phagedenic ulcer


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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 ulcers" >stasis ulcers occur as a result of insufficiency" >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 stasis" >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" >peptic ulcer.gastric ulcer an ulcer of the inner wall of the stomach, one of the two most common kinds of peptic ulcer" >peptic ulcer.Hunner's ulcer one involving all layers of the bladder wall, seen in cystitis" >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.2. tropical phagedenic ulcer.pressure ulcer see pressure ulcer.rodent ulcer ulcerating basal cell carcinoma of the skin.stasis ulcer ulceration on the ankle due to insufficiency" >venous insufficiency and stasis" >venous stasis.stress ulcer a type of peptic ulcer" >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 leishmaniasis" >cutaneous leishmaniasis.2. tropical phagedenic ulcer.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" >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.

phag·e·den·ic ul·cer

a rapidly spreading ulcer attended by the formation of extensive sloughing. Synonym(s): sloughing ulcer

phagedenic ulcer

A rarely used, nonspecific term for a rapidly progressive ulcer.

phag·e·den·ic ul·cer

(faj'ĕ-den'ik ŭl'sĕr) A rapidly spreading ulcer attended by the formation of extensive sloughing.

ulcer

(ul'ser) [L. ulcus, sore, ulcer] A lesion of the skin or mucous membranes marked by inflammation, necrosis, and sloughing of damaged tissues. A wide variety of insults may produce ulcers, including trauma, caustic chemicals, intense heat or cold, arterial or venous stasis, cancers, drugs (such as nonsteroidal anti-inflammatory drugs [NSAIDs]), and infectious agents such as Herpes simplex or Helicobacter pylori.

amputating ulcer

An ulcer that destroys tissue to the bone by encircling the part.APHTHOUS ULCER

aphthous ulcer

An ulcer of the oral mucosa, usually less than 0.5 cm in diameter. If it persists for longer than 2 weeks, it should be biopsied to rule out cancer. Synonym: aphthous stomatitis; canker sore See: illustration

Etiology

Aphthous ulcers are found in stomatitis, Behçet syndrome, Crohn disease, acquired immunodeficiency syndrome, and some cancers.

Treatment

For patients with oral ulcers, application of a topical anesthetic or a protective paste provides symptomatic relief and makes it possible to eat without pain.

arterial ulcer

Ischemic ulcer.

atonic ulcer

A chronic ulcer with little tendency to heal.

Buruli ulcer

An infection of the skin and underlying tissues with Mycobacterium ulcerans. The infection, common in the tropics and subtropics, develops slowly from a painless or minimally painful nodule on the skin into underlying bone, which it gradually destroys. The spread of the disease may be prevented with bacille Calmette-Guérin (BCG) vaccine.

callous ulcer

A chronic, slowly healing ulcer with indurated, elevated edges but no granulation.

Cameron ulcer

See: Cameron ulcer

chiclero ulcer

A Central American term for cutaneous leishmaniasis.

chronic leg ulcer

Any long-standing, slowly healing ulcer of a lower extremity, esp. one caused by occlusive disease of the arteries or veins or by varicose veins.

Curling ulcer

See: Curling ulcer

Cushing ulcer

See: Cushing, Harvey

decubitus ulcer

Pressure ulcer

denture ulcer

An ulcer of the oral mucosa caused by irritation from wearing dentures.

Patient care

To prevent irritation and ulceration of the mucous membranes of the mouth, denture wearers should clean dentures daily and remove them while sleeping. Poorly fitting dentures should be reconstructed or padded by a denturist.

diabetic foot ulcer

Diabetic foot infection.

duodenal ulcer

An open sore on the mucosa of the first portion of the duodenum, most often the result of infection with Helicobacter pylori. It is the most common form of peptic ulcer. See: peptic ulcer

follicular ulcer

A tiny ulcer originating in a lymph follicle and affecting a mucous membrane.

fungal ulcer

1. An ulcer in which the granulations protrude above the edges of the wound and bleed easily. 2. An ulcer caused by a fungus.

gastric ulcer

An ulcer of the gastric mucosa.

Etiology

Common causes are NSAIDs, use of alcohol or tobacco, and infection with H. pylori.

