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Wounds, ulcers, fistulae & cysts

woundswounds

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Mechanism of injuryMechanism of injury Traumatic woundsTraumatic wounds Sharp, penetrating Sharp, penetrating Blunt Blunt BulletBullet Surgical woundsSurgical wounds

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Types of woundsTypes of wounds Cut wounds Cut wounds incised incised

Lacerated woundsLacerated wounds

Crushed wounds Crushed wounds

Wounds with skin loss Wounds with skin loss

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Types of SuturingTypes of Suturing Primary suturingPrimary suturing Excision and primary suturingExcision and primary suturing Delayed primary suturing Delayed primary suturing Secondary suturingSecondary suturing Skin grafting Skin grafting

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Elements of Wound Elements of Wound HealingHealing

1- Contraction

2- Connective tissue formation (granulation tissue)

3- Epithelization

Surgical WoundsSurgical Wounds

Clean Clean

Clean contaminated Clean contaminated

Contaminated Contaminated

DirtyDirty

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Factors which affect wound Factors which affect wound healinghealing

General:General: Malnutrition, ureamia, Malnutrition, ureamia, malignancy, radiothempy, cytotoxic drugs, malignancy, radiothempy, cytotoxic drugs, duabetes, vitc deficiency. duabetes, vitc deficiency.

Local Factors:Local Factors: -- Blood supply Blood supply-- Tension in wound Tension in wound -- presence of necrotic tissue and F.B presence of necrotic tissue and F.B-- presence of haematoma presence of haematoma-- excessive cauterization, rough excessive cauterization, rough manipulationmanipulation

-- infection infection88

Complications of Wounds:Complications of Wounds:Wound infection Wound infection Wound dehiscenceWound dehiscence Hyper trophied scar, keloidHyper trophied scar, keloid

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Principles of wound Principles of wound managementmanagement

Correct all local and systemic factors Correct all local and systemic factors that might impair wound healingthat might impair wound healing

Wound toiletWound toilet

Wound dressingWound dressing

Antibiotics if infectedAntibiotics if infected1010

UlcersUlcers

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Ulcers are non-healing wounds that Ulcers are non-healing wounds that develop on the skin, mucous membranes develop on the skin, mucous membranes or eye. Although they have many causes, or eye. Although they have many causes, they are marked by:they are marked by:

1.1. Loss of integrity of the area Loss of integrity of the area 2.2. Secondary infection of the site by Secondary infection of the site by

bacteria, fungus or virusbacteria, fungus or virus3.3. Generalized weakness of the patient Generalized weakness of the patient 4.4. Delayed healing Delayed healing

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LocationLocation1.1. Lower limbsLower limbs: most ulcers of the : most ulcers of the

foot and leg are caused by foot and leg are caused by underlying vascular insufficiency . underlying vascular insufficiency . The skin breaks down or fails to The skin breaks down or fails to heal because of repeated insult or heal because of repeated insult or trauma. trauma.

2.2. Sacrum and ischiumSacrum and ischium

3.3. Mouth ulcerMouth ulcer

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ContCont……4. Peptic ulcer:4. Peptic ulcer: This includes ulcers of This includes ulcers of

the esophagus, stomach, large and small the esophagus, stomach, large and small intestine intestine

5.5. Genitalia:Genitalia: May be penile, vulvar or May be penile, vulvar or labial. Most often are due to sexually-labial. Most often are due to sexually-transmitted disease. transmitted disease.

6.6. Eyes:Eyes: corneal ulcers are the most corneal ulcers are the most common type. Conjunctival ulcers also common type. Conjunctival ulcers also occur. occur.

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causescauses Bacterial , viral & fungal infectionBacterial , viral & fungal infection Cancer both primary & secondary Cancer both primary & secondary Venous stasis Venous stasis Arterial insufficiency Arterial insufficiency Diabetes Diabetes Rheumatoid arthritis Rheumatoid arthritis Loss of mobility Loss of mobility

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DescriptionDescription SiteSite SizeSize ShapeShape BaseBase EdgeEdge TendernessTenderness DischargeDischarge Surrounding tissue & lymphaticsSurrounding tissue & lymphatics

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TypesTypes Peptic ulcer Peptic ulcer Mouth ulcerMouth ulcer Pressure ulcer (decubitus) Pressure ulcer (decubitus) Arterial insufficiency ulcer Arterial insufficiency ulcer Venous insufficiency ulcer Venous insufficiency ulcer Diabetic foot ulcer Diabetic foot ulcer

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Ischaemic ulcerationIschaemic ulceration By definition caused by inadequate blood By definition caused by inadequate blood

supply supply ““large \ small artery obliterationlarge \ small artery obliteration”” In elderly , who also have symptoms of In elderly , who also have symptoms of

coronary vascular disease.coronary vascular disease. Men predominate Men predominate Risk factor – Smoking, atherosclerosisRisk factor – Smoking, atherosclerosis Very painful, causes rest pain Very painful, causes rest pain Do not bleed but discharge thin serous Do not bleed but discharge thin serous

exudates which can become purulent exudates which can become purulent Distal pulses are impalpable Distal pulses are impalpable

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Neuropathic ulcerationNeuropathic ulceration Deep penetrating ulcer which occur over Deep penetrating ulcer which occur over

pressure point, but the surrounding tissue pressure point, but the surrounding tissue are healthy and have good circulation.are healthy and have good circulation.

