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Ulcer

Dr. Rajalakshmi VK (AIIMS)MBBS

December 26, 2020

December 26, 2020

Ulcer
Ulcer

Our skin and mucosal membranes form a protective layer over the body. An ulcer is an open sore or lesion in this protective layer. This opening or discontinuity in the skin or mucosal membrane (inner lining of cavities like the mouth and internal organs like the intestines) impairs the functioning of the affected area and can take a long time to heal.

Ulcers can occur anywhere on or inside the body. Bedsores, genital ulcers, peptic ulcers, leg and foot ulcers, anal fissures and ulcers, corneal ulcers, venous ulcers and mouth ulcers are all ulcers in different parts of the body.

Ulcers tend to be painful, and they can recur. For example, some people who are prone to mouth ulcers keep getting them over and over again.

Some chronic conditions and lifestyle habits make people more susceptible to some types of ulcers. For example, people with diabetes are more likely to get foot ulcers (diabetic foot ulcer), people who smoke or take non-steroidal anti-inflammatory drugs (NSAIDs) regularly have a greater chance of developing peptic ulcers (that affect the digestive tract) and people who bite the inside of their cheek are prone to more mouth ulcers. (Read more: Home remedies for mouth ulcers)

The causes of an ulcer can vary from sexually transmitted infections to a wound that takes a long time to heal. For example, bedsores, also called pressure ulcers, can occur when someone lies in bed on the same side for several hours every day or if they have a cast around a broken bone for some weeks.

Whether they are on the outer surfaces of the body (for example, bedsore or leg or foot ulcers) or inside the body (example, peptic ulcers or anal ulcers), ulcers need to be looked over by a doctor. The reason: while some ulcers go away on their own or with over-the-counter medication, others can point to serious underlying health issues and require proper treatment.

Read on to know about the different types of ulcers, ulcer symptoms, ulcer causes, how to prevent an ulcer, ulcer diagnosis and treatment for ulcers:

Ulcer types

Depending on where they occur in the body, and why, ulcers can be of different types:

On the body

  • Skin ulcers can occur anywhere on the skin. They can happen for a number of reasons, from an injury or infection to ulcerative sarcoidosis (this is a rare presentation of sarcoidosis, an inflammatory disease).
  • Pressure ulcers (bedsores) can occur all over the body. They are different from skin ulcers in that they occur where a bone pushes against the skin for a long time, as with patients who need to lie on their back or either side for many hours daily.
  • Diabetic foot ulcer is a common complication of diabetes. If you have diabetes, it is very important to get foot ulcers examined by a doctor asap to reduce the chances of gangrene
  • Corneal ulcer: The cornea is the topmost layer of the eye—the eye is covered with a mucosal membrane. Some factors that can contribute to a corneal ulcer are wearing contact lenses for prolonged periods and getting an eye infection.

Inside the body

  • Mouth ulcer and canker sores: Canker sores are ulcers at the base of the gums or inside the mouth.
  • Peptic ulcer can be caused by a break in the mucosal lining of the stomach (stomach ulcer) or small intestine (duodenal ulcer). You should rush to a hospital if you experience sudden onset stomach pain, fast heartbeat (tachycardia) and abdominal rigidity (stomach feels stiff or rigid), as these could be signs that the ulcer has become perforated (developed holes). A perforated peptic ulcer can allow the highly acidic contents of the stomach to pour out into the abdominal cavity.
  • Stress ulcers occur in the stomach and gut (proximal duodenum) as a result of shock, sepsis, trauma, or illnesses like peritonitis (inflammation of the inner wall of the stomach). Severe acute illness (or sudden onset severe illness) and systemic burns can increase the chances of stress ulcers (Curling ulcer). Additionally, mechanical ventilation for over 48 hours can increase one’s risk of stress ulcers.
  • Cushing ulcer also affects the stomach, but the reason is usually a head injury or other conditions like a brain tumour or infection that can increase pressure in the brain (intracranial pressure) and affect the working of the vagus nerve.
  • Venous ulcer affects the veins, especially the veins of the legs and feet in people with poor blood circulation and in people living with obesity.
  • Ulcerative colitis is one of two types of inflammatory bowel disease (IBD). It affects the colon or large intestine.
  • Ulcerative lichen planus: Lichen planus can cause lacy whitish spots in the lining of the mouth and/or vagina. In some cases, it can also cause sores or lesions in the mouth or vagina.
  • Genital ulcers can be a sign of sexually transmitted diseases like syphilis, herpes or chancroid. Though these may also be caused by an inflammatory condition.