 See: peptic ulcer

Hunner ulcer

Interstitial cystitis.

indolent ulcer

A nearly painless ulcer usually found on the leg, characterized by an indurated, elevated edge and a nongranulating base.

ischemic ulcer

An ulcer caused by diminished blood flow through an artery, esp. one that nourishes a finger or toe. These ulcers are usually found in patients with peripheral vascular disease. They may result in loss of digits as a result of gangrene. Synonym: arterial ulcer

Marjolin ulcer

See: Marjolin ulcer

Meleney ulcer

See: Meleney ulcer

Mooren ulcer

See: Mooren ulcer

peptic ulcer

An ulcer in the lining of the duodenum, the lower end of the esophagus, or the stomach (usually along the lesser curvature). Peptic ulcer disease is a common illness, affecting about 10% of men and 5% of women during their lifetimes. Curling ulcer; Helicobacter pylori; stress ulcer; Zollinger-Ellison syndrome;

Etiology

Common causes of peptic ulcer are factors that increase gastric acid production or impair mucosal barrier protection, e.g., salicylates and NSAIDs, smoking, H. pylori infection of the upper gastrointestinal tract, pathological hypersecretory disorders, consumption of alcohol and coffee, and severe physiological stress. Ulcers occur in men and women and occur most frequently in patients over age 65, with about 1.6 million cases diagnosed annually in the U.S. The relationship between peptic ulcer and emotional stress is not completely understood.

Symptoms

Patients with peptic ulcers may be asymptomatic or have gnawing epigastric pain, esp. in the middle of the night or when no food has been eaten for several hours. At times, heartburn, nausea, vomiting, hematemesis, melena, or unexplained weight loss may signify peptic disease. Food intake often relieves the discomfort. Peptic ulcers that perforate the upper gastrointestinal tract may penetrate the pancreas, causing symptoms of pancreatitis (severe back pain) and chemical peritonitis followed by bacterial peritonitis or an acute abdomen as irritating gastrointestinal (GI) contents and bacteria enter the abdominal cavity. Bacterial peritonitis can lead to sepsis, shock, and death.

Diagnosis

Endoscopy (esophagogastroduodenoscopy) provides the single best test to diagnose peptic ulcers because it allows direct visualization of the mucosa and permits carbon–13 urea breath testing, cytological studies, and biopsy to diagnose H. pylori and rule out cancer. During endoscopy, tissue can be excised, vessels ligated, or sclerosants injected. Barium swallow or upper GI x-ray series may also be used to provide images for diagnosis or follow-up and may be the initial test for patients whose symptoms are not severe.

Treatment

H. pylori causes most peptic ulcers in the duodenum; antibiotics (clarithromycin and amoxicillin) are prescribed to treat H. pylori, and antisecretory (proton pump inhibitor) drugs like lansoprazole or omeprazole should be given to all patients with duodenal ulcers. Bismuth or other coating agents may be used as a barrier to protect the duodenal mucosa. Peptic ulceration of the stomach may be treated with the same medications if biopsies or breath tests reveal H. pylori. When patients have ulcers caused by the use of NSAIDs or tobacco, withholding these agents and treating with an H2 blocker, e.g., ranitidine, provides an effective cure. The prostaglandin analogue misoprostol may also be used to suppress or prevent peptic ulcer caused by use of NSAIDs. GI bleeding is managed initially with passage of a nasogastric tube and iced saline lavage, possibly with norepinephrine added. Gastroscopy then allows visualization of the bleeding site and laser or cautery coagulation. When conservative medical treatment is ineffective, vagotomy and pyloroplasty may be used to reduce hydrochloric acid secretion and enlarge the pylorus to enhance gastric emptying. More extreme surgical therapy (including subtotal gastric resection) may be needed in rare instances of uncontrollable hemorrhage or perforation occurring as a result of peptic ulcer disease.

Patient care

The ambulatory patient is educated about agents that increase the risk for peptic ulceration and given specific instructions to avoid them. Instruction should include the importance of adhering to prescription drug therapies, adverse reactions to H2-receptor antagonists and omeprazole (dizziness, fatigue, rash, diarrhea), and the need for follow-up examination and care.

