But like thousands of years ago (this form of pathology noted back in
Ancient Egypt, among the dynasties of the Pharaohs), it exists today.
Trophic ulcers of the lower extremities are a consequence of various diseases
violating the local hemodynamics of arterial, venous,
lymphatic systems, including the microcirculatory level of destasction. In addition to these
factors, cause of venous ulcers may have different skin injury,
soft tissue and peripheral nerves.
There are many forms of skin diseases, which for many years
long course can also lead to the appearance of gross
trophic disorders in the extremities.
to determine (choose) the best option of treatment of patients with trophic ulcers
the lower limb clinician should first pay attention to the main
medical history, ie focus on all the most commonly occurring variants
pathology, as well as recall andmorerare, sometimes even
exclusive forms of complications known diseases.
is no doubt that gross trophic disorders of the lower extremities
occur mostly among patients with chronic venous
insufficiency (CVI). It should be emphasized that among patients with primary varicose veins
these trophic ulcers are relatively rare,
about 3% of cases. But among patients who had a history of single or repeated
deep vein thrombosis at various levels of limb, including pelvic
segment, trophic ulcers are found in 14-30% of cases, and with
growth period of the disease increases the risk of developing ulcers .
The guide (Phlebology, 2001), edited by Academician VS Saveliev
contains the following approximate frequency of the etiologic venous ulcers:
At the same time, many authors in the Proceedings of the International Conference of Russian
Angiology and Vascular Surgery (Yaroslavl 2002) noted that the main cause of ulcers
is previously migrated deep venous thrombosis
system (58,7-68,0%) [Babadjanov VR, Vasyutkov VY].
important point determines treatment of trophic ulcers of CVI is
mix it with chronic arterial insufficiency, which occurs
approximately 10-20% of patients.
With this combination is not recommended compression therapy (elastic bandaging
, golf, etc.), and the operation, especially in the tibia, may
complicated by poor wound healing, suppuration that attributed to a lack
arterial blood supply. Therefore, the first stage it is desirable to perform
arterial reconstasction (various profundoplastiki or
bedrennopodkolennuyu reconstasction method enarterektomii or bypass surgery).
improve cutaneous blood flow to the tibia may also lumbar sympathectomy, which
performed endoscopic method.
main cause of venous ulcers is the formation of stable
pathological "vertical" reflux in the deep and superficial venous
system, as well as the existence of "horizontal" reflux at the level of venous communicants
and perforators, located on the lower leg, especially on its inner surface in
lower thirds.
orthostatic phlebostasia triggers the progression of venous hemodynamics and
trophic tissue.
Based on these provisions and the basic principles of pathogenesis
due to the treatment of patients. The most important ones are:
1. Adherence of work and rest with the restriction of stay in an upright position
.
2. Compression therapy to 30-40 mmHg
3. Medication: flebotoniki patients without marked trophic
disorders may use venoastona, troxeastin and others, but if
venous ulcers is desirable to use micronized forms of diosmin
to 2 tablets daily for 1-2 months. The big advantage of this dasg
is its rapid absorption and accumulation within 4-6 hours and accumulation in the area
trophic ulcers.
4. The use of antiplatelet (low-dose acetylsalicylic acid 0,1 g.
day, pentoxifylline, preparations of nicotinic acid).
5. Local therapy of ulcers (Gepatrombin).
6. Operative treatment. His goal the elimination of the "vertical" and "horizontal"
blood reflux. Most surgeons currently prefer to perform these operations
in 2 stages. We first removed the tasnk of the great saphenous vein to
upper third of the leg, the second step is performed after complete healing of sores or
reduce its size and the elimination of perifocal inflammation. Optimal for the patient
option is subfascial ligation of the veins of a group of Cockett
with the help of endoscopic technology, which allows the lowest traumatization for
tissues to carry out correction of venous hemodynamics.