Ulcer symptoms

The symptoms could vary, based on where and how the ulcers occur in the body:

  • Skin ulcer: A skin ulcer is an open wound that can be seen with the naked eye. In the initial stages, before the ulcer develops, the skin may appear red or shiny and inflamed. If left untreated, the ulcer may deepen to look like a small open pit that may also leak a clear fluid or blood. As the ulcer gets worse, it may become more painful.
  • Pressure ulcer: Pressure ulcer is a type of skin ulcer, so the symptoms are similar except they tend to occur in bony areas like the elbows, heels, knees, lower back and hips, and are very common in people who are forced to spend hours in bed like paralysis patients. Pressure ulcers also tend to get worse (instead of better) unless something is done about them. You should rush to a hospital if you have bedsore (pressure) ulcers and
    • Your skin is cold and your heart is beating fast
    • You have pus oozing from the ulcer and/or fever
  • Diabetic foot ulcer: Diabetics have more sluggish blood flow and high blood sugar. Both of these make them prone to ulcers. A diabetic foot ulcer could start innocuously, with thickened skin around the edges of the ulcer and/or light fluid discharge. In some cases, the edge of the ulcer could appear dark or black (eschar)—an indication that poor blood flow to the area may be causing tissue death. This type of ulcer can become quite deep, as diabetics with nerve problems (diabetic neuropathy) have reduced sensation in the feet and may not get pain signals to alert them when something’s wrong. Foul-smelling fluid discharge from the ulcer could be a sign of gangrene.
  • Corneal ulcer: An eye infectiondry eye syndrome or eye disorder could cause an ulcer to form on the cornea. The symptoms may include severe eye pain, red eyes, the feeling of grit in your eyes, blurred vision, eyes watering, sensitivity to light, among other signs.
  • Mouth ulcer, including canker sores: Painful sores inside the mouth that can sting when you eat spicy or hot food, pain in the affected area while chewing or brushing your teeth, loss of appetite as a result of pain while chewing and in contact with salty or spicy foods.
  • Peptic ulcers can produce symptoms like loss of appetite, stomach pain that goes away on taking an antacid, and weight loss.
  • Venous ulcers occur mostly in the legs. The symptoms may include hardening and discolouration of the affected area, feeling of heaviness in the legs, leg pain and swollen ankles. (Read more: Swelling in feet)
  • Ulcerative colitis is a type of irritable bowel disease in which ulcers develop in the innermost lining of the large intestine (colon) and rectum. Symptoms include diarrhoearectal bleedingmucus in stools, stomach ache and cramps, pain in the rectum, weight loss and fatigue. Patients may feel the need to pass stool but may not be able to go when they try.
  • Genital sores or ulcers present with fever and rashes and bumps that may or may not hurt.
  • Rectal ulcers can present with signs like rectal bleeding, blood in stools, rectal pain and painful bowel movement.

Causes of ulcers

Again, depending on the type of ulcer, the causes can vary:

  • Skin ulcer: Blood disorders and poor blood circulation can slow down wound healing and increase the chances of skin ulcers.
  • Pressure ulcer: Causes could vary from a friction injury to wearing a cast over a fractured bone and being bedridden.
  • Diabetic foot ulcer: Having uncontrolled diabetes or having had diabetes for a long time, poor blood circulation and lack of sensation in the foot are some of the factors that could lead to a diabetic foot ulcer.
  • Corneal ulcer: Usually an eye injury that causes trauma to cornea, followed by eye infection is the cause.
  • Mouth ulcer, including canker sores: Some nutritional deficiencies like zinc deficiencyvitamin B deficiency, iron deficiency; mouth injuries; sensitivity to acidic foods like pineapples; dental work including dental braceshormonal imbalance (during pregnancy or menopause, etc.). A family history of recurring mouth ulcers is a risk factor.
  • Peptic ulcers: Causes include certain infections like H. pylori bacterial infection and wrong or prolonged usage of certain drugs—especially a class of painkillers called non-steroidal anti-inflammatory drugs or NSAIDs like ibuprofen. Lifestyle factors like high levels of stressalcohol consumption and smoking are risk factors.
  • Venous ulcer: Weakened veins or venous insufficiency (usually because the valves in the veins of the legs don’t function properly) can result in poor blood flow and ultimately venous ulcers. Varicose veins, deep vein thrombosis, surgeries on the leg including knee replacement surgery, leg injuries and advancing age are all risk factors for weaker leg veins/leg vein valves.
  • Ulcerative colitis: This condition is usually inherited. It is thought to be an autoimmune disorder. Factors like stress can make some people’s symptoms worse.
  • Ulcerative lichen planus: Lichen planus can occur in different parts of the body, like the mouth, vagina and vulva. Certain medicines and certain fungal infections and bacterial infections are thought to trigger this condition.
  • Genital sores or ulcers: Sexually transmitted diseases like herpes and syphilis, trauma and some inflammatory diseases like Behçet's syndrome can cause genital sores. Additionally, some skincare products may cause an allergic reaction when applied to the skin around the genitals or the anus—these may also result in skin ulcers in these areas.
  • Rectal ulcers may occur due to constipation, IBD or a condition called solitary rectal ulcer syndrome (which in turn is caused by chronic constipation). A rectal prolapse (when the rectum drops from its normal position) can also result in rectal ulcers.