For the hospitalized patient with ulcer-related bleeding, careful monitoring of vital signs, fluid balance, hemoglobin levels, and blood losses may enhance early recognition of worsening disease. Intravenous (IV) access is established, and IV opiates are administered as prescribed for pain control. The patient is kept nil per os (NPO). Electrolytes and fluids are replaced as needed. Endoscopic or other diagnostic and treatment procedures are explained to the patient, and the effects of prescribed therapies or transfusions are carefully assessed. All patient care concerns apply after major surgery. The patient is assessed for possible complications: hemorrhage, shock, malabsorption problems (iron, folate, or vitamin B12 deficiency anemias), and dumping syndrome. To avoid these problems, the patient is advised to drink fluids between meals rather than with meals, eat 4 to 6 small, high-protein, low-carbohydrate meals daily, and lie down after eating. Before and after discharge, health care professionals should help the patient to develop coping mechanisms to relieve anxiety. Patients are taught to recognize signs and symptoms of disease recurrence (e.g., coffee-ground emesis, the passage of black or tarry stools, or epigastric pain). Patients who use antacids and have a history of cardiac disease or whose sodium intake is restricted for any reason are warned to take only those antacids that have low amounts of sodium. The need for ongoing medical care is stressed.

perforating ulcer

An ulcer that erodes through an organ, e.g., the stomach or duodenum.

phagedenic ulcer

Tropical ulcer.

postpolypectomy ulcer

An erosion through the lining of the gastrointestinal tract resulting from endoscopic removal of a tumor. PRESSURE UCLER

pressure ulcer

Damage to the skin or underlying structures from compression of tissue and inadequate perfusion. Pressure ulcers typically occur in patients who are bedridden or chair bound. Patients with sensory and mobility deficits (such as patients with spinal cord injury, stroke, or coma); malnourished patients; patients with peripheral vascular disease; hospitalized elderly patients; and nursing home residents are all at risk. Some evidence also suggests that incontinence is a risk factor. Synonym: bed soredecubitus ulcerpressure sore See: Norton scale for table.

The most common sites of skin breakdown are over bony prominences (the sacrum and the trochanters, the heels, the lateral malleoli and also the shoulder blades, ischial tuberosities, occiput, ear lobes, elbows, and iliac crests). The combination of pressure, shearing forces, friction, and moisture leads to tissue injury and occasionally necrosis. If the ulcer is not treated vigorously, it will progress from a simple red patch of skin to erosion into the subcutaneous tissues, eventually extending to muscle or bone. Deep ulcers often become infected with bacteria and develop gangrene. See: illustration

Treatment and Prevention

The most important principle is to prevent the initial skin damage that promotes ulceration. In patients at risk, aggressive nursing practices, such as frequent turning of immobile patients and the application of skin protection to bony body parts, are frequently effective. Gel flotation pads, alternating pressure mattresses, convoluted foam mattresses and sheepskins or imitation sheepskins may be employed. Specialized air-fluid beds, waterbeds, or beds with polystyrene beads provide expensive but effective prophylaxis. If the patient develops an ulcer, topical treatments with occlusive hydrocolloid dressings, polyurethane films, absorbable gelatin sponges, collagen dressings, wound-filter dressings, water-vapor permeable dressings, and antibiotic ointments aid the healing of partial-thickness sores. Deeper lesions may need surgical débridement. Skin-damaging agents such as harsh alkaline soaps, alcohol-based products, tincture of benzoin, hexachlorophene, and petroleum gauze should be avoided. Consultation with a wound care specialist is advantageous.

Patient care

The skin is thoroughly cleansed, rinsed, and dried, and emollients are gently applied by minimizing the force and friction used, esp. over bony prominences. Patients who are not able to position themselves are repositioned every 1–2 hr to prevent tissue hypoxia resulting from compression. A turning sheet or pad is used to turn patients with minimal skin friction. Care providers should avoid elevating the head of the bed higher than 30° (except for short periods) to reduce shearing forces on the skin and subcutaneous tissues overlying the sacrum. Range-of-motion exercises are provided, early ambulation is encouraged, and nutritious high-protein meals are offered. Low-pressure mattresses and special beds are kept in proper working order. Doughnut-type cushions should not be used because they decrease blood flow to tissues resting in the center of the doughnut.

