Refractory Ulcers Research Articles

Refractory Peptic Ulcer Disease

The eradication of Helicobacter pylori and the widespread use of effective antisecretory therapies, including proton pump inhibitors, have improved the management of peptic ulcer disease. However, in some patients, peptic ulcer disease is refractory to 8 to 12 weeks of standard antisecretory drug treatment. For refractory peptic ulcer disease, further evaluation of the risk factors and causes of refractory peptic ulcer disease, including patient risk factors and noncompliance (smoking, nonsteroidal anti-inflammatory drug use, and noncompliance with medical treatment), persistent H. pylori infection, and non-H. pylori-related factors (giant ulcer, gastrinoma, infections other thanH. pylori, and malignancy), is essential. The treatment should focus on the cause of the refractory peptic ulcer disease, avoiding smoking and nonsteroidal anti-inflammatory drug, the treatment of persistent H. pylori, use of high-dose proton pump inhibitors, or surgical excision of gastrinomas. Surgery should be considered in patients who are at high risk for complications and recurrent peptic ulcer disease despite medical treatment. In this review, I describe the diagnosis and treatment of refractory peptic ulcer disease. Key words: Anti-inflammatory agents, non-steroidal; Helicobacter pylori; Peptic ulcer; Ulcer, refractory

Twelve months of oral ulceration, weight loss and unexplained fevers: a clinicopathologic conference

AbstractExtranodal NK/T‐cell lymphoma (ENKL) is a rare, aggressive form of non‐Hodgkin's lymphoma with a distinct ethnic predilection favouring populations from Asia and Central and South America. The nasopharynx is the most commonly affected anatomical site. One of the key markers of this disease entity is infection with Epstein‐Barr virus (EBV), which is detected by in situ hybridisation. Histopathology and immunohistochemistry play a vital role in the diagnostic process, with cells typically expressing CD56, TIA‐1 and CD3ε. We present here a very unusual case of ENKL in a Caucasian female with an extranasal presentation, absence of CD56 expression and presence of EBV‐positive cells in the bone marrow. The unusual presentation of the disease in this case, as well as the many diagnostic challenges encountered, are detailed in this paper. It is hoped that this case will prompt clinicians to consider the possibility of an underlying malignant process in cases of refractory oral ulceration with concurrent clinical signs and symptoms.

A Case of Dermatomyositis Complicated with Refractory Multiple Skin Ulcer

A Case of Dermatomyositis Complicated with Refractory Multiple Skin Ulcer

A Case of Difficult Diagnosis of a Refractory Duodenal Ulcer due to Pancreatic Arteriovenous Malformations

A Case of Difficult Diagnosis of a Refractory Duodenal Ulcer due to Pancreatic Arteriovenous Malformations

A Case of Refractory Oral Mucosal Ulcer Caused by Improper Use of Nicotine Gum

A Case of Refractory Oral Mucosal Ulcer Caused by Improper Use of Nicotine Gum

A case of refractory ulcers due to CLI cured with near-infrared irradiation

A case of refractory ulcers due to CLI cured with near-infrared irradiation

CASE REPORT: SUBCONJUNCTIVAL INJECTION WITH AUTOLOGOUS PLATELET-RICH PLASMA FOR REFRACTORY CORNEAL ULCERS IN A DOG

A 12-year-old, intact, male Golden Retriever dog presented with a 1-month history of corneal ulcer, redness, and occasional squint in the left eye (oculus sinister [OS]). A thorough ophthalmological examination revealed corneal edema, diffuse corneal vascularization, and excessive granulation tissue growth. The tentative diagnosis was chronic superficial keratitis or pannus. After 3 weeks of treatment for OS, blepharospasm and superficial corneal ulceration with a lip of nonadherent epithelium of the right eye (oculus dexter [OD]) developed. No improvement was observed after autologous serum eye drop treatment combined with simple debridement and grid keratotomy on both eyes (oculi uterque [OU]) for 3 months; thereafter, blindness developed. The diagnosis was refractory corneal ulcers. The application of autologous platelet-rich plasma (PRP) was instilled via subconjunctival injection OU every 2 weeks for 2 months. The OU corneas started to re-epithelialize and heal, and the granulation tissues significantly decreased while the vision improved. Therefore, PRP was continued to be administered every 1–2 months for 6 months. After more than 1 year, the OU corneas have healed without recurrent ulceration and with only mild haze. In conclusion, autologous PRP subconjunctival injection is a potentially beneficial addition to the medical management of refractory corneal ulcers in dogs.

