Ulcer - Surgery

Summary

This lecture discusses critical concepts in surgery, focusing on the identification and differentiation of sinuses, fistulas, and ulcers. It explains the characteristics and clinical significance of each, emphasizing how to describe ulcers in detail (e.g., borders, floor, and base). The lecture also covers malignancies like basal cell and squamous cell carcinoma, their distinctive features, and the role of lymph nodes in diagnosis. By providing practical examples and diagnostic tips, this session offers valuable insights into evaluating and managing common surgical conditions, ensuring clear differentiation between benign and malignant cases.

Takeaways

• 😀 Sinus refers to an opening that communicates with a blind tract, often caused by abscesses, and can be found in areas like the sacrum or anus.
• 😀 Fistula is a tract formed by granulation tissue between two structures, characterized by two openings (internal and external), such as in anal fistulas or between the intestine and skin.
• 😀 An ulcer is a discontinuity or defect in the skin or mucous membrane, which can be traumatic or pathological in origin.
• 😀 When describing an ulcer, key factors to examine include the border, margin, skin around the ulcer, floor, base, depth, shape, exudate, surrounding tissue, and distal effects.
• 😀 The **border** of the ulcer refers to its outline, while the **margin** is a 1-2 mm area around the border that may be raised or beaded.
• 😀 **Floor** of the ulcer refers to what is visible (such as granulation tissue, pus, or necrotic material), while the **base** refers to what is felt on physical examination (induration or softness).
• 😀 **Malignant ulcers** (e.g., basal cell carcinoma or squamous cell carcinoma) often have raised or inverted edges, with necrotic material at the base.
• 😀 **Chronic inflammatory ulcers** tend to show induration at the borders, often confined to the ulcer, and can be differentiated from malignant ulcers based on these characteristics.
• 😀 Lymph nodes that are greater than 1 cm, hard, or tender may indicate a significant finding, such as malignancy, whereas smaller, mobile lymph nodes are less concerning.
• 😀 Understanding the **distal effects** of ulcers, such as edema or nerve palsy, is essential in evaluating the overall impact and progression of the ulcer.

Q & A

What is the difference between a sinus and a fistula?

A sinus is an opening or tract that communicates with a cavity, often seen in abscesses where pus drains through an opening. A fistula, on the other hand, is a tunnel or tract formed by granulation tissue that connects two organs or between an organ and the skin. Fistulas typically have two openings (internal and external), while sinuses are usually blind, meaning they end in a cavity without an opening.

What are the key characteristics of an ulcer?

An ulcer is defined as a discontinuity of the skin or mucous membrane, which may be traumatic or pathological. Key characteristics to describe an ulcer include its border, margin, the skin surrounding it, the floor (what is visible inside the ulcer), and the base (what can be felt beneath the ulcer). Induration or hardening around the ulcer, shape, and size are important for diagnosis.

What is the significance of the margin in ulcer classification?

The margin refers to the area just around the border of the ulcer, typically one or two millimeters in width. It may be raised or beaded. The margin is important for distinguishing between different types of ulcers, such as venous ulcers, which often have skin changes like pigmentation and hair loss around them.

How does the floor of an ulcer differ from its base?

The floor of an ulcer is what can be seen by the examiner and may contain healthy granulation tissue, infected material, or necrotic tissue. The base, however, refers to the underlying tissue felt by the examiner, and can show signs of fibrosis, induration, or other changes that help differentiate between acute and chronic ulcers.

What is the role of induration in diagnosing chronic or malignant ulcers?

Induration refers to the hardening of tissue around the ulcer. In chronic ulcers, the induration is usually limited to the ulcer's border. However, in malignant ulcers, the induration often extends beyond the ulcer’s border, indicating a deeper or more widespread pathology, such as cancer.

What are some common types of ulcer shapes and their associated conditions?

Ulcers can have various shapes, each indicating different underlying causes. Sloping edges are often seen in healing ulcers. Undermined edges, where the ulcer extends beneath the surface, are characteristic of tuberculosis. Punch-out ulcers, where the ulcer has sharply defined, circular edges, are seen in conditions like cancer, particularly basal cell carcinoma.

How can the pattern of ulcer edges help diagnose malignancy?

Malignant ulcers typically have raised, inverted, or rolled edges, which differ from the more defined or sloped edges of chronic ulcers. These irregular and often aggressive edge patterns are common in basal cell carcinoma and squamous cell carcinoma.

What are the distal effects of ulcers, and why are they important for diagnosis?

Distal effects refer to the systemic consequences of an ulcer, such as nerve palsy, edema, or ischemia. For example, if a malignant ulcer invades a nerve, it may cause foot drop. These effects are critical for understanding the severity of the ulcer and planning treatment, as they suggest deeper or more extensive involvement.

What are some factors that make lymph nodes significant in diagnosing ulcers?

Lymph nodes are significant in ulcer diagnosis because their size, mobility, and tenderness can indicate whether an ulcer is infected or malignant. Lymph nodes larger than 1 cm are often concerning, especially if they are tender or fixed, suggesting infection or cancerous spread.

How can you differentiate between chronic inflammatory ulcers and malignant ulcers?

Chronic inflammatory ulcers usually show induration confined to the ulcer's borders and may heal over time. In contrast, malignant ulcers exhibit induration that extends beyond the border and may present with features such as raised, inverted edges, or other irregularities in the surrounding tissue. These differences are crucial in distinguishing benign from malignant ulcers.