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7/29/2019 Slides 2 - Wounds,Ulcers
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Dr.Ghazi Qasaimeh
Management
of Wound
Consultant Surgeon
K.A.U.HAssociate professor of surgery
J U S T
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J U S T
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Management of Wounds
Mechanism of injury Traumatic wounds
Sharp, penetrating Blunt
Bullet
Surgical wounds
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Types of wounds
Cut wounds incised
Lacerated wounds
Crushed wounds
Wounds with skin loss
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Examination of Wounds
Associated injuries:
Vessels Abdominal Cavity
Nerves Chest CavityTendons cranial Cavity
Museles
Bones, Joints
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Types of Suturing Primary suturing
Excision and primary suturing
Delayed primary suturing Secondary suturing
Skin grafting
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Elements of Wound Healing
1- Contraction
2- Connective tissue formation (granulationtissue)
3- Epithelization
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Phases of Healing1- Lag phase (preparation phase)
2- Proliferation phase
3- Maturation (differentiation)
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The organ of repairWound strengthWound histology:Neutrophils 1st day
Monocytes after 24 hrsFibroblasts 5-6 days
Capillaries 5-6 days
Collagen after 4th day
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Wound Biochemistrysynthesis
Collagen lyses (collagenase)Factors affecting healing:Age
Nutrition: Protein: Ascorbic acid: ZincVascularity
Sepsis
OxygenWound dressing
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Other measures: Fasciotomy
Types of healing
Healing by first intention
Healing by second intention
Bullet injuries: high velocity missileshock waves
temporary cavitation
Blast injuries: complex blast waves
mass air movement
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Surgical WoundsClean
Clean contaminated
Contaminated
Dirty
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Factors which affect wound healing General: Malnutrition, ureamia, malignancy,
radiothempy, cytotoxic drugs, duabetes, vitcdeficiency.
Local Factors:- Blood supply- Tension in wound
- presence of necrotic tissueand F.B
- presence of haematoma
- excessive cauterization, roughmanipulation
- infection
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Complieations of Wounds:
Wound infection
Wound dehisconce
Hyper trophied scar, keloid
Management of wound infection.
Role of antibiotics.
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Ulcers
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Definition
A Break in the skin continuity extending to all its
layers or break in the mucous membrane lining the
alimentary tract, that fails to heal and is often
accompanied by inflammation Or in other words, it isa macroscopic discontinuity of the normal epithelium
(microscopic discontinuity of epithelium is called
erosion)
http://en.wikipedia.org/wiki/Epitheliumhttp://en.wikipedia.org/w/index.php?title=Erosion_(medicine)&action=edithttp://en.wikipedia.org/w/index.php?title=Erosion_(medicine)&action=edithttp://en.wikipedia.org/wiki/Epithelium7/29/2019 Slides 2 - Wounds,Ulcers
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Cont Ulcers are non-healing wounds that develop on the
skin, mucous membranes or eye. Although theyhave many causes, they are marked by:
1.
Loss of integrity of the area2. Secondary infection of the site by bacteria, fungus
or virus
3. Generalized weakness of the patient
4. Delayed healing
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classification
Merck Manual classification
National Pressure Ulcer Advisory Panel
(NPUAP)
Wagner's classification
http://en.wikipedia.org/wiki/Ulcerhttp://en.wikipedia.org/wiki/Ulcerhttp://en.wikipedia.org/wiki/Ulcerhttp://en.wikipedia.org/wiki/Ulcerhttp://en.wikipedia.org/wiki/Ulcerhttp://en.wikipedia.org/wiki/Ulcerhttp://en.wikipedia.org/wiki/Ulcerhttp://en.wikipedia.org/wiki/Ulcerhttp://en.wikipedia.org/wiki/Ulcerhttp://en.wikipedia.org/wiki/Ulcerhttp://en.wikipedia.org/wiki/Ulcer7/29/2019 Slides 2 - Wounds,Ulcers
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NPUAP
Stage I - There is erythema of intact skinwhich does not blanch with pressure. It may bethe heralding lesion of skin ulceration.