WOUND HEALING ACTIVITY OF JATROPHA TANJORENSIS LEAVES

The term “wound” is defined as a disruption of normal anatomical structure. Therefore, “healing” is the complex and dynamic process that results in the restoration of anatomical continuity and function. Albino Wistar rats (150-180 g) of both sexes were selected. The experiment of Wound Healing Activity by Excision Wound Model and Incision Wound Model by the simple ointment B.P., reference standard drug (0.2% w/w nitrofurazone ointment), stigmasterol ointment (0.2% w/w), hexane, chloroform and methanol extract ointments of 3%, 4% and 5% w/w of leaves in Jatropha tanjorensis in simple ointment base (where 3g, 4g and 5 g of the extracts was incorporated in 100 g of simple ointment separately). The time for wound closure to methanol extract ointment (5% w/w) and stigmasterol (0.2% w/w) was similar to that of standard drug, nitrofurazone ointment (0.2% w/w) 16 ± 2 days in Excision Wound Model. The significant tensile strength at 3%: 4%: 5% w/w methanol extract ointments (p<0.001), followed by chloroform extract and hexane extract. Stigmasterol ointment at 0.2% w/w produced tensile strength comparable with Standard drug, nitrofurazone ointment (0.2% w/w) (p<0.001) in Incision Wound Model. Kirithikar and basu stated that the juice of the Jatropha plant and the pounded leaves are applied to wounds and refractory ulcers. The juice is very successfully used to treat scabies, eczema and ringworm. The present study proved that the leaves have wound healing activity.

Comparative Effectiveness of a Bilayered Living Cellular Construct and an Acellular Fetal Bovine Collagen Dressing in the Treatment of Venous Leg Ulcers

Aim: To compare the effectiveness of bilayered living cellular construct (BLCC) and an acellular fetal bovine collagen dressing (FBCD) for the treatment of venous leg ulcers. Methods: Data from WoundExpert® (Net Health, PA, USA) was used to analyze 1021 refractory venous leg ulcers treated at 177 facilities. Results: Kaplan-Meier analyses showed that BLCC (893 wounds) was superior to FBCD (128 wounds), p = 0.01 for: wound closure by weeks 12 (31 vs 25%), 24 (55 vs 43%) and 36 (68 vs 53%); reduction in time to wound closure of 37%, (19 vs 30 weeks); and improvement in the probability of healing by 45%. Conclusion: BLC versus FBCD showed significant differences in both time to and frequency of healing suggesting that BLCC may provide significant cost savings compared with FBCD.

Autologous platelet-rich gel treatment for diabetic chronic cutaneous ulcers: A meta-analysis of randomized controlled trials.

In recent years, many studies have reported that autologous platelet-rich gel (APG) is an effective adjuvant treatment for chronic cutaneous ulcers in diabetics. The aim of this study was to explore the efficacy and safety of APG for the topical treatment of diabetic chronic cutaneous ulcers. The China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), VIP Database for Chinese Technical Periodicals (VIP), Chinese Wanfang database, PubMed, EMBASE, EBSCOhost, and Cochrane Library were systematically searched for relevant studies published up to 18 October 2017. Fixed- and random-effects models were used to calculate risk ratios (RR), odds ratios (ORs), and mean difference (MD) with 95% confidence intervals (95% CI). Subgroup analyses were conducted according to the Diabetic Foot Wagner Classification. Fifteen randomized control trials (RCTs) with 829 patients were eligible for inclusion in this analysis. Compared with standard care or conventional treatment, APG significantly improved the healing rate (RR 1.39; 95% CI 1.29, 1.50; P < 0.00001), shortened the healing time (MD -9.18; 95% CI -11.32, -7.05; P < 0.00001), and reduced the incidence of infection (OR 0.34; 95% CI 0.15, 0.77; P = 0.009). Current evidence suggests that APG is effective and safe, and is feasible for use as an adjuvant treatment for diabetic ulcers, especially chronic refractory ulcers. However, more RCTs with a good design and of a high quality are needed before the use of APG can be implemented widely.

Palliative surgery for refractory purulent corneal ulcer

Palliative surgery for refractory purulent corneal ulcer

In situ transplantation of adipose tissue-derived stem cells organized on porous polymer nanosheets for murine skin defects.

Stem cell transplantation is expected to be an effective early-phase treatment for deep burn injuries and intractable ulcers. Localizing and proliferating stem cells on the lesion utilizing engineered scaffolds is important for this treatment. In this study, we demonstrated in situ transplantation of adipose-tissue derived stem cells (ASCs) organized on free-standing porous polymer ultrathin films (referred to as "porous nanosheets") to a skin defect model in diabetic mice. Porous nanosheets were prepared by a combination of micro-gravure coating with macrophase separation of poly(d,l-lactic acid) and polystyrene under a roll-to-roll process and solvent etching process with cyclohexane. The permeable structure of porous nanosheets (thickness of 150 nm, average pore diameter of 4 μm) allowed for proliferation of ASCs and also provided sufficient nutrient inflow into multilayered ASC constructs. Then, transplantation of a trilayered ASC-laden porous nanosheet achieved homogeneous transference of ASCs onto the skin lesion. Transplanted ASCs contributed to wound healing in a dorsal skin defect model in diabetic mice. Thus, cell transplantation using porous nanosheets will be a new method for promoting wound healing in diabetic and other kinds of refractory ulcers. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1363-1371, 2019.

Chronic refractory leg ulcers in mosaic Klinefelter's syndrome: the importance of a prompt diagnosis and appropriate treatment.

article: Chronic refractory leg ulcers in mosaic Klinefelter’s syndrome: the importance of a prompt diagnosis and appropriate treatment - Italian Journal of Dermatology and Venereology 2021 February;156(1):93-5 - Minerva Medica - Journals

Paraneoplastic Pemphigus Associated with Lymphoid Leukemia: A Case of Persistent and Refractory Oral Ulcerations

A 53-year-old man was diagnosed with chronic lymphoid leukemia in December 2016 and was subjected to FCR-Lite protocol (cyclophosphamide 249 mg/m2 and fludarabine 33.2 mg/m2) in January 2017. The patient developed exanthema on the skin (torso and lower members), bullous lesions on the feet, and ulcers in the oral mucosa. Initially, the diagnosis was pharmacodermia and mucositis, rendered by oncologists. The dental team prescribed 0.12% alcohol-free chlorhexidine associated with low-level laser therapy for analgesia. The oral lesions have persisted with an increased extension and bleeding in the lips. Therefore, an incisional biopsy of skin lesions was performed and revealed intraepidermal vesicles, which supported the initial hypothesis of pharmacodermia. Due to persistence of the oral lesions, paraneoplastic pemphigus was suggested by the dental team as a diagnostic hypothesis and confirmed after an incisional biopsy and immunofluorescence assay. A 2-week follow-up revealed improvement of oral lesions, and no pain symptoms were reported.

Leg ulcers (ulcus cruris): The frequent macrovascular causes

Leg ulcers (ulcus cruris): The frequent macrovascular causes Abstract. Four pathologies make up the macrovascular etiologies of leg uclers: Venous leg ulcers (50 %), mixed venous-arterial leg ulcers (20 %), arterial leg ulcers (5 %), and Martorell hypertensive ischemic leg ulcer (5 %). The remaining 20 % concern a large array of other etiologies. Every leg ulcer requires vascular (arterial and venous) work-up, that can be completed with microbiology, biopsy, and more in-depth internal diagnostics, as indicated. Venous leg ulcers are treated with compression therapy. Incompetent saphenous veins and tributaries are abolished if the deep venous system is patent. Occluded iliac veins are recanalised and stented, as possible. Refractory venous leg ulcers are grafted with split skin or punch grafts, depending on their surface. Extensive dermatolipofasciosclerosis may be tangentially removed by shave therapy or fasciectomy, that can be combined with negative pressure wound treatment (NPWT). Skin equivalents are an alternative to treat superficial venous leg ulcers that fail to epithelialise. Their indication in the treatment of more complex leg ulcers still needs to be better investigated and understood. The use of dermal matrices leads to more stable scars. Mixed venous-arterial leg ulcers heal slower and recur more frequently. Compression needs to be reduced. Refractory cases require arterial revascularisation, to transform the mixed venous-arterial into a venous leg ulcer. Arterial leg ulcers require arterial revascularization and split skin graft. Martorell hypertensive ischemic leg ulcer is still underrecognised and often confounded with with pyoderma gangrenosum, which leads therapy into a wrong direction. Necrosectomy, antibiotic treatment in the presence of relevant bacterial superinfection, and repeated split skin grafts eventually heal the vast majority of these extremely painful and potentially mortal wounds.

