Venous & Arterial Ulcers

Gross(ish) pictures coming up! You’ve been warned…


Venous & Arterial Ulcers

Definition: an ulcer is a an abnormal break in an epithelial surface.

Causes of ulcers: venous, arterial (large vessel, small vessel), neuropathic, diabetic (neuropathic, arterial or both), lymphoedema, vasculitis, malignant, infective (TB, syphilis), traumatic (pressure), pyoderma gangrenosum, drug induced.

-This post focuses on venous and arterial ulcers.

Aetiology/risk factors:

Venous: ulcer of the lower limb caused by venous insufficiency.

-venous hypertension caused by superficial (e.g. varicose veins) or deep venous incompetence (may be 2ry to DVT)  results in increased hydrostatic pressure, tissue oedema, impaired microcirculation and eventually tissue necrosis and ulceration.

Arterial: ulcer caused by ischaemia due to poor blood supply i.e. Peripheral Arterial Disease (PAD)

R/Fs of PAD- smoking, hypertension, diabetes, hypercholesterolemia, FHx

Epidemiology:

-leg ulcers affect ∼2% in developed countries, and venous disease accounts for 70%.

-mixed arterial and venous disease- 15%

-arterial disease alone- 2%

Symptoms:

Venous

Features of chronic venous insufficiency:

-heaviness of legs

-leg aching

-ankle swelling

-skin changes

-itching

-ulceration

     – venous ulcers are typically located in the ‘gaiter’ region, above the medial malleolus

Image result for venous ulcer

Arterial

Image result for arterial ulcerFeatures of peripheral arterial disease:

-history of claudication (cramping pain felt in calf, thigh or buttock after walking for a given distance and relieved by rest)

-history of critical limb ischaemia/ ischaemic rest pain (foot pain at rest; e.g. burning pain at night relieved by hanging legs over side of bed)

-ulceration

   -intensely painful ulcer

-mostly located on the lateral surface of the ankle or the distal digits

Signs:

Venous

Features of chronic venous insufficiency (surrounding the ulcer):

-varicose veins (superficial varicosities)

Related image

-varicose eczema

-lipodermatosclerosis = induration, pigmentation & inflammation of the skin

Image result for lipodermatosclerosis

-pigmentation (hemosiderin deposition)

-atrophie blanche

Image result for atrophie blanche

Ulcer:

-typically located in the ‘gaiter’ region, above the medial malleolus

-often shallow, with sloping edges

Image result for venous ulcer

Arterial

Features of peripheral arterial disease:

-absent femoral, popliteal or foot pulses (PT, DP)

-cold, pale leg(s)

-atrophic skin- shiny, atrophic,  with hair loss or atrophic nails

-postural/ dependent colour change

-Buerger’s sign- pallor when leg is elevated, followed by reactive hyperaemia on lowering

-vascular (Buerger’s) angle < 20º and toe capillary refill time > 15 secs = severe ischaemia

Buerger’s test is used in an assessment of arterial sufficiency. Buerger’s angle, is the angle to which the leg has to be raised before it becomes pale, whilst lying flat. A normal limb will stay pink, even when the limb is raised by 90 degrees. In an ischaemic leg, elevation to 15 degrees or 30 degrees for 30 to 60 seconds may cause pallor.

Ulcer:

-punched out ulcers with raised edge (often painful)- e.g. under toes or classically over lateral malleolus

-cold

-deep wound- may extend to tendon

-has grey or yellow fibrotic base and undermining skin margins

Image result for arterial ulcer

 

Investigations:

Bloods: FBC, glucose, lipids, clotting

Ankle-Brachial Pressure Index- screen for arterial disease

Microbiology swab- if signs of infection: discharge, erythema, cellutis, pyrexia

Skin & ulcer biopsy– may be needed e.g. to assess for vasculitis or malignant change in established ulcer

(Marjolin’s ulcer = squamous cell carcinoma presenting in chronic wound)

-To investigate PAD- Arterial duplex USS, CT or MR angiography, digital subtraction angiography if having intervention

Management:

-treat cause e.g. surgical treatment of varicose veins, stenting in PAD

-control risk factors e.g. smoking

-focus on prevention e.g. compression stockings

-optimise nutrition

-expert nursing care required

-advice on elevation and bedrest

-consider referral to specialist community nurse or leg ulcer/ tissue viability clinic:

  • ‘Charing-Cross’ 4 layer compression bandaging better than standard bandages (= wool, crepe, elastic & cohesive bandages)

Image result for charing cross compression bandaging

  • Negative pressure wound therapy helps heal diabetic ulcers
  • Surgery, larval therapy (maggots), and hydrogels (avoid in diabetic ulcers) are used to debride sloughy necrotic tissue
  • Antibiotics, only if there is infection
  • Skin grafts, rarely

-Once healed, compression stockings prevent recurrence

Complications: chronic wounds, infection, recurrence, development of malignancy in long-standing ulcers (Marjolin’s ulcer)

Prognosis: often a chronic problem, with variable healing rates. After healing, recurrence of venous ulcers is ∼ 25% at one year and 33% at 18 months.

References: Cheese & Onion, Rapid Surgery
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