Stage 2 - There is partial skin loss involvingthe epidermis, dermis, or both. The ulcer issuperficial and presents as an abrasion, orwound with a shallow center.
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Cont
Stage 3 - This is an entire thickness skin loss.
It may involve damage to or necrosis of
subcutaneous tissue that may extend down to,
but not through, the underlying fascia. Theulcer presents as a deep crater with or without
undermining of adjacent intact tissues.
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Cont
Stage 4 - Here there is entire thickness skinloss with extensive destruction, tissue necrosis,or damage to muscle, bone, or supporting
structures. tendons, and joints may also beexposed or involved. There may beundermining and/or sinus tracts associatedwith ulcers at this stage.
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Location
1. Lower limbs: most ulcers of the foot and leg
are caused by underlying vascular
insufficiency . The skin breaks down or fails
to heal because of repeated insult or trauma.
2. Sacrum and ischium
3. Mouth ulcer
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Cont
4. Peptic ulcer: This includes ulcers of the esophagus,
stomach, large and small intestine
5. Genitalia: May be penile, vulvar or labial. Most
often are due to sexually-transmitted disease.6. Eyes: corneal ulcers are the most common type.
Conjunctival ulcers also occur.
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causes
Bacterial , viral & fungal infection
Cancer both primary & secondary
Venous stasis Arterial insufficiency
Diabetes
Rheumatoid arthritis Loss of mobility
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Description
Site
Size
Shape
Base
Edge
Tenderness
Discharge
Surrounding tissue & lymphatics
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Types
Peptic ulcer
Mouth ulcer
Pressure ulcer (decubitus) Arterial insufficiency ulcer
Venous insufficiency ulcer
Diabetic foot ulcer
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Cont
Hunners ulcer (of the bladder caused by
Interstitial Cystitis)
Ulcerative colitis (of the colon)
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Ischaemic ulceration
By definition caused by inadequate blood supply large\ small artery obliteration
In elderly , who also have symptoms of coronaryvascular disease.
Men predominate
Risk factor
Very painful, causes rest pain
Do not bleed but discharge thin serous exudateswhich can become purulent
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Cont
May penetrate into joints making movement
painful.
Site,size,shape,tenderness,edge,TM,
depth,base,surrounding tissue
Pulses
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Neuropathic ulceration
Deep penetrating ulcer which occur over pressurepoint, but the surrounding tissue are healthy and havegood circulation.
Diagnostic features:-
1- painless
2- surrounding tissues are unable to appreciate pain
3- surrounding tissues have normal blood supply
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Cont
Causes:-
- peripheral nerve lesions diabetes ,nerve injuries
-
Spinal cord lesionsspina bifida,tabes dorsalis
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Venous ulceration
Follow many year of venous disease.
Women predominant
Risk factor Site, size,shape, tenderness, edge, discharge,
TM, surrounding tissues
pulses
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Fistulas
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definition
Fistulas is an abnormal communication
between tow epithelial or endothelial surfaces
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Types of fistulas Congenital ( e.g. oesophageal atresia with a fistulous
communication with the trachea) Acquired : - external fistulas involve the
skin (e.g. enterocutaneous)
- internal fistulas affect adjacent
organs contiguously or morethrough an intervening
abscess cavity (e.g. entro-
enteric,entrocolic,etc.)
