Spoljar Sanja
Klinicki bolnicki centar Sestre milosrdnice, Klinika za kozne i spolne bolesti, Referentni centarza kronicne rane Ministarstva zdravlja RH, Zagreb, Hrvatska.
Acta Med Croatica. 2013 Oct;67 Suppl 1:21-8.
Many factors contribute to the pathogenesis of leg ulcer. Most patients have venous leg ulcer due to chronic venous insufficiency. Less often, patients have arterial leg ulcer resulting from peripheral arterial occlusive disease, the most common cause of which is arteriosclerosis. Leg ulcer may be of a mixed arteriovenous origin. In diabetic patients, distal symmetric neuropathy and peripheral vascular disease are probably the most important etiologic factors in the development of diabetic leg ulcer. Other causes of chronic leg ulcers are hematologic diseases, autoimmune diseases, genetic defects, infectious diseases, primary skin diseases, cutaneous malignant diseases, use of some medications and therapeutic procedures, and numerous exogenous factors. Diagnosis of leg ulcer is based on medical history, inspection, palpation of skin temperature, palpation of arteries, fascia holes, presence and degree of edema, firm painful cords, and functional testing to assess peripheral occlusive arterial disease or identify superficial and deep venous reflux of the legs. Knowledge of differential diagnosis is essential for ensuring treatment success in patients with leg ulcer. There are many possible etiologic factors of leg ulcers and sometimes, clinical findings are similar. Additional testing should be performed, e.g., serologic testing such as blood count, C-reactive protein, HBA1c, erythrocyte sedimentation rate, differential blood count, total proteins, electrolytes, coagulation parameters, circulating immune complex, cryoglobulins, homocysteins, AT, PAI-1, APC resistance, proteins C and S, paraproteins, ANA, ENA, ANCA, dsDNA, antiphospholipid antibodies, urea, creatinine, blood lipids, vitamins and trace elements. Also, biopsy of the lesion for histopathology, direct immunofluorescence, bacteriology and mycology should be included. Other tests are Raynaud (cold stimulation) test and pathergy test. Device-based diagnostic testing should be performed for future clarification. Ankle brachial pressure index, color duplex sonography, plethysmography, MSCT and MR angiography, digital subtraction angiography, phlebography, angiography, x-ray, and capillaroscopy in lupus erythematosus are indicated. Except for bacteriologic analyses of wound biopsies, there is no test to provide specific information on the wound condition.
许多因素导致腿部溃疡的发病机制。大多数患者因慢性静脉功能不全而患有静脉性腿部溃疡。较少见的情况是，患者因外周动脉闭塞性疾病而患有动脉性腿部溃疡，其最常见的病因是动脉硬化。腿部溃疡可能具有动静脉混合起源。在糖尿病患者中，远端对称性神经病变和外周血管疾病可能是糖尿病腿部溃疡发生发展中最重要的病因。慢性腿部溃疡的其他病因包括血液系统疾病、自身免疫性疾病、基因缺陷、传染病、原发性皮肤病、皮肤恶性疾病、某些药物和治疗程序的使用以及众多外部因素。腿部溃疡的诊断基于病史、检查、皮肤温度触诊、动脉触诊、筋膜孔、水肿的存在及程度、坚硬疼痛的索状物以及评估外周闭塞性动脉疾病或识别腿部浅静脉和深静脉反流的功能测试。了解鉴别诊断对于确保腿部溃疡患者的治疗成功至关重要。腿部溃疡有许多可能的病因，有时临床表现相似。应进行额外的检查，例如血清学检查，如血细胞计数、C反应蛋白、糖化血红蛋白、红细胞沉降率、分类血细胞计数、总蛋白、电解质、凝血参数、循环免疫复合物、冷球蛋白、同型半胱氨酸、抗凝血酶、纤溶酶原激活物抑制剂 -1、活化蛋白C抵抗、蛋白C和S、副蛋白、抗核抗体、可提取核抗原、抗中性粒细胞胞浆抗体、双链DNA、抗磷脂抗体、尿素、肌酐、血脂、维生素和微量元素。此外，应包括对病变进行组织病理学活检、直接免疫荧光、细菌学和真菌学检查。其他检查有雷诺（冷刺激）试验和针刺反应试验。为了进一步明确诊断，应进行基于设备的诊断测试。踝臂压力指数、彩色双功能超声、体积描记法、多层螺旋CT和磁共振血管造影、数字减影血管造影术液造影、血管造影、X线以及红斑狼疮中的毛细血管镜检查均有必要。除了伤口活检的细菌学分析外，没有任何检查能提供有关伤口状况的具体信息。
