Ulcer

Endoscopic images of a duodenal ulcer.

An ulcer (from Latin ulcus) is a lesion or eroded area on the surface of the skin or mucous membranes characterized by tissue disintigration and formation of pus. Essentially, it impacts the epithelium—the tissue that covers organs and surfaces of the bodies of animals, including both outside surfaces (the skin) and inside cavities. As such, an ulcer can impact such areas as the gastrointestinal tract, the oral cavity, the lower extremities, feet, the eyes (most often the cornea), and so forth. However, in common usage, ulcer often is used to refer to peptic ulcers, which are disorders in the upper digestive tract (stomach, proximal duodenum and jejunum in the small intestine, lower part of esophagus).

Causes of ulcers are varied and include injury, circulatory problems (failure of blood supply), infectious agents (bacteria, virus), diseases (typhoid, tuberculosis, baccillary dysentery, syphilis, leprosy, cancer), nutritional deficiencies, burns or other trauma, and so forth. Peptic ulcers, once attributed to stress are now commonly linked to infection by the bacterium Helicobacter pylori, as well as use to use of nonsteroidal anti-inflammatory drugs (NSAIDS, such as aspirin, ibuprofen, etc.), overproduction of digestive juices (Zollinger-Ellison syndrome), among others. Ulcers of genetalia are most often due to sexually transmitted diseases. Mouth ulcers are often tied to bacterial or viral infections.

Description

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

Loss of integrity of the area
Secondary infection of the site by bacteria, fungus, or virus
Generalized weakness of the patient
Delayed healing

Essentially, there is disintegration of the tissue (death of cells and tissue), which opens up to the tissue below. The surrounding tissue becomes inflamed.

Ulcer classification schemes

Classification systems are used to communicate the severity and depth of an ulcer. It is an easy way to communicate changes for the better, or worse.

Merck Manual classification

Stage 1: *The skin is red. The underlying tissue is soft. The redness disappears with minor pressure.
Stage 2: There is redness, swelling, and hardening of the skin around the area. Sometimes there is blistering. Sometimes there is loss of the superficial skin.
Stage 3: The skin becomes necrotic (death of cells and living tissues). There may be exposure of the fat beneath the skin. The skin may be lost through all its layers.
Stage 4: There is more loss of fat and more necrosis of the skin through to the muscle beneath.
Stage 5: Continuing loss of fat and necrosis of muscle below.
Stage 6: Bone destruction begins with irritation of the bone, erosion of the bone cortex progressing to osteomyelitis. There may be sepsis of a joint, pathologic fracture or generalized body infection, septicemia.

National Pressure Ulcer Advisory Panel (NPUAP)

This staging system for rating ulcers is designed to rate the severity of pressure ulcers.

Stage 1 - There is erythema of intact skin, which does not blanch with pressure. It may be the heralding lesion of skin ulceration.
Stage 2 - There is partial skin loss involving the epidermis, dermis, or both. The ulcer is superficial and presents as an abrasion, blister, or wound with a shallow center.
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. The ulcer presents as a deep crater with or without undermining of adjacent intact tissues.
Stage 4 - Here there is entire thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Tendons, and joints may also be exposed or involved. There may be undermining and/or sinus tracts associated with ulcers at this stage.

Wagner's classification

This classification system is intended to rate the severity of diabetic foot ulcerations.

Grade 0 - Skin with prior healed ulcer scars, areas of pressure that are sometimes called pre-ulcerative lesion, or the presence of bony deformity ,which puts pressure on an unguarded point.
Grade 1-A - The wound is superficial in nature, with partial or full-thickness skin involvement but does not include tendon, capsule or bone.
Grade 1-B - As above, the wound is superficial in nature, with partial or full thickness skin involvement but not including tendon, capsule nor bone; however the wound is infected. The definition of this wound implies superficial infection without involvement of underlying structures. If the wound shows signs of significant purulence or fluctuance, further exploration to expose a higher grade classification of infection is in order.
Grade 1-C - As above but with vascular compromise.
Grade 1-D - As above but with ischemia. Because ischemia is a type of vascular compromise, the distinction between these two grades is often difficult to make.
Grade 2-A - Penetration through the subcutaneous tissue exposing tendon or ligament, but not bone.
Grade 2-B - Penetration through the deep tissues including tendon or ligament and even joint capsule but not bone.
Grade 2-C - As above 2B, but including ischemia
Grade 2-D - As above 2C, but including infection
Grade 3-A - A wound which probes to bone but shows no signs of local infection nor systemic infection.
Grade 3-B - A wound which probes to bone and is infected.
Grade 3-C - A wound which probes to bone is infected and is ischemic.
Grade 3-D - A wound which probes to bone characterized by active infection, ischemic tissues and exposed bone.
Grade 4 - Gangrene of the forefoot
Grade 5 - Gangrene of the entire foot

Pathology of ulceration

Causes

The most common causes (not in order) are:

Bacterial infection
Viral infection
Fungal infection
Cancer - both 'primary' and 'secondary'
Venous stasis
Arterial Insufficiency
Diabetes
Rheumatoid Arthritis
Amyloidosis
Loss of mobility
Hypertension
GERD

Types

Some specific types of ulcers are:

Peptic ulcer (of the stomach, esophageal cardium or duodenum)
Mouth ulcer
Pressure ulcer (decubitus, such as bedsore or pressure sore)
Crural ulcer (due to venous insufficiency or other causes)
Hunner's ulcer (of the bladder caused by Interstitial Cystitis)
Ulcerative colitis (of the colon)
Curling's ulcer
Cushing ulcer
Arterial insufficiency ulcer
Venous insufficiency ulcer
Diabetic foot ulcer
Corneal ulcer

References
ISBN links support NWE through referral fees

Blakemore, C., and S. Jennett. 2001. The Oxford Companion to the Body. New York: Oxford University Press. ISBN 019852403X.
Longe, J. L. 2006. The Gale Encyclopedia of Medicine. Detroit: Thomson Gale. ISBN 1414403682.

Credits

New World Encyclopedia writers and editors rewrote and completed the Wikipedia article in accordance with New World Encyclopedia standards. This article abides by terms of the Creative Commons CC-by-sa 3.0 License (CC-by-sa), which may be used and disseminated with proper attribution. Credit is due under the terms of this license that can reference both the New World Encyclopedia contributors and the selfless volunteer contributors of the Wikimedia Foundation. To cite this article click here for a list of acceptable citing formats.The history of earlier contributions by wikipedians is accessible to researchers here:

Ulcer ^history

The history of this article since it was imported to New World Encyclopedia:

History of "Ulcer"

Note: Some restrictions may apply to use of individual images which are separately licensed.