Arteriovenous fistulas are an abnormal communication
between an artery and a vein it could be :- congenital
- acquired :
*trauma
*iatrogenic ( for hemodialyisis )
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Internal abdominal fistulas :Majority result
from an underlying gastro-
intestinal disease ( e.g. colonic diverticular
disease, crohns disease, colonic carcinoma,
radiation enteritis ,intestinal tuberculosis ,
chronic cholecystitis , etc )
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External abdominal fistulas arise as acomplication of surgery or to the trauma to theintra-abdominal organs such as anastomotic
leakage , accidental or unrecognized injuryduring operation
Other external fistulas are due to primaryabscess formation which involve bowel andskin and these are best exemplified by theperianal fistulas
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The effect of internal abdominal fistulas depend on
: - site
- pathology of the condition causing it
E.g. :- malabsorption and steatorrhoea may occurwith entero-enteric and enterocolic fistulas
- cholangitis may follow bilio-enteric fistula
- severe cystitis with pneumaturia may becaused by vesicocolic fistula etc.
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Constitutional effects are minimal with external
colonic fistulas
Malnutrition and fluid and electrolyte depletion
accompany high output bowel fistulas Skin excoriation and digestion of the abdominal wall
is a serious feature of pancreatic , duodenal and high
small bowel fistulas
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Internal abdominal , perianal and anorectal fistulas
seldom if ever close spontaneously
Healing of external abdominal fistulas can be
expected if there is no distal obstruction to theinvolved bowel , the healing depend on :
- adequate drainage of any abscess
- the maintenance of a good nutritional state
Management is complex and requires definition
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Management is complex and requires definitionof the exact underlying pathological anatomy byappropriate contrast radiology with a sinogram
and/or barium enema, barium meal follow-through
Surgical intervention is required for internalfistulas and for external abdominal fistulasassociated with
- distal obstruction or when discontinuity of thebowel
- underlying neoplastic intestinal disease- when conservative medical management with
parenteral nutrition has failed to produce healing
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Mammary duct fistula
Most commonly in patients with mammary
duct ectasia
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Biliary fistulas
External which are secondary to bile duct
trauma or leakage or accessory bile ducts and
gallbladder bed
internal which are classified into three types :
bilio-enteric, broncho-biliary and bilio-pleural,
bilio-biliary
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Pancreatic fistulas
May be internal or external and carry a substantialmorbidity from sepsis, hemorrhage and persistent
pancreatitis
An external fistula may be secondary to a pancreaticabscess complicating acute pancreatitis, but may alsofollow abdominal trauma and operative intervention
An internal pancreatic fistula is almost always due toa pancreatic abscess which complicates acute
pancreatitis in 1-5 % of patients
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Gastrocutaneous fistulas
These are usually iatrogenic following unrecognizedoperative injuries during splenectomy or vagotomy
Partial necrosis of the lesser curve to duodenumanastomosis after a billlroth 1 gastrectomy may also
result in a gastric leak and fistula Some apparently arise as a result of erosion by drains
A small percentage are caused by benign gastriculcer, pancreatic abscess and pancreatic carcinoma
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Gastrojejunocolic fistula
Severe complication is usually found in
association with inoperable carcinoma of the
stomach or transverse colon
Less frequently encountered as a result of
recurrent ulcer at gastrojejunal anastomosis
largely due to overall improvement in the
results of ulcer management and surgicaltreatment
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Small-bowel fistulas
The majority (80-90 %) of small bowel fistulas
follow operations on the intestinal tract either from
anastomotic leakage or iatrogenic injury
Often the anastomotic dehiscence is attributed to thepresence of underlying small bowel disorder, crohns
disease being the most common, but radiation
enteritis and intestinal tuberculosis featuring often in
several published series
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External colonic fistula
These most commonly follow colonic surgery,
including colostomy closure
Trauma accounts for some cases as does
perforated colonic diverticular disease and
cancer
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Colovesical and colovaginal fistulas The former is one of the commonest forms of internal
abdominal fistulas Both are usually encountered in association with
diverticular disease and a pericolic abscess whichperforates into the bladder or vagina, especially in
females after hysterectomy as this allows the diseasedbowel to lie directly onto the bladder or vaginal vault
Less commonly these fistulas may be due to cervicalor rectal carcinoma
Crohns disease of the large and small bowel may becomplicated by the development of entero/colovesicalfistula
Radiotherapy for malignant disease of the pelvisaccounts for the majority of rectovaginal/vesical
fistulas
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Treatment
Conservative :
* the mainstays of medical management are:
- nutritional support
- meticulous collection of fistulous discharge
- skin-stoma care
- control of sepsis
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Surgical :
* the absolute indications for operative intervention are:
- intestinal distal obstruction- peritonitis
- abscess formation
- bowel discontinuity
- presence of malignant disease
- persistent inflammatory bowel disease
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Cysts
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What is a cyst?
