Venous ulcer

The term leg ulcer (Latin ulcus " ulcer " and crus " leg, lower leg ' ) referred to in medicine a substance defect in the tissue of the distal lower leg area, which is an open, mostly exuding wound that does not heal typically over a long time, impressed. This disorder has been described very early. Colloquially, the ulcer cruris is also referred to as an "open leg". It affects mostly older, affected by several underlying diseases ( multimorbid ) people.

Often, a duodenal ulcer occurs as a severe form of chronic venous insufficiency ( venous ulcers ). Shows it at that, despite optimal therapy within three months no healing tendency and does not heal from within twelve months, it is considered resistant to therapy.

• 6.1 Operational Procedure 6.1.1 Venous Leg Ulcers
• 6.1.2 Arterial leg ulcers

Definition

Under a leg ulcer is defined as a non-traumatic loss of tissue substance ( at least until reaching into the dermis ), which typically associated with signs of inflammation. Most commonly it is found in the region of the distal lower leg near the ankle ( leg ulcers ). This intrinsic defect presents clinically as an infected, often painful wound with the characteristic, very low tendency to heal.

Dissemination

From a leg ulcer affects more women than men. Before the age of 40, the ulcer cruris comes before barely. From the age of 80 the incidence increases according to different studies on about one to about three percent. In Germany suffer about 80,000 people at a venous leg ulcer. Approximately 80 % to 90 % of all ulcers are considered to be conditionally venous and about 10% are due to arterial circulatory disorders.

Causes and development

Basic cause of ulcers in all forms of the ulcer is healing reduction trend in lack of blood flow to the affected tissue (macro - and microcirculation ). Trigger is often a minor trauma ( micro- injury). An open ulcer is colonized by bacteria and usually shows as well as in the area of inflammation.

( Non-inflammatory ) Vascular (peripheral arterial disease, venous insufficiency, angiodysplasia and lymph drainage ) of inflammatory -like running ( Begleitvaskulitis in collagen or the like, Livedoid, periarteritis nodosa, pyoderma gangrenosum and cutaneous leukocytoclastic vasculitis) will cause Referred distinguished. Next, a distinction is microcirculatory disturbances (diabetic microangiopathy, cryoglobulinemia, necrobiosis lipoidica, ulcer hypertensive Martorell, cholesterol embolism, and calciphylaxis ) of hematologic ( spherocytosis, thalassemia, sickle cell and sideroblastic anemia), myeloproliferative ( polycythemia vera, thrombocythemia and Werlhof's disease ) as well as neuropathic causes. Also infections (mycoses, bacteria, protozoa, and viruses), metabolic disorders ( amyloidosis, gout and diabetes mellitus ), skin tumors and injuries can lead to leg ulcers.

In common causes these can also be found in the specific clinical description of a leg ulcer again. Leg ulcers (commonly occurring in the context of venous disease ) ulcers with its sub-forms, the leg ulcers, varicose ( as part of a Varicosis ) and the leg ulcer postthromboticum ( as a symptom of post-thrombotic syndrome ) of leg ulcers Arterial ( in the PAD), leg ulcers traumaticum ( accidental ), leg ulcers neoplasticum ( carcinombedingt ), leg ulcers infectiosum (infection as the main cause). As a leg ulcer mixtum is a form of leg ulcers referred to in the PAD and CVI seem equally relevant.

In addition to factors such as allergies to ointments or decreased blood levels of albumin, iron, folic acid, selenium, vitamin C and zinc are indeed in most cases not the cause, but can delay the progression of the healing unfavorable.

Venous leg ulcers

The venous leg ulcer as a severe form of chronic venous insufficiency ( CVI - Stage III ° Widmer ) is, according to the study, with 57 to 80 % of all chronic ulcers, the most common cause of not spontaneously abheilender wounds dar.

(→ Main article venous leg ulcers )

(→ to causes and consequences of CVI in general, see the main article)

Arterial leg ulcers

Arterial ulcers are caused, mixed in 4-30 % found arterio-venous ulceration in about 10-15% and all other forms in about 6 to 10%. Common contributory cause is also a venous congestion in the tissues, the arterial blood flow additionally limits (congestion in the capillaries so ). Often there are minor injuries that do not heal due to the insufficient supply of arterial tissue, get infected and lead to ulcers.

Among the other forms of circulatory disorder, a chronic compartment syndrome may be hidden as a cause of circulatory disturbance, which must be detected as quickly as possible to prevent further tissue destruction.

Leg ulcer mixtum

As a leg ulcer mixtum refers to a ulcer, for which the causes of venous and arterial leg ulcers are equally responsible. In the patients so there is a PAD along with a CVI

Leg ulcer neoplasticum

From a leg ulcer neoplasticum is when the "open legs " caused by malignant growths. This additional distinction, for example, when basal cell carcinoma according to the depth extent of the leg ulcer ulcerating ( superficial ) and the leg ulcer Terebrans ( deep).

