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I now have comprehensive information from multiple textbooks. Let me compile the complete hernia viva Q&A.

Hernia - Comprehensive Viva Q&A

1. DEFINITION & BASICS

Q: Define hernia. A: A hernia is a protrusion of a viscus (or part of a viscus) through an abnormal opening in the wall of the cavity that normally contains it.
Q: What are the essential parts of a hernia? A: Every hernia has three components:
  • Sac - a peritoneal diverticulum composed of mouth, neck, body, and fundus
  • Contents - what is inside the sac (omentum, small bowel, large bowel, bladder, ovary, etc.)
  • Coverings - the layers of the abdominal wall that cover the sac
Q: What is the most common content of a hernia? A: Omentum (epiplocele). Small bowel is the next most common.

2. ANATOMY

Q: What are the boundaries of Hesselbach's (Hesselbachs) triangle? A:
  • Medially - lateral border of rectus abdominis
  • Inferiorly - inguinal ligament
  • Laterally - inferior epigastric vessels
Direct inguinal hernias pass through this triangle.
Q: What are the boundaries of the femoral canal? A (from S. Das):
  • Superoanteriorly - inguinal ligament
  • Inferoposteriorly - pubic ramus and pectineus muscle
  • Medially - lacunar (Gimbernat's) ligament
  • Laterally - femoral vein
Q: What is the difference between the deep and superficial inguinal rings? A:
  • Deep inguinal ring: opening in the transversalis fascia, lies lateral to the inferior epigastric vessels
  • Superficial inguinal ring: opening in the external oblique aponeurosis, lies just above and medial to the pubic tubercle
Q: What is the inguinal canal? A: A 4 cm oblique passage in the lower abdominal wall running from deep inguinal ring (laterally) to superficial inguinal ring (medially). It runs parallel to and just above the medial half of the inguinal ligament.
  • Anterior wall: external oblique aponeurosis (and internal oblique laterally)
  • Posterior wall: transversalis fascia (and conjoint tendon medially)
  • Roof: arching fibers of internal oblique and transversus abdominis
  • Floor: inguinal ligament and lacunar ligament medially

3. INDIRECT vs DIRECT INGUINAL HERNIA

Q: Differentiate indirect from direct inguinal hernia.
FeatureIndirectDirect
PathThrough deep inguinal ring, along canal, out superficial ringDirectly through posterior wall of inguinal canal (Hesselbach's triangle)
Relation to epigastric vesselsLateralMedial
TypeCongenital or acquiredAlways acquired
NeckNarrow - high risk of strangulationWide - low risk of strangulation
Descent into scrotumCommonRare
AgeYounger patientsOlder patients
Sac relation to cordWithin spermatic cordMedial to cord
Zieman's test fingerIndex fingerMiddle finger
(Bailey & Love; General Anatomy - Thieme Atlas)
Q: Which is more common - direct or indirect inguinal hernia? A: Indirect inguinal hernia is more common (accounts for ~60% of inguinal hernias). Overall, inguinal hernia is the most common hernia.
Q: Why is the right side more common for indirect inguinal hernia? A: Because the right testis descends later than the left; the processus vaginalis closes later on the right, leaving a patent processus for longer and increasing risk.

4. CLINICAL TYPES / COMPLICATIONS

Q: What are the clinical types of hernia?
  1. Reducible hernia - Contents can be returned into the abdominal cavity
  2. Irreducible (Incarcerated) hernia - Contents cannot be returned; no blood supply interference yet
  3. Obstructed hernia - Irreducible + intestinal obstruction; no interference with blood supply (yet)
  4. Strangulated hernia - Irreducible + obstruction + arrest of blood supply to contents - a surgical emergency
  5. Inflamed hernia - Rare; contents become inflamed (appendix, Meckel's, salpinx); not tense, no intestinal obstruction
(S. Das, Manual on Clinical Surgery)
Q: What is strangulation? How is it diagnosed? A: Strangulation = blood supply to hernial contents is cut off. Diagnosis: hernia is irreducible, extremely tense, tender, no impulse on coughