traumatic, thermal, electrical, chemical and other; infectious - specific (tuberculosis, syphilis, actinomycetaceae and others) and non-specific; ulcers, developing as a result of disorders of blood circulation and lymph circulation (endarteriit and atherosclerosis, venous congestion) or innervation (neurotrophic ulcers, trophic ulcers); changes of the vascular wall in atherosclerosis, obliterating endarteritis, and others; blastomycosis process (blastomycosis ulcers); local action of penetrating radiation (radiation ulcers; Fig. 6).

the plague Fig. 6. Trophic ulcer hands as a result of action of x-rays.

Fig. 7. Provadiya foot ulcer.
Fig. 1. Varicose ulcer of the lower third of the Shin.
Fig. 2. The same plague that took trophic character.
Fig. 3. Primary trophic ulcer (Provadiya foot ulcer).
Fig. 4. Radiation ulcer as a result of action of x-rays.

In some cases, ulcers can be caused by a combination of reasons. For example, necrosis of the skin followed by the formation of ulcers in the bedsore (see) is called, on the one hand, the pressure on the tissue, on the other - a violation of their viability due to the depletion of the patient or in connection with the disorder of their innervation (especially in injuries to spinal cord).
The characteristics of the course allocate ulcers: corrosive (gradually increasing in the plane); creeping (from one end of the ulcer is the healing, with another - erosion); probcause (forming a through hole in the wall of hollow organ or body part; Fig. 7); penetrating (penetrating from the affected organ to another, spasica with him the body, for example from the stomach into the liver).
Ulcers of the skin, the available survey (skin, mouth, etc.), recognized easily by the data of the anamnesis (duration) and by kind granulating defect. The difficulty of recognition can only be applied for determining the nature of the ulcer, which is necessary for correct treatment, consisting primarily in removing the causes of canker sores. Most simply recognition and treatment of traumatic ulcers caused by the pressure of prosthetic limbs for stump, denture - on the gum edge of the tooth on the tongue, etc., In these cases the ulcer heals as soon as you stop the injury.
Traumatic ulcers often formed on the place of the deep wounds or burns elbow bend, popliteal, in the field calf muscles, the Achilles tendon is generally in places where granulating defect is being davleniem and stretching movements. These sores quickly heal when immobilization limbs, with strict bed rest, but often open again, once a person begins to use the limb. In these cases it is shown surgery - excision ulcers and closing the defect with a skin graft.
Chemical ulcers occur on the hands of sbolshakov, fish and bacon industry; they are usually multiple, small, often complicated by a purulent infection. Prevention - protection of hands from the brine rubber gloves; treatment - ointment dressing with weak antiseptics (syntomycin emulsion, Vishnevsky ointment). At significant damage - exemption from work to complete healing of ulcers that comes quickly. Much harder occurring chemical ulcers caused by constant contact with skin digestive juices from the exterior of the gastric and intestinal fistula. Especially sharp changes of the skin occur in the duodenal and high intestinal fistulas. In this case, measures of protection of the skin from the digestive action detachable ineffective, ulcer heals only after surgical closure of the fistula. In the field fistula colonic ulcers can be formed only at poor care (see Anus praeternaturalis).

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