Arterial ulcers of limbs
Their formation occurs as a result develop severe ischemic tissue
limb especially in the distal parts of it on foot, and much less on
tibia. The main reason for the defeat of the great arteries is currently
is atherosclerosis, which are diagnosed not only
very elderly, but also among middle-aged persons. So, (according to Haemovici H,
1987) surveyed a thousand arterial disease of lower extremities (in%) was found
:
husband. Female. Age
1,8 0,6 4554
5,1 1,9 5565
6,3 3 August 6574
Unfortunately, over the years, the number of these patients is not reduced, and
the contrary, continues to grow.
At the same time, we should emphasize the important fact that in the last 10-15 years
patients with thromboangiitis obliterans comprise only 1,5-2% of all patients with obliterating diseases
extremities.
The cause of venous ulcers in this pathology is the sharp decline
perfusion pressure in the arterial line (up to 40-30 mm Hg), it
pressure is regarded as critical, as it does not exceed the pressure at the arteriolar level
develops stasis of blood and severe tissue hypoxia. Study
level of performance of transcutaneous oxygen tension (pO 2 ) in patients with
yazvennonekroticheskimi changes in the foot and lower leg showed that
level of 20-30 mm Hg is critical if there is no increase in its
lowering limbs down. There is also no clinical signs of improvement in
the treatment is a testament to the real threat of amputation.
Another possible reason for the appearance of pockets of severe local ischemia may be
micro and makroembolii from the upper parts of the arterial system with sites
ateromatoznoizmenennoy walls with intimal or calcified plaques. Clinic
obliterating diseases of lower limb arteries is quite informative.
Start characterized by a sense of chilliness, cold extremities, fatigue
when walking, especially when climbing stairs. Then there is a constant symptom
"intermittent claudication", whose degree is progressively rises and reaches
150-50 meters, which causes the patient to apply to vrachuhiasrgu.
next phase of the disease if treatment is not adequately shown
first night and then the constant pain in the legs, the appearance of yazvennonekroticheskih
changes on the fingers or the interdigital space at the rear of the foot, heel,
tibia . An important feature of the development of these ulcers is a "traumatic" factor.
minor injuries to the skin, soft tissues of extremities in the form of a contusion, a small
cut, damaged skin while wearing shoes with improperly selected coarse
internal suture in a decrease in blood flow may provoke
ulcer, a rapidly progressing in size and
causing severe pain that requires the use of dasgs.
particularly important point in assessing the clinical condition of the patient
a mandatory blood and urine for glucose.
Type 2 diabetes is very often (10-15%) occurs in patients with chronic lower limb ischemia
.
at outpatient level, each patient complaints typical of
obliterating diseases of arteries, should be examined on the subject of conservation
or absence of pulsation of the terminal aorta,
femoral, popliteal arteries and the arteries at the ankle.
Another important diagnostic technique is auscultation of the carotid area,
subclavian arteries, abdominal aorta, iliac and femoral arteries. Availability
systolic murmur in the projection of vessels indicates a stenosis of its lumen
morethan 40-50%.
extremely difficult but vital question of the differential diagnosis
"pure" diabetic ulcers and trophic disorders in a patient with
atherosclerosis and diabetes mellitus. Understand this situation
doctor may find the following features of the clinic for these states.
In "pure" diabetic ulcer patients:
These lesions are usually in patients with diabetes mellitus complicated
severe neuropathy, with complete or partial loss of sensitivity on the part of the lower extremities
. For these cases, is characterized by symptoms of "Ragged
socks or gloves." The essence of this symptom is that the study of surface
sensitivity of the patient on a limb (foot, and n / c legs) occur together
located areas of the skin to preserve the sensitivity and full anesthesia.
absence of pain in the ulcers, explained by a violation of innervation leads to
that patients are very late to turn to a surgeon for a long time engaged in self-
at home or in the clinic. The most serious complication in
this situation is the addition of an infection with the rapid development of wet
gangrene, requiring amputation to save the limb.
main principle of treatment "diabetic" ulcers is compliance
bedrest or exclusion of the load on the limb with impaired trophic,
especially impressed by the plantar surface of the foot.