a cyst is : any closed epithelium-lined cavity or
sac, normal or abnormal, usually containing
liquid or semisolid material" (Dorland's, 1995,
pp.209).
It is common can occur anywhere any age.
Cysts vary in size
Its wall called the cyst capsule
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What are the causes of a cyst?
Cysts are usually formed through one of these
mechanisms:
1. 1"Wear and tear" or simple obstructions to the flow
of fluid .
2. Infections and chronic inflammations
3. Tumors
4. Genetic (inherited) conditions5. Defects in developing organs in the embryo
http://www.medicinenet.com/script/main/art.asp?articlekey=3573http://www.medicinenet.com/script/main/art.asp?articlekey=3225http://www.medicinenet.com/script/main/art.asp?articlekey=3225http://www.medicinenet.com/script/main/art.asp?articlekey=35737/29/2019 Slides 2 - Wounds,Ulcers
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Types of cysts
cysts in the neck :
1. Branchial cleft cysts.
2. Thyroglossal duct cysts.
3. Dermoid cysts.
4. Sebaceous cysts
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Branchial cyst
Embryology :
congenital abnormality that is presented in adult
life .
-incomplete involution of the branchial clefts
-lined with epithelium derived from the branchial
ectoderm.
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Branchial cyst continued
Clinical feature:
presenting complaint.
Age
Location
complication
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Branchial cyst continued
Diagnosis
By location C.T. scan ultrasound can help.
Treatment:
A small incision is made in the neck and the cystis removed. Sinuses may occasionally needtwo incisions for complete repair. Cysts are
removed to prevent infection.This is a daysurgery operation
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Thyroglossal cyst
Embryology and pathogenesis:
The thyroglossal tract arises form foramen caecum
Arises at junction of anterior 2/3 and posterior 1/3 of
the tongue Any part of the tract can persist causing a sinus,
fistulae or cyst
Most fistulae are acquired following rupture orincision of infected thyroglossal cyst
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Thyroglossal cyst cont..
Clinical features:
-Usual location midline
-Painless surrounded by lymphoid tissue
-age 40% present < 10 years of age
65% present < 35 years of age
Protrude the tongue in its examination
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Thyroglossal cyst cont..
Treatment
-The treatment is by surgical excision .the cyst
along with the centre of the hyoid bone along
with the thyroglossal duct up to the base of thetongue should be excised to ensure complete
removal.
It must be differentiated from the lymphoidtissue through us before incision .
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dermoid cysts
it occurs when skin and skin structures become
trapped during fetal development. Along the
line of embryonic closure.the mid line . It
can be a true hamartoma. Two types intra and extra abdominal
Dermis like capsule with all skin layer
Surgically remove dermoid cysts. The spread of thesecontents can cause foreign body reactions and severe complications
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-A mid line structure
-A symptomatic
-Soft on palpation
-Good prognosis
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sebaceous cysts
it is caused by obstruction of the sebaceous glandduct leads to accumulation of secretions which mayget infected specially by staph. Bacteria withsecondary enlargement .they are common in thehead and neck skin it is presence may point to DMand should not be confused with Kaposi sarcoma inaids patients.
a drainage sinus may form and may be multible
treatment :
wide surgical excision may be needed withoutopening them to prevent complication
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