ULCERS, SINUSES & FISTULAE :ULCERS, SINUSES & FISTULAE Associate Professor Dr Sein Win M.B.,B.S. M.Med.Sc.(Surgery) Department of Surgery FMHS, UNIMAS


ULCER :ULCER Breach or discontinuity of an epithelium or mucosal surface.


Classification :Classification Infective (a) non-specific (b) specific – TB, gumma Traumatic Venous Arterial Neuropathic Neoplastic Iatrogenic CHEMICAL PHYSICAL


Slide 4:Thrombo-phlebitis occurring in varicose veins Epithelioma of hand with typical edge  Early rodent ulcer on the side of the nose


Diagnosis – :Diagnosis – 1. History: age (young – infective, >40 Ca, 60 Rodent) sex (female – varicose, male – squamous cell Ca) Race (Chinese – Varicose ulcer) Religion (Muslim/Jews - squamous cell Ca) Occupation - prolong standing (baker/hairdresser – varicose veins)


Slide 6:2. Mode of onset: acute inflammation/trauma  sudden -chronic chronic inflammation very slowly malignant  rapid


Slide 7:3. Duration: very short (days) – acute infection; short (month) – malignant; long - chronic inflammation


Slide 8:4. Progress: very rapid – acute inflammation, rapid – malignant, slow – chronic inflammation


Slide 9:5. Pain: acute inflammation, arterial ulceration– painful (venous – not usually very painful) Neuropathic – less pain malignant – early – usually painless.


Slide 10:6. Fever: infective/TB 7. Loss of weight: malignant/TB 8. Smoking: Buerger's disease, artherosclerosis Past History – TB, Syphilis, Diabetes Mellitus, Hypertension Responses to Antibiotics: (+) in infection (-) in malignancy


PHYSICAL EXAMINATION :PHYSICAL EXAMINATION General – cachexia, anaemia,weight loss (Ca, TB) Local: 1. Number (single or multiple –TB) 2. Site Rodent –lobule of ear & angle of the mouth;


Slide 12:Varicose – medial aspect of lower half of leg, Arterial – tip/between toes, malleoli, heel Pigmentation & Residual varicosity, linear healing ulcer  Arterial ulcer due to ischaemic pressure to the heel


Slide 13:SCC – lower lip, Gumma – s/c bone ~ tibia/sternum/skull Diabetic/Perforating/trophic – heel/ball of the foot (head of 1st /2nd metatarsals TB – neck, axilla, groin Lupus – face, fingers, hands, Chancre/soft sore – ext.genitalia


Slide 14:Rodent ulcer Lupus vulgaris Hunterian chancre Primary chancre of upper lip with lymphadenitis


Slide 15:3. Size (depends on duration & rate of growth) 4. Shape (oval – varicose, circular – rodent, irregular – malignant) 5. Edge: (a) flat sloping ~ simple or healing ulcer, venous ulcer (edge red, blue, transparent zone)


Slide 16:Healing granulating ulcer with skin islands.  FLAT SLOPING ULCERS OF A BURN LESION TO LEG


Slide 17:(b) square cut or punched out – gumma, trophic, diabetic - Chronic GU/DU, leprosy (rapid death & loss of whole thickness of skin without much attempt by the body to repair the defect)


Slide 18:(c) undermined – TB, amoebic, bed sore, carbuncle (infection affects underneath tissue more than epithelial surface) BUTTOCK SLOUGH IN THE BASE OF DEEP SACRAL ULCER


Slide 19:(d) raised & rolled up – rodent/BCC (slow growth of tissue in the edge of ulcer, edge pale pink or white with clumps of cluster of cells visible through paper thin superficial coverings of squamous cell)


Slide 20:(e) raised & everted – malignant ulcer, epithelioma (tissue in edge growing quickly and spilling out of the ulcer to overlap normal skin or mucosa)


Slide 21:Everted edges which to the palpating fingers feels hard - Ca Slightly raised edges – Rodent Septic ulcer (commonest – varicose ulcer) sloping edges Undermined edges - tuberculous Punched out ulcer – tertiary syphilis