Clinical manifestations

A leg ulcer impressed principle as substance defect of skin and underlying tissues that is infected.

The venous leg ulcer is particularly common in the distal lower leg. It may include the lower leg also circular.

A leg ulcer arteriosum is more common on the toes, but also on the soles of the level of the heads of the metatarsal bones.

Methods of investigation

Inspection and measurement of the ulcer, if possible, a photographic documentation, facilitate the subsequent assessment of therapeutic measures as well as the cooperation of the patient and there are instances of forensic importance. However, not a lower leg alone, but the whole body is examined, as a result of most existing multiple diseases of old people determine the chronicity of the action may be several factors.

The aim of the clinical investigation beyond measures is to differentiate as safe as possible the relevant underlying diseases. As diagnostic procedures for this purpose, among others, Doppler sonography of the veins and arteries, as well as in peripheral arterial occlusive disease angiography in use.

Related, it may also be necessary, neuropathic ulcers (Mal perforans ), such as diabetes mellitus, infectious ulcers ( eg Leishmaniosis cutis, tropicum ulcer, ulcerative syphilis), ulcerating malignant tumors (eg, squamous cell carcinoma | also to differentiate basal cell carcinoma, sarcoma, malignant lymphoma) and more rarely, ulcers in hematologic disease ( eg, sickle cell anemia) | on the bottom of a leg ulcer.

Treatment

The treatment is based on the causes. This is often difficult to eliminate. Primarily, therefore, in principle general measures, particularly for the reduction of risk factors such as reducing obesity, optimum setting of a possibly existing diabetes mellitus or increased blood pressure helpful.

Operative Procedure

Venous leg ulcers

In chronic compartment syndrome, a fascial surgery ( fasciotomy and fasciectomy ) is performed with subsequent skin graft to prevent the ongoing and progressive tissue damage due to the tight fascial sheath.

In venous insufficiency of the superficial veins ( varicose veins ) can be achieved surgically, a pressure relief in the venous system ( for example, by vein stripping ). This is usually only one of several necessary measures to address the ongoing and progressive damage are important for the microcirculation smallest blood vessels.

(→ Main article varicose veins )

Arterial leg ulcers

Goal here is to promote blood circulation, compression therapy is contraindicated. In some cases, surgical procedures can achieve an improvement of the arterial blood flow. Suitable measures in this regard may be specific indications balloon dilatation or a supply by vascular prosthesis.

(→ Main article PAD)

Conservative treatment

The local treatment of a leg ulcer takes place according to the principle that the ulcer is to clean first, then the formation of granulation tissue and then leading to healing epithelialization be encouraged. Meanwhile, the edema should be minimized particularly in the area of the wound bed, as it will decrease the time required to cure microcirculation sensitive.

When venous ulcer therapy also aims primarily at improving the venous return. Of particular importance is the compression therapy here. To improve venous function, a sclerotherapy is used. In associations is to ensure that the so-called " resting pressure " is low, but the swelling is still significantly reduced ( working pressure). In wound by hand associations therefore short-stretch compression bandages long-stretch compression bandages are preferable.

When Arterial leg ulcers of treatment focuses on improving arterial blood flow. Compression therapy is to be regarded as basically contraindicated if the peripheral arterial pressure below 80 mmHg. But even with better pressure values, the compression therapy in PAD belongs in the hands of the experienced. It is particularly difficult to assess at the same time mediasclerosis as it is practical to meet regularly in diabetes mellitus.

Frequently, treatment trials with animal fat preparations, bath additives, enzymes, fly maggots, leeches, temporary use of hydrocolloid skin substitutes, and made ​​ointments and powders (the latter partly antibiotikahaltig ). This is a high risk of sensitization

Treatment and prevention

A compression therapy with compression stockings and compression bandages to support the muscle -joint pump is used in order to ensure a high working pressure and a low static pressure, wherein the effectiveness of the compression effect can be increased by the use of pressure pads. However, may be affected by this therapy also the microcirculation. This must be advised to use adequate exercise at the same time, if a compartment syndrome is eliminated or excluded, since any strain on your legs when walking would also heilungsverzögernd otherwise. There are also special compression stockings that are suitable with 20mmHg pressure at the ankle to the duration of compression. They are made ​​of a silver-coated suture material that prevents bacterial colonization and odors. By an inspection hole below the ball of the foot blood circulation can be well controlled. An alternative preventive measure is the intermittent vacuum therapy, short IVT. This will allow the use of pressure and vacuum to control the venous return, stimulate the lymph flow and improve blood circulation in the periphery and muscles.

Economic Aspects

Since this disease a high level of suffering and - to judge causes high costs and over the next 40 years, the share of population will increase massively over-80s, is a special emphasis on the prevention of cervical cancer at an early age - alone, as far as the treatment material.