Successful treatment of digital ischemic ulcer with stellate ganglion blockade

Stellate ganglion blockade (SGB) could be used for the treatment of sympathetic dependent circulatory insufficiency in the upper limb. The sympathetic blockade produces relaxation of the upper extremity arteries, which increases blood flow of capillary and helps to relieve ischemia then facilitate peripheral wound healing. We report a patient with refractory ischemic ulcer in distal phalanges, who was successfully treated with SGB. A 36-year-old female patient admitted in department of plastic surgery for contact burn wound in the right hand. There were 2nd degree burn in the right 2nd through 5th fingertips ( Fig. 1 ). Despite of 2 months of dressing, digital burn wound was not healed and seems to be refractory. Suspecting vascular insufficiency, upper extremity angiography was done. It revealed decreased perfusion in 2nd through 5th fingers ( Fig. 2 ) and digital fingertip wounds were diagnosed as ischemic ulcer. For the improvement of circulation in her vulnerable fingers, physical modalities were applied and 100 mg of aspirin was prescribed daily. The sympathetic skin response was conducted for the evaluation of sympathetic nerve system. It showed no response in right hand and foot. We planned SGB to increase blood flow at the fingers and SGB was done under ultrasonography, twice per week for 3 weeks. The follow-up angiography showed significant improvement of fingertip perfusion ( Fig. 3 ). Consequently fingertip wounds were completely healed ( Fig. 1 ). Finally, she could achieved independent ADL with her hand. The SGB can be effective on improving blood flow for healing of ischemic ulcer in the fingertips. We suggest the SGB could be an alternative option to overcome intractable condition.

Outcome of Helal osteotomy for chronic plantar foot ulcers

Category: Diabetes Introduction/Purpose: Chronic ulceration of the forefoot is a major problem in neuropathic and diabetic feet. Foot ulceration represents a risk factor for the development of osteomyelitis and increases the risk of amputation.The purpose of this study was to evaluate the effectiveness of Helal osteotomies concerning the development of plantar foot ulcers. Methods: Eighteen patients with a mean age of 69 years (min 55 yr, max 85 yrs) suffering from chronic, refractory ulcerations of the forefoot underwent Helal osteotomies. Demographic parameters, radiologic parameters, ulcer classification, complications, ulcer recurrence and ulcer healing were documented.The ulcerations were assessed according to the Wagner Armstrong classification. Results: The mean follow up was 30 months (min 6, max 68 months). Preoperatively, there were 3 grade 1A, 1 grade 1B,5 grade 2A, 8 grade 2B and 1 grade 3B ulcers. The most common site of ulceration was the MTP 3 joint, followed by the MTP 2 joint. All ulcers recovered with a mean healing time of 5.5 weeks (min: 1 week, max. 12 weeks). One ulcer recurred due to a secondary ossification of the osteotomy. After a reosteotomy, a permanent healing of the ulcer was achieved. There were 4 complications (1 hematoma, 2 wound infections, 1 ossification), of which only the ossification required revision surgery. Conclusion: The Helal osteotomy is a safe and effective method in treating neuropathic forefoot ulcerations. The procedure allows for rapid mobilization of the patient.