Ulcer diagnosis

Most ulcers on the outer surface of the body can be diagnosed through a physical examination. In some cases, your doctor may want to test any fluid discharge from the ulcer. He/she may also advise tests such as:

  • X-ray
  • Barium X-ray (for upper and lower gastrointestinal tract)
  • Ultrasound, example rectal ultrasound for rectal ulcers.
  • Biopsy (for ulcerative colitis)
  • Colonoscopy (for ulcerative colitis), anoscopy (for rectal ulcer), endoscopy (for peptic ulcers)
  • Slit-lamp test (for corneal ulcers)
  • Blood tests
  • STD tests like the VDRL test for syphilis

The type of test recommended will, of course, be determined by the kind of ulcer suspected by the doctor and by your symptoms.

Ulcer treatment

The treatment will depend on the type of ulcer. Below are some of the more common examples:

  • Mouth ulcers: Benzocaine creams and gels are available to soothe and treat mouth ulcers and tongue ulcers. It is a good idea to see your doctor if you get mouth ulcers often, as these can signal health problems from nutritional deficiencies like iron deficiency or vitamin B12 deficiency to mouth cancer (if the ulcer does not heal for several weeks).
  • Skin ulcer: Ulcers are a break in the skin. It is important to keep them clean to avoid infections. Antibiotics and wound management (including bandaging) are usually used for treatment. In some cases, pain medication may also be prescribed.
  • Pressure ulcer: Applying topical (cream or gel) antibiotics, having the wounds cleaned and dressed regularly, identifying and addressing the cause of the pressure ulcers can help. For example, if the reason for pressure ulcers is being bed-ridden, then asking a caretaker to help you change sides and use skin cleansers to keep the body clean can go a long way.
  • Diabetic foot ulcer: Proper hygiene is important to prevent and treat diabetic foot ulcer. In addition to this, wearing diabetic shoes or compression stockings that improve blood flow can help. Your doctor can advise you on the best options for therapy and medicines to treat the wound—these may include foot baths, enzyme treatments and in extreme cases antibiotics and antiplatelet medicines to prevent blood clots from forming (check with your doctor before taking any medicines; it’s possible that you are already on a blood thinner if you have diabetes).
  • Corneal ulcer: Depending on the cause of the infection that led to the ulcer, the doctor may prescribe antibiotic, antiviral or antifungal eye drops for treatment.
  • Peptic ulcers: Your doctor may prescribe medicines to reduce the amount of stomach acid—these may include proton pump inhibitors or H2 receptor blockers. The doctor may also prescribe some antibiotics.
  • Venous ulcer: Treatment may include wearing compression socks to improve blood flow, painkillers and blood thinners (anticoagulants to prevent blood clots).
  • Ulcerative colitis: Anti-inflammatory medicines like corticosteroids, immunosuppressants like azathioprine and biologics like infliximab may be used for treatment. In some cases, the doctor may recommend surgery to remove the colon and rectum (proctocolectomy) followed by an ileoanal anastomosis to allow patients to pass stools normally. Painkillers and anti-diarrhoea medicines may also be prescribed to ease the symptoms.
  • Genital sores or ulcers: Treatment involves antibiotics or antivirals to treat the underlying infection.
  • Rectal ulcers: Depending on your symptoms, the doctor may prescribe laxatives, antibiotics or surgery. For minor cases, making lifestyle changes like avoiding straining while sitting on the toilet, drinking lots of fluids, and eating healthily can help to promote healing and prevent a recurrence.