Slide 22:Multiple gummatous ulcers in lower limb Varicose ulcer confined to the lower quarter of the leg Perforating ulcer on the sole Exuberant granulation tissue around a sinus OM rib


Colour of the Edge :Colour of the Edge Red  inflammation Pale or cyanosed  ischaemia Late  blue, purple, black Pigmentation  venous ulcer, malignant melanoma Pearly edge  BCC Keratinization  Neuropathic ulcer


Slide 24:6. Floor: Haemorrhage & necrotic slough– malignant purulent - acute infection washed leather- gumma bluish unhealthy granulation tissue TB (whitish in brownish space/ apple jelly) solid brown or gray – dead tissue full thickness skin death


Slide 25:7. Discharge: On dressing gauze – serous, sero- sanguinous, purulent, offensive, copious, or so slight – dries up into a scab. 8. Surrounding skin, state of local tissue, blood supply, innervation ss of infln – infective, scar – TB


PALPATION :PALPATION Temperature difference/tenderness - in acute infected ulcer Base – induration +/-, Mobility of ulcer over underlying structures – fixed – malignant; bleed on touch +/- regional lymphatics – enlarged -> inflammation hard – malignant


Systemic Examination: :Systemic Examination: Infection – constitutional symptoms - TB cachexia, anaemia, loss of weight- - malignant hypertension, artherosclerosis – - ischaemic ulcer Hensens’, tabes dorsalis, peripheral numbness - neuropathic


Investigation :Investigation D. Mellitus – Urine sugar/ RBS/FBS Infective - fbc, culture TB - CXR, AFB, ESR Syphilis - KT, VDRL Discharge – smear, Gram stain, C&S Biopsy - wedge/incisional biopsy margin of the ulcer & normal tissue which allows (a) comparison with normal tissue (b) known organ & (c) +/- or infiltration


Slide 29:Curling’s ulcer – acute peptic ulcer in burn as a reaction to stress Cushing’s ulcer – acute PU in head injury, early days following spinal cord injury Marjolin’s ulcer – malignant change in a scar, ulcer, sinus (Chr.venous ulcer, burn, Chr.OM sinus – slow growth – avascular, painless – scar not have cut. nerve fibres, late lymphatic spread – obliterated lymphatics)


Slide 30:GRANULATING TISSUE ESCHAR FOLLOWING SHIN TRAUMA


Stages of Ulcer :Stages of Ulcer


Principles of Assessment :Principles of Assessment Combination of aetiologies in any one lesion, especially diabetic foot. Pain indicates invasion of nerve endings. When the diagnosis relates directly to treatment, biopsy may be necessary.


SINUS & FISTULA :SINUS & FISTULA


Slide 34:SINUS ~ A tract which connects a cavity lined by granulation tissue (usually an old abscess) with an epithelial surface. {blind tract leading from surface down to tissue} FISTULA ~ Pathological connection between 2 epithelial surfaces usually lined by granulation tissue but can become epithelialized.


Slide 36:SINUS JAW SINUS FROM SEPTIC ARTHRITIS OF THE SHOULDER DUE TO ACTINOMYCOSIS 


Slide 37:History Since birth - preauricular sinus; due to Osteomyelitis(high fever + swelling + bone pain) TB -lymph node enlargement or TB bone or joints Perianal- h/o perianal/ischiorectal abscess (intermittent contraction of anal sphincter prevent proper rest) [Pain + inflammatory/blockage; Fever/redness of surrounding skin inflammatory] Past history TB, Crohn’s, U.colitis, actinomycosis, colloid Ca, operation complication Family history TB, Crohn’s, U.colitis


Slide 38:INSPECTION 1.Number – Single/Multiple (watering can perineum – Crohn’s rectum/anal canal, U.Colitis – fistulae; actinomycosis (multiple sinueses) 2. Site – Preauricular (failure of fusion of ear tubercles - at root of helix or on tragus of pinna; direction – upwards and backwards) Branchial (2nd & 5th branchial arch) at the lower 3rd of the neck in front of sternomastoid muscle Pilonidal – in the middle behind, finger webs Actinomycosis – multiple indurated sinuses in upper part of the neck A single sinus over the lower irregular jaw – due to osteomyelitis OM


Slide 39:Actinomycosis of the left side of the jaw with multiple sinus formation.