Application of suction assisted closure to repair refractory ulcers of leukemia in children

Objective To investigate the effect of suction assisted closure (SAC) in treatment of children′s leukemia with refractory ulcers. Methods The clinical data of 15 children who had leukemia associated with refractory ulcers from January 2013 to April 2017 in Department of Orthopedics, Wuhan Children′s Hospital, Tongji Medical College of Huazhong University of Science & Technology were retrospectively analyzed.There were 8 males and 7 females, among whom 9 cases were acute non-lymphocytic leukemia and 6 cases were acute lymphoblastic leukemia.Patient′s ages ranged from 2 to 9 years old with the mean age of 6.2 years.There were 5 cases of refractory ulcers located in the medial side of thigh and 4 cases in the perineum and around anus, 3 cases in the ankle, 2 cases in the crus and 1 case in the lateral side of thigh.The refractory ulceration area varied from 2 cm×3 cm-7 cm×5 cm, and the depth varied from 0.6-1.8 cm.All the 15 cases were cultured with secretions, including 7 cases of Staphylococcus aureus, 4 cases of Escherichia coli, 2 cases of Klebsiella pneumoniae, 1 case of Pseudomonas aeruginosa, and 1 case with no bacteria detected.These children were transferred from Department of Hematology to Department of Orthopedics when there was no improvement in conventional therapy with the average treatment of 26 d (11-36 d). All of these children underwent SAC after thorough debridement.Secondary suturing of ulcers closure was performed or skin transplantation according to the recovery condition of ulcers. Results All the 15 patients of refractory ulcers achieved fresh granulation tissue after SAC treatment.Ten of them who had refractory ulcers could be sutured directly after once SAC treatment, and 5 cases who had refractory ulcers underwent SAC treatment again, in which 3 cases could be sutured directly, and the other 2 cases needed to reduce the wound area and autologous skin graft.All of these patients had refractory ulcers healed after SAC treatment, without any local or systemic complications. Conclusions SAC can bring the deep refractory ulcers into full drainage, protect the refractory ulcers against contamination, stimulate the growth of granulation tissue.SAC is a simple and effective method in treatment of children′s leukemia with refractory ulcers. Key words: Child; Leukemia; Suction assisted closure; Debridement

Comparative effectiveness of a bilayered living cellular construct and an acellular fetal bovine collagen dressing in the treatment of venous leg ulcers.

Aim: To compare the effectiveness of bilayered living cellular construct (BLCC) and an acellular fetal bovine collagen dressing (FBCD) for the treatment of venous leg ulcers. Methods: Data from WoundExpert® (Net Health, PA, USA) was used to analyze 1021 refractory venous leg ulcers treated at 177 facilities. Results: Kaplan-Meier analyses showed that BLCC (893 wounds) was superior to FBCD (128 wounds), p=0.01 for: wound closure by weeks 12 (31 vs 25%), 24 (55 vs 43%) and 36 (68 vs 53%); reduction in time to wound closure of 37%, (19 vs 30weeks); and improvement in the probability of healing by 45%. Conclusion: BLC versus FBCD showed significant differences in both time to and frequency of healing suggesting that BLCC may provide significant cost savings compared with FBCD.

A novel dressing seeded with embryonic artery CD133+ cells and loaded with the Sirt1 agonist SRT1720 accelerates the healing of diabetic ischemic ulcers

Refractory ischemic ulcers that occur in patients with diabetes present a major clinical challenge. Embryonic artery cluster of differentiation 133+ cells (EACCs) may promote the healing of diabetic ulcers; however, the high glucose environment in the diabetic ulcers decreases the survival rate of transplanted EACCs and inhibit their biological function. Furthermore, microcirculation in diabetic ischemic ulcers is impaired, which inhibits the beneficial effect of EACCs. In the current study, the Sirt1 agonist SRT1720 was selected as a therapeutic drug and loaded into a dressing composed of PLGA, collagen and silk (PCSS) formed using electrospinning technology. EACCs were seeded onto the PCSS dressing and this was used to treat diabetic ulcers. The results indicated that SRT1720 promotes the proliferation of EACCs, enhances the secretion of vascular endothelial growth factor A, interluekin 8 and basic fibroblast growth factor, and inhibits the secretion of tumor necrosis factor α. Furthermore, SRT1720 promoted the paracrine function of EACCs and promoted the proliferation and migration of human umbilical vein endothelial cells. PCSS induced the steady release of SRT1720 over a 15-day period and PCSS seeded with EACCs (PCSS-EACCs) were transplanted into the diabetic ischemic ulcers of mice with diabetes. The results of these experiments indicated that angiogenesis and the healing of diabetic ischemic ulcers was significantly improved following the transplantation of PCSS-EACCs. Therefore, PCSS-EACCs may be a novel and effective treatment for diabetic ischemic ulcers.