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DR IMRANA AZIZAssistant ProfessorSurgical
Department
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CYSTS ULCERS
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CYSTS

• Cyst is a fluid filled sac bound by a wall.
• Fluid is often clear, colorless or cholesterol
  crystals, or tooth paste like.
• True Cyst lined with epithelial or endothelial
  cells.
• False Cyst which are walled off fluid collection
  not by epithelium
• e.g. Pancreatic pseudocyst

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Classification

• Congenital
• Acquired

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CONGENITAL CYSTS

• Sequestration dermoid
• Tubuloembryonic
• Cysts of embryonic remnants
• Hydatid of Morgagni
• Cysts of the urachus
• Cyst of vitellointestinal duct
• Cysts of wolffian duct
• Branchial Cyst
• Thyroglossal Cyst

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ACQUIRED CYSTS

• Retention cysts
• Cystic tumours
• Implantation dermoids
• Traumatic cysts
• Degeneration
• Parasitic cysts
• Hydatid,
• trichniasis,
• cysticercosis

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• Sequestration dermoid
• This is due to dermal cell being buried along to
  the lines of closure of embryonic clefts and
  sinuses by skin fusion.
• Lined by epidermis and containing paste like
  material.
• Sites midline of body
• outer canthus
• anterior triangle of mouth.

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• Tubuloembryonic cyst
• in the track of ectodermal tube
  development.
• e.g thyroglossal cyst, ependymal cyst.

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• Acquired cyst
• Retention cyst
• due to accumulation of secretion in gland
  behind an obstruction of a duct.
• e.g sebaceous cyst, Pseudu pancreatic cyst,
  parotid gland cyst.

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• Distension cyst
• occur in thyroid from dilatation of acni.
• cystic hygroma and lymphatic cyst.

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• Exudation Cyst
• Exudative fluid accumulate in endothelium
  lined anatomical space.
• e.g Hydrocele, bursa.

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• Cystic tumor
• e.g cystic teratoma, cystadenoma.
• Implantation dermoid
• Squamous epithelium driven beneath skin by
  penetrating wound.

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Clinical Features

• Varies according to the site size
• Pain ? enlarging cysts,
• Pain ? Secondary to haemorrhage, infection,
  rupture, torsion
• Acute abdominal emergency torsion or rupture of
  ovarian cyst

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Clinical Features

• Compression symptoms resulting from compression
  of adjacent structures
• Haemorrhage in thyroglossal cyst ? increase in
  size ? compress the trachea
• Large ovarian cyst ? abd fullness reduced
  appetite resulting from raises I/abd pressure
• Obstruction to pelvic veins ? varicose veins of
  lower limbs

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COMPLICATIONS

1. Infection
2. Haemorrhage
3. Torsion
4. Obstruction
5. Calcification
6. Malignancy ( very rarely)

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INVESTIGATIONS

• Signs Fluctuant, transilluminant if containing
  clear fluid
• Diagnosis obvious in cases of superficial cysts
• Deep seated intra-abdominal or thoracic cysts
  need U/sound, CT scan, MRI

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ULCER

• An ulcer is a break in the continuity of an
  epithelial surface.
• Characterized by progressive destruction of the
  surface epithelium and a granulating base which
  may clean, healthy or containing necrotic slough

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Clinical Examination

• Size
• Shape
• Edge
• Floor
• Base
• Discharge

• Surrounding area
• Lymph nodes
• Pain
• General exam
• Pathological exam

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Marjolins ulcer

• Malignant change occurring in any long standing
  benign ulcer irrespective of its cause.
• Change usually occurs at the edge of a chronic
  ulcer

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Management

• Treatment of cause
• Accurate assessment of the ulcer
• Identify correct the co - morbid factors
• Adequate drainage desloughing
• Antiseptics and topical antibiotics
• Wound dressings
• Hydrogel
• Alginates
• Lyofoam
• Tegaderm
• Alleyvn

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SINUSES

• A sinus is a blind tract usually lined with
  granulation tissue that leads from an epithelial
  surface into the surrounding tissue.
• e.g. pilonidal sinus

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FISTULA

• It is a communicating track between two
  epithelial surfaces, commonly between a hollow
  viscus and the skin ( external fistula) or
  between two hollow viscera ( internal fistula)
• The track is lined with granulation tissue which
  is subsequently epithelialzed

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CLASSIFICATION

• Congenital
• Acquired

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Pathological sinuses

• CONGENITAL
• 1. Preauricular
• 2. Umbilical
• 3. Urachal
• 4. Coccygeal
• 5. Sacral

• ACQUIRED
• 1. Pilonidal
• 2. Suture
• 3. Post-surgical
• 4. Actinomycosis
• 5. Tuberculosis
• 6. Osteomyelitis

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Persistence of a sinus or fistula

• F Foreign Body Necrotic Tissue
• R Radiation
• I Immunosupression
• Infection
• Ischemia
• E Epithelization
• N Neoplasia
• D Drugs (eg Steroids , Cytotoxic drugs)
• Distal Obstruction
• S Systemic Diseases (eg AIDS)

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Clinical features

• Asymptomatic
• Recurrent or persistent discharge
• Pain
• Infection

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Diagnosis

• Assess the accurate direction, depth presence
  of multiple tracts.
• Microbiological examination of discharge ( gut
  organism, actinomycosis, tuberculosis)
• Sinogram

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Management of Sinus

• Complete excision of all sinus tract.
• Sinus is laid open or excised
• Biopsy of tissue is sent
• Removal of the cause

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