Diagnostic features:-Diagnostic features:-1- painless1- painless2- surrounding tissues are unable to 2- surrounding tissues are unable to

appreciate pain appreciate pain 3- surrounding tissues have normal blood 3- surrounding tissues have normal blood

supply supply

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ContCont… … Causes:-Causes:-- peripheral nerve lesions peripheral nerve lesions ““diabetes ,nerve diabetes ,nerve

injuriesinjuries””- Spinal cord lesions Spinal cord lesions ““spina bifida,tabes spina bifida,tabes

dorsalisdorsalis””

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Venous ulcerationVenous ulceration Follow many year of venous disease.Follow many year of venous disease. Commonly occur on the medial side Commonly occur on the medial side

of the leg above the ankleof the leg above the ankle Predominantly in womenPredominantly in women Risk factor – Varicose veinsRisk factor – Varicose veins Pulses are normalPulses are normal

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FistulasFistulas

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DefinitionDefinition

Fistulas is an abnormal Fistulas is an abnormal communication between two communication between two epithelial or endothelial surfacesepithelial or endothelial surfaces

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Types of fistulaTypes of fistula

NameConnection

Tracheo-oesophageal fistulaTrachea - oeasophagus

EnterocutaneousColon - Skin

Rectovaginal fistulaRectum - Vagina

Arterivenous fistulaArtery - Vein

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Why do they occurWhy do they occur??

Some are congenital e.g. Some are congenital e.g. Tracheooesophageal fistulaTracheooesophageal fistula

Internal abdominal fistulas :Majority result Internal abdominal fistulas :Majority result from an underlying gastro-from an underlying gastro-

intestinal disease ( e.g. colonic diverticular intestinal disease ( e.g. colonic diverticular disease, crohndisease, crohn’’s disease, colonic s disease, colonic carcinoma, etc )carcinoma, etc )

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External abdominal fistulas arise as a External abdominal fistulas arise as a complication of surgery or to the complication of surgery or to the trauma. trauma.

Other external fistulas are due to Other external fistulas are due to primary abscess formation and primary abscess formation and rupture on to skin. E.g. perianal rupture on to skin. E.g. perianal fistulafistula

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ManagementManagement

Difficult to treat

Is complex and usually surgical

Depend on the site of the fistula

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TreatmentTreatment

Conservative :Conservative :

The mainstays of medical management The mainstays of medical management are:are:

- nutritional support - nutritional support

- meticulous collection of fistulous - meticulous collection of fistulous dischargedischarge

- skin-stoma care - skin-stoma care

- control of sepsis- control of sepsis3535

Surgical :Surgical : The absolute indications for operative The absolute indications for operative

intervention are :intervention are : - intestinal distal obstruction - intestinal distal obstruction - peritonitis - peritonitis - abscess formation- abscess formation - bowel discontinuity- bowel discontinuity - presence of malignant disease - presence of malignant disease - persistent inflammatory bowel disease - persistent inflammatory bowel disease

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CystsCysts

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What is a cystWhat is a cyst??

a cyst is : any a cyst is : any closed epithelium-lined closed epithelium-lined cavity or saccavity or sac, normal or abnormal, , normal or abnormal, usually containing liquid or semisolid usually containing liquid or semisolid material" (Dorland's, 1995, pp.209).material" (Dorland's, 1995, pp.209).

It is common can occur anywhere It is common can occur anywhere any age.any age.

Cysts vary in size Cysts vary in size Its wall called the cyst capsuleIts wall called the cyst capsule

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What are the causes of a cystWhat are the causes of a cyst??

Cysts are usually formed through Cysts are usually formed through one of these mechanisms:one of these mechanisms:

1.1. ObstructionsObstructions to the flow of fluid to the flow of fluid

2.2. Infections and chronic inflammationsInfections and chronic inflammations

3.3. Tumors Tumors

4. Genetic (inherited) conditions (inherited) conditions 5.5. Defects in developing organs in the Defects in developing organs in the

embryo

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Examples of cystsExamples of cysts

Thyroglossal cystThyroglossal cyst Ovarian cystOvarian cyst Sebaceous cystSebaceous cyst

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TreatmentTreatment

Usually surgical - CystectomyUsually surgical - Cystectomy

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