Slide 40:3. Opening of sinus Sprouting granulation tissue - + of FB (stitch, sequestrum, bullet) Wide margin, thin blue undermined edge – TB Sinus 4. Discharge OM  plus; TB  serosanguinous; Actinomycosis  sulphur granule Urine, faeces, bile


Slide 41:5. Surrounding skin Scar indicating Chr. OM or previously healed TB. Dermatitis with pigmentation  Chron’s / Actinomycosis


PALPATION :PALPATION 1. Tenderness  Inflammatory source OM 2. Wall of sinus thickening –fibrosis– chronicity 3. Mobility Sinuses resulting from OM is fixed to bone (irregular, thickened, tender) 4. Lump  + in neighbourhood  TB adenitis 5. Examination of draining lymph nodes


Slide 43:Examination with a probe (with due precaution) direction and depth of sinus presence of F/B (sequestrum), moveable at wound depth fistula communicated with a hollow viscus or not whether fresh discharge comes out on withdrawal of the probe or not.


Slide 44:Mammary fistula


Slide 46:General Examination Depends on site and cause – particular system Sinus in loin - spine, ribs, kidneys Chronic empyema - chest Osteomyelitis- bone Around anus- PR/proctoscopy, sigmoid scope, whole abdomen Multiples in perineum/scrotum lower urinary tract Groin sinus hip joint/spine (bursting of cold abscess)


Slide 47:Investigatons Examination of discharge – marcro/physical/chemical/microscopy X-rays - sequestrum, opaque foreign bodies/ sino/fistulogram


Failure to close :Inadequate drainage Specific infection (actinomycosis, TB, syphilis) Foregin body (stitch) Epitheliazation of cavity Malignant change in the cavity Dense fibrosis around the wall of the tract preventing collapse (empyema) Absence of rest Failure to close


Slide 49:Thank You


Primary Skin Lesions :Primary Skin Lesions Macule – a small flat area of altered colour or texture Papule – a small solid elevation of skin less than 0.5 cm in diameter Nodule - >0.5 cm Plaque – elevated area of skin greater than 2 cm in diameter without substantial depth Vesicle – circumscribed elevation of skin 0.5 cm Pustule – visible accumulation of pus in the skin Abscess - > 1cm Weal – elevated white compressible evanescent area produced by dermal oedema


Slide 51:Papilloma – a nipple like mass protruding from the skin Petechiae – Pin-head sized macules of blood in the skin Purpura – A larger macule or papule of blood in the skin Ecchymosis – a larger extravasation of blood into the skin Haematoma – a swelling from gross bleeding Burrow – a linear or curvilinear papule, caused by a burrowing scabies mite Comedo – a plug of keratin and sebum wedged in a dilated pilosebaceous orifice Telangiectasia – visible dilatation of small cutaneous blood vessels


Secondary lesions (evolved from primary lesion :Secondary lesions (evolved from primary lesion Scale – a flake arising from the horny layer Crust – look like a scale, but is composed of dried blood or tissue fluid Ulcer – an area of skin from which the whole of epidermis and at least the upper part of the dermis has been lost Excoriation – an ulcer or erosion produced by scratching Erosion – an area of skin denuded by a complete or partial loss of the epidermis Fissure – a slit in the skin Sinus – a cavity or channel that permits the escape of pus or fluid Scar – the result of healing in which normal structures are permanently replaced by fibrous tissue Atrophy – thinning of the skin due to diminution of the epi/dermis, s/c fat Striae – a streak like, linear, atrophic, pink, purple or white lesion of the skin due to changes in the connective tissue