Ulcer prevention

Though it may not be possible to prevent all types of ulcers, following some healthful rules of thumb can help:

  • Know your body: If foods like pineapples or strawberries give you mouth ulcers, make a note of it and avoid these in the future
  • Avoid taking too many medicines, even over-the-counter medicines like NSAIDs for pain relief
  • Try to reduce the amount of stress in your life
  • Try to change positions, or ask someone to help you do turn sides if you need to stay in bed for long periods for any reason
  • Practise safe sex and get yourself tested annually if you are sexually active, especially if you have multiple partners
  • Maintain hygiene, keep your surroundings clean and wash your hands often to avoid infections
  • Don't delay seeing a doctor in case of an injury, such as an eye injury
  • Eat a balanced diet. Make sure to include fibre-rich foods, zinc-rich foods, and foods rich in vitamin B and iron to reduce the risk of mouth ulcers.
  • Exercise regularly to maintain good blood flow and a healthy weight
  • If you have a chronic condition like diabetes, make sure to manage it properly with medication, diet for diabetes, exercises for diabetes and other lifestyle changes


References

  1. Moody F.G. and Cheung L.Y. Stress ulcers: their pathogenesis, diagnosis, and treatment. The Surgical Clinics of North America, December 1976; 56(6): 1469-1478. PMID: 793064.
  2. Siddiqui A.H., Farooq U. and Siddiqui F. Curling ulcer (stress-induced gastric) In: StatPearls [Internet]. Treasure Island (FL): StatPearls, Updated 22 April 2020.
  3. Kemp W.J., Bashir A., Dababneh H. and Cohen-Gadol A.A. Cushing's ulcer: Further reflections. Asian Journal of Neurosurgery, April-June 2015; 10(2): 87-94. PMID: 25972936.
  4. American Family Physician [Internet]. Genital ulcers: What causes them?, 1 February 2012; 85(3): 269.
  5. National Health Service [Internet]. UK; Pressure sores
  6. Geusau A. and Jalili A.P. Genital ulceration: infection or autoinflammatory disease?. Sexually Transmitted Infections, 2013; 89: A123.
  7. Cleveland Clinic, US [Internet]. Leg and foot ulcers: management and treatment.
  8. Zhu Q.C., Shen R.R., Qin H.L., Wang Y. Solitary rectal ulcer syndrome: clinical features, pathophysiology, diagnosis and treatment strategies. World Journal of Gastroenterology, 21 January 2014; 20(3): 738-44. doi: 10.3748/wjg.v20.i3.738. PMID: 24574747; PMCID: PMC3921483.
  9. Tarasconi A, Coccolini F, Biffl WL, Tomasoni M, Ansaloni L, Picetti E, Molfino S, Shelat V, Cimbanassi S, Weber DG, Abu-Zidan FM, Campanile FC, Di Saverio S, Baiocchi GL, Casella C, Kelly MD, Kirkpatrick AW, Leppaniemi A, Moore EE, Peitzman A, Fraga GP, C
  10. Lamb C.A., Kennedy N.A., Raine T., Hendy P.A., Smith P.J., Limdi J.K., Hayee B., Lomer M.C.E., Parkes G.C., Selinger C., Barrett K.J., Davies R.J., Bennett C., Gittens S., Dunlop M.G., Faiz O., Fraser A., Garrick V., Johnston P.D., Parkes M., Sanderson J.
  11. Ungaro R., Mehandru S., Allen P.B., Peyrin-Biroulet L., Colombel J.F. Ulcerative colitis. Lancet, 29 April 2017; 389(10080): 1756-1770. doi: 10.1016/S0140-6736(16)32126-2. Epub 1 December 2016. PMID: 27914657; PMCID: PMC6487890.
  12. Looker K.J., Johnston C., Welton N.J., James C., Vickerman P., Turner K.M.E., Boily M.C. and Gottlieb S.L. The global and regional burden of genital ulcer disease due to herpes simplex virus: a natural history modelling study. BMJ Global Health, 8 March 2020; 5(3): e001875. doi: 10.1136/bmjgh-2019-001875. PMID: 32201620; PMCID: PMC7061890.

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Medicines for Ulcer

Medicines listed below are available for Ulcer. Please note that you should not take any medicines without doctor consultation. Taking any medicine without doctor's consultation can cause serious problems.

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