Treatment of such patients in the outpatient setting can be regarded as a tactical mistake
threatening rapid worsening of trophic disorders and infections.
All these patients should be hospitalized in the surgical hospital, because
essential for treating venous ulcers and diabetes mellitus is
full correction of glucose levels under careful control of endocrinology and
also intense local treatment of ulcers. Special mention should emphasize the fundamental difference
treatment of patients with trophic ulcers on a background of chronic venous insufficiency
from patients with arterial ulcers with chronic ischemia.
This latter group necessarily requires specialized
angiologicheskogo surveys, preferably in the relevant departments of vascular surgery
. The range of ultrasound examinations include the definition of the difference
pressure at different levels of lower limb arteries and the brachial artery;
duplex study аортоподвздошнобедренноподколенного segment;
contrast rentgenoangiografiya limb segments are listed. Also, it is desirable to
pO 2 , the meaning of which mentioned above.
Only such an approach to treating this population to evaluate
ability to perform angioplasty to remove
threat of amputation. In the arsenal of modern vascular surgery are
revascularizing various types of operations, allowing the withdrawal symptoms
ischemia for a long period in 75-90% of patients. Thanks to the advances of modern pharmacology
in the arsenal of physicians appear very effective dasgs
dasgs from a group of prostaglandins (alprostadil), significantly improving the microcirculation and enhancing
pO 2 in the zone of ischemia, which reduces the
frequency ablation in 3,5 times.
But widespread use of this regimen is limited to the high cost of
rate and the need to repeat to maintain their clinical
effect.
Neurotrophic ulcers are observed in patients who had a history of trauma
spine and peripheral nerves. The appearance of venous ulcers of the lower extremities
in patients after trauma, usually associated with damage
sciatic or tibial nerve. Symptoms are most pronounced in
three points: on the plantar surface of the foot first toe, heel and outer
half of the foot. In addition to skin manifestations, there are neurological symptoms and
effects of osteoporosis. In the area of these ulcers was a complete anesthesia or
sharp decrease in sensitivity. In most cases, such trophic ulcers
developed in the late periods after trauma. Tactics of treatment of such patients
complex and based on the results of a special neurological
surveys and opinion of a neurosurgeon.
Fig. 1. Trophic ulcers of leg
Martorell ulcer (ulcer of hypertensive)
described for the first time a Spanish surgeon Martarellom in 1944. The main
contingent, who shows such ulcers, are women between the ages of 40 to 60 years
. The main disease they have is resistant hypertension
predominantly malignant course, against which there is persistent
spasm, and then complete occlusion at the level of small arteries and arterioles of
anteroposterior of the leg in the lower and middle third, and As a asle,
defeat symmetrically on both legs. Feature of these ulcers is greatly
pain syndrome, a gradual progression in size and propensity
to infection. Confirmation of diagnosis is the histological examination of skin
assessing the state of the arterioles. The treatment focuses on the treatment of hypertension and
local sanitation ulcers.
Any long-existing trophic ulcers pose risk of malignancy in
1,6-3,5% cases. So, according to MM? Sinyavsky, among 1,234 patients with
trophic ulcers of different etiology malignancy is marked only 1,1%
observations. The clinical symptoms of malignancy are manifested in the increased size
ulcers and the degree of pain. In addition, around the ulcer formed
valoobraznye thickening. Malignancy is a consequence of inadequate treatment (irritant
ointments, UV, laser irradiation). But at the same time it is difficult to imagine that 1-2
course of this exposure can lead to such an outcome. Babajanov BR
(2002) reported that a short 2-week course of laser therapy resulted in complete healing of ulcers in
84,6%, while according to Kovchur OI (2002), a similar effect
achieved in 50 % of cases.
in clinical practice may occur evenmorerare forms of trophic
ulcers caused by radiation therapy, frostbites and burns, congenital arteriovenous fistula
, tuberculosis, syphilis.
