EVALUATION OF THE PATIENT

Examining the patient with varicose ulcers one should found out the cause, as this dictates the therapeutic modality.

1. Inspection of the ulcer for the following parametres:

• size;

• shape;

• the wound edges and base: the wound edge can either be even or uneven, undermined, firm or raised; the base can be lined with necrotic masses, fibrin or granulation (fig. 128, colour inset).

Atherosclerotic ulcers are small in size and oval or round in shape and tend to occur in the elderly and be located on the lower third of the leg or on the foot. The granulation is scanty, pale; the wound edges are usually firm, uneven; there are signs of marked chronic arterial insufficiency (see " Arterial occlusions" ).

Varicose ulcers are commonly large and deep, and located over the medial malleolus; surrounding tissues are indurated and blotchy. The ulcers are unlikely to be tender on palpation. It is noteworthy that one of the diagnostic clues is a combination of ulcer and varicosity of the superficial veins.

Post-thrombophlebitic ulcers result from chronic venous insufficiency in lower limb and are generally located around the medial malleoli. The size of an ulcer may range from tiny (a few centimetres in diameter) to gigantic.

Huge ulcers stretch circularly around the whole lower third of the leg (in the form of a cuff). These are often superficial and have flat margins, their surface being covered by nonviable granulation tissues.The skin on the lower limb, particularly that around the ulcer, is oedematous, firm and markedly indurated (indurative cellulitis).

Post-radiation ulcers usually result from ionising radiation (e.g. radiotherapy, accidental exposure). Necrosis is preceded by skin changes such as focal pigmentation, bright red teleangiectasia, alopecia and skin atrophy; necrosis and ulcer follow. Such ulcers tend to be deep, round or oval in shape with sheer edges with occasional protrusion into the muscles and bones. Areas of sclerotic subcutaneous fat and skin atrophy are commonly found around the ulcer.

Ulcerated tumours are characterised by induration, deep extension, immobility and firm adherence to the surrounding tissues and organs, and have an ulcer on their surfaces. The ulcer has thickened firm, nodular and uneven edges; the base is lined with necrotic tissues, areas of growth (vegetation) are commonly identified along the wound edges (progressive tumour growth).

In a persistent ulcer with firm callous edges (so called «callous ulcer») a biopsy of edge and base is mandatory to confirm either its malignant character or its aetiology (tuberculosis, syphilis, leprosy etc.).

The three therapeutic principles are as follows:

1. Pathogenesis-oriented measures aimed to hamper the tissue degeneration:

— restoring circulation [e.g. excision of the varicose veins of the lower limbs; arterioplasty (see " Arterial insufficiency" );

— excising necrotic tissues (see Chapter XIII)].

2. Topical measures (that may either precede or accompany pathogenesis oriented measures) aim at fast cleansing necrotic tissues and eradicating causative microorganisms with enzymatic proteolysis and excision of the ulcer. To enhance tissue regeneration, both physiotherapy and dressing with reparative agents (methyluracyl, pentoxyl) can be applied. Also, skin graft (autodermoplasty)accelerates wound healing (fig 129, 130, see fig. 128, colour inset).

3. Supportive measures:

— adequate vitamin and trace element supplementation;

— healthy diet;

— anabolism promotion.

A fistula is a pathologic narrow canal within tissues with the walls covered by the epithelium or granulations. It connects organs, normal or pathologic cavities with body surfaces or cavities with one another.

The causes of pathologic fistulae are diverse; the pathologic fistulae can be either congenital (due to defective intrauterine development) or acquired (due to inflammation, trauma or tumour). In contrast, artificial (external or internal) fistulae result from surgeries, e.g. gastrostomy, enterostomy, colostomy, epicystostomy.

Depending on the structure, the following types of fistulae are identified:

• epithelised, or tubular (i.e. the walls of the fistula are covered by the epithelium);

• labial, i.e. the mucous epithelium of the hollow organ spreads as far as the skin;

• granulated, the walls are covered by granulations.

The epithelised fistulae, which are (usually congenital, granulated) are pathologic, while the labial ones usually are typically artificial.

Each fistula has the external skin opening, the canal of different size and the internal opening.

The diagnosis of fistula is based on routine examination of the patient:

1. History: the presence of fistula; the character and the volume of effusion; problems associated with feeding, defaecation, urination, etc.; the genesis of the fistula (congenital versus acquired - trauma, operation).

2. Inspection: presence of the fistula, its localization, structure (tubular, labial), the character and the volume of effusion.

3. Laboratory investigation: intubation, X-ray techniques (fistulography, fistuloscopy), endoscopy.

The treatment of external bowel fistula includes the three aspects:

1. Local therapy;

2. Systemic therapy;

3. Surgery.

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