Ulcers are cleansed and débrided, and other therapeutic measures are instituted according to institutional protocol or prescription. Consultation with a nutritionist may be needed to assess and optimize the patient's nutritional status, and to provide high-protein meals with added vitamin C to promote healing, protein and calorie-rich supplements, or enteral feedings. Weak or debilitated patients should be assisted to eat, with care taken to prevent swallowing difficulties.

RODENT ULCER: on the ear

rodent ulcer

A basal cell carcinoma that has caused extensive local invasion and tissue destruction, esp. on the face. The usual sites are the outer angle of the eye, near the side and on the tip of the nose, and at the hairline. Synonym: Jacob ulcer See: illustration

Saemisch ulcer

See: Saemisch ulcer

serpiginous ulcer

A creeping ulcer that heals in one part and extends to another. See: Mooren ulcer

shield ulcer

A corneal ulcer found in some patients with vernal conjunctivitis. The ulcer is sometimes associated with corneal plaques that may permanently impair vision.

simple ulcer

A local ulcer with no severe inflammation or pain.

specific ulcer

An ulcer caused by a specific disease, e.g., syphilis or lupus erythematosus.

stercoral ulcer

A rarely occurring ulcer of the colon caused by pressure from impacted feces. Perforation through the walls of the colon may cause peritonitis, sepsis, and sometimes death.

stress ulcers

Multiple small, shallow ulcers that form in the mucosa of the stomach or, occasionally, in the duodenum in response to extreme physiological stressors. See: Curling ulcer; Cushing ulcer under Cushing, Harvey; peptic ulcer

traumatic ulcer

An ulcer due to injury of the oral mucosa. Its causes include biting, denture irritation, toothbrush injury, and sharp edges of teeth or restorations.

trophic ulcer

An ulcer caused by the failure to supply nutrients to a part.

tropical ulcer

1. An indolent ulcer, usually of a lower extremity, that occurs in those living in hot, humid areas. The cause may or may not be known; it may be caused by a combination of bacterial, environmental, and nutritional factors. Synonym: phagedenic ulcer2. The tropical sore caused by leishmaniasis.

varicose ulcer

An ulcer, esp. of the lower extremity, associated with varicose veins.

venereal ulcer

An ulcer caused by a sexually transmitted disease, i.e., chancre or chancroid.VENOUS STASIS ULCER: On lateral malleolus

venous stasis ulcer

A poorly and slowly healing ulcer, usually located on the lower extremity above the medial malleolus. Typically it is edematous, pigmented, and scarred. The skin is extremely fragile and easily injured. In the U.S. about 3.5% of people over 65 have venous stasis ulcers. Women are three times more likely than men to be affected. See: illustration

Patient care

Assessment includes a detailed medical and surgical history and physical examination. When the lower extremities are examined, characteristic markers of venous ulceration include ankle flare (distention of small veins on the medial aspect of the foot due to chronic venous hypertension); dermatitis; pigmentation changes on the skin surface, usually appearing as brown discolorations affecting the medial part of the leg; woody induration of the leg; and varicosities. The health care professional should examine the leg for lesions superior to the medial malleolus and should carefully measure the size, shape, and margins of wounds; drainage or exudates; surrounding skin; and pain or tenderness. The patient should be advised to elevate the legs 7 in (18 cm) above the heart for 2 to 4 hr during the day and at night. Compression devices (such as graduated pressure stockings, Unna boot) are used to help reduce edema, improve venous blood flow, and aid healing. Before applying any compression device or wrap, the health care professional should measure the patient’s leg circumference at the wound and the wound size of the ulcer. The wound should be cleansed regularly, and aggressive debridement employed as needed. Wounds with light to moderate drainage benefit from a moisture-retentive dressing (such as hydrocolloid, transparent film, some foams), whereas wounds with moderate to heavy drainage do better with an absorbent dressing (such as foams, alginates, special absorptive dressings). Underlying problems such as obesity, deep venous thrombosis, diabetes, and cardiovascular disease must be assessed and managed as part of the wound care protocol.