Without a doubt, the best option for the treatment of most forms of
venous ulcers is the treatment of a patient in a hospital environment, where there
moreopportunities to conduct comprehensive impact directly on the ulcer itself and
correction of associated disorders.
for the start of treatment to produce crops with surface ulceration
for determining the nature of the microflora and its sensitivity to antibiotics.
in the literature Oregon
protocol treatment of venous trophic ulcers, contains 7 items:
1. Strict settlement?? Spasce mode.
2. Systemic antibiotic therapy.
3. Daily WC wound with soap and water.
4. Vatnomarlevaya dry bandage.
5. Compression stockings 30-40 mmHg
6. Local corticosteroid therapy for dermatitis and eczema.
7. Permanent compression therapy after ulcer healing.
to treat ulcers of different etiologies of this protocol is warranted the use of 1,2,3,6
points. Direct choice of dasgs depends on
phase of wound healing (6-14 days exudation, granulation 15-30 days;
epitalizatsiya 30-45 days).
At the same time take into account the causative factor of ulcer, which requires
with venous ulcers of the mandatory application flebotonikov, antiplatelet,
compression therapy. Ischemic ulcers treated with appropriate intensive care
desagregants, anticoagulants, alprostadilom.
diabetic ulcers, other than the above, require the normalization of glucose
with diet and medication.
justified the inclusion in the scheme of treatment of any ulcers method
hyperbaric oxygen therapy for relief of ischemia and infection control.
Any ulcer accompanied by the development of significant areas of inflammation on the area around the ulcer
in violation of the microcirculation, therefore pathogenetically
most appropriate local application of medicines,
affect these two factors. In the treatment of ulcers was used in this
variety of dasgs.
dasg Gepatrombin (Hemofarm Yugoslavia) has been successfully used in the treatment of
this pathology. In contrast to all previously applied ointment form (heparin
ointment geparoid), the tool contains from 30 000 to 50 000 IU of heparin, ie, in
3-5 times higher than in the old forms. Such a local effect on the area of impaired microcirculation
will be much stronger.
of the dasg is also dekspantenon 0.25 n, which derives
pantothenic acid, has a marked effect on the formation and function of epithelial tissue
. Positive were also anti-inflammatory and
dermatoprotektivnoe effect of the dasg. A similar effect is achieved
0,25 g of allantoin, which is part of ointment and gel "Gepatrombin.
Thus, a complex effect on the ulcer and surrounding tissue
promotes removal of inflammation, improve microcirculation and, consequently,
leads to a reduction in the size of ulcers until complete healing.
Treatment of patients with trophic ulcers of the lower extremities is a complicated and
difficult problem for both the patient and the doctor. The most important key to success
in the treatment of such patients is an accurate elucidation of the reasons that caused the emergence of
this plague, and the background of accompanying changes in the patient's disease (
cardiovascular system, diabetes, etc.).
Outpatient treatment of this population is extremely difficult due to the limited
patients in the movement, inability to use integrated
effects on ulcer, including physiotherapy, intravenous infusion,
frequent dressings and surgical techniques treatment.
Therefore, the main attention should be paid to treating patients in the hospital,
where the faster you can achieve a radical change in the clinical situation, as well as
reduce ulcer size in the final stage of treatment the patient may continue to
outpatient.
Literature:
1. Babajanov BR, Sultanov IJ "A comprehensive long-term therapy
nonhealing venous ulcers. Angiology and Vascular Surgery 2002. N.3 (application) p.18.
2. Vasyutkov VD "The combined conservative and surgical treatment of venous
venous ulcers. Ibid, p. 35-36.
3. Vasyutkov V., Protsenko NV "Trophic ulcers of the foot and ankle." M. 1993.
4. Savel'ev VS "Phlebology" 2003.
5. Sinyavsky MM "Trophic ulcers of the lower extremities, Minsk, 1973.
6. Haemovici H. Vascul. Surgery Norwaid: Aslepton Centory 1984 / 1187.
Published with permission from Russian
Medical Journal.