Trophic ulcer – an open skin wound or mucous, arisen after rejection of the become lifeless fabrics and not healing within 6 and more weeks. The reason of development of a trophic ulcer – local violation of blood circulation or an innervation of fabrics. Trophic ulcers develop against the background of various diseases, differ in a persistent long current and hardly will respond to treatment. Recovery directly depends on the course of the main disease and a possibility of compensation of violations which led to developing of an ulcer.
Trophic ulcer — it is long not beginning to live defect of skin and the fabrics located under it. Varicose trophic ulcers arise in the lower third of a shin against the background of varikozno expanded veins more often. On an edematous extremity there is a cyanotic painful spot, then small sores which gradually merge in one defect. From an ulcer bloody or purulent separated exudes, it is frequent with a smell. The current the recidivous, progressing, full treatment of varicose trophic ulcers is possible only during removal of the changed veins.
Chronic venous insufficiency (at a varicosity, a posttromboflebitichesky disease) can lead deterioration in arterial blood circulation to development of a trophic ulcer (at a hypertension, diabetes, atherosclerosis), violation of outflow of a lymph (limfedem), a trauma (freezing injuries, burns), chronic diseases of skin (eczema etc.). The trophic ulcer can develop at poisoning with chrome or arsenic, some infectious diseases, system diseases (vaskulita), violation of local blood circulation at a long immovability as a result of a disease or a trauma (decubituses).
More than 70% of all trophic ulcers of the lower extremities are caused by diseases of veins. In such cases the flebologiya is engaged in diagnostics and elimination of the reasons of emergence of a trophic ulcer.
Reasons of development of venous trophic ulcers
The violation of a venous blood-groove caused by diseases of venous system leads to deposition of blood in the lower extremities. Blood stands, in it waste products of cages collect. Food of fabrics worsens. Skin is condensed, accustomed to drinking with hypodermic cellulose. Dermatitis, the becoming wet or dry eczema develop.
Because of ischemia process of healing of wounds and scratches worsens. As a result the smallest injury of skin at chronic venous insufficiency can the reason of development become long the flowing, badly giving in to treatment trophic ulcer. Accession of an infection makes heavier the course of a disease and leads to development of various complications.
Developing of trophic ulcers can be caused by any disease of superficial or deep veins which is followed by chronic venous insufficiency. At diagnosis the disease which caused formation of an ulcer as tactics of treatment and the forecast substantially depends on the nature of the main venous pathology is very important.
Symptoms of a venous trophic ulcer
Development of a trophic ulcer of a venous etiology is preceded by emergence of characteristic signs of the progressing defeat of venous system. In the beginning patients note strengthening of hypostases and feeling of weight in calves. Night muscular spasms become more frequent. There is an itch, feeling of heat or burning. The hyperpegmentation amplifies, its zone extends. Collecting in skin causes eczema and dermatitis. Skin in the struck area takes a varnish form, is thickened, becomes motionless, intense and painful. Develops , leading to a transsudation of a lymph and education on skin of the small droplets by the form reminding dew.
After a while in the center of an affected area the whitish center of an atrophy of epidermis appears (a predjyazvenny state – a white atrophy). At the minimum injury of skin which can take place for the patient unnoticed in the field of an atrophy minor ulcer defect is formed. In an initial stage the trophic ulcer settles down superficially, has the damp dark red surface covered with a scab. Further the ulcer extends and goes deep. Separate ulcers can merge among themselves, forming extensive defects. The multiple started trophic ulcers in some cases can form a uniform wound surface on all circle of a shin.
Process extends not only in breadth, but also deep into. The ulcer penetration in deep layers of fabrics is followed by sharp strengthening of pains. Ulcer defeat can take gastrocnemius muscles, an Achilles tendon and the forward surface of a tibial bone. Periostit, complicated by a secondary infection, can pass into osteomyelitis. At damage of soft fabrics in an ankle joint there is arthritis with the subsequent development of a contracture.
Character of separated depends on existence of a secondary infection and a type of the infectious agent. At initial stages separated hemorrhagic, then – muddy with threads of fibrin or purulent with an unpleasant smell. Maceration of skin around a trophic ulcer quite often leads to development of microbic eczema.
As a rule, the secondary infection is caused by conditionally pathogenic bacteria. At the elderly weakened patients accession of a fungal infection which makes heavier the course of a disease is possible, becomes the reason of bystry progressing of trophic frustration and worsens the forecast.
At infection of an ulcer danger of emergence of complications increases. Quite often trophic ulcers are followed by a piodermiya, allergic dermatitis. Can develop limfangit, purulent varikotromboflebit, an erysipelatous inflammation, pakhovy lymphadenitis. In some cases the trophic ulcer is complicated by phlegmon and even sepsis. The recurrent infection causes damage to lymphatic vessels and leads to development of a secondary limfedema.
Diagnosis of a venous trophic ulcer
Confirmation of a venous etiology of a trophic ulcer are the accompanying varicose veins and postponed . The high probability of the postponed thrombosis of deep veins is demonstrated by existence in the anamnesis of diseases of system of blood, reception of hormonal medicines, kateterization and punctures of veins of the lower extremities, episodes of a long immovability at injuries, chronic diseases and surgical interventions.
Typical localization of a venous trophic ulcer – an internal surface of the lower third of a shin. Skin around an ulcer is condensed, pigmented. Eczema or dermatitis is quite often observed. At a palpation in a zone of trophic violations the crateriform failures (the place where through a fastion of a shin there are changed kommunikantny veins) can be defined. Visually the expanded veins most often located on the medial and back surface of a shin and the back surface of a hip come to light varikozno.
For assessment of a condition of venous system functional tests, UZDG of veins of the lower extremities, an ultrasonic duplex research are carried out. For a research of microcirculation the reovazograiya of the lower extremities is shown. Trophic ulcers of a venous etiology often develop at elderly patients with whole "bunch" of associated diseases therefore tactics of treatment has to be defined only after comprehensive inspection of the patient.
Treatment of a trophic ulcer
In the course of treatment of a trophic ulcer the phlebologist has to solve the whole complex of problems. It is necessary to eliminate or whenever possible to minimize displays of the main disease which became the reason of formation of an ulcer. It is necessary to struggle with a secondary infection and to carry out treatment of the most trophic ulcer.
The general conservative therapy is carried out. To the patient appoint medicines for treatment of the main disease (flebotonik, antiagregant etc.), antibiotics (taking into account sensitivity of microflora). Locally to clarification of a trophic ulcer apply enzymes, to fight against a secondary infection – local antiseptics, after elimination of an inflammation – wound healing mazevy bandages.
Surgical treatment is carried out after preparation (healing of an ulcer, normalization of the general condition of the patient). Carry out the operations directed to restoration of a venous blood-groove in the field of defeat: shunting, removal varikozno expanded veins (miniflebektomiya, flebektomiya).
Prevention of a venous trophic ulcer
Preventive measures consist in early detection and timely treatment of a varicosity. The patients having varicosity and a posttromboflebitichesky disease have to use means of an elastichesky compression (medical jersey, elastic bandage). It is necessary to observe recommendations of the doctor, to avoid long static loadings. Work in hot shops, long overcooling, work in a motionless state is contraindicated to patients with chronic venous insufficiency. Moderate physical activity is necessary for stimulation of a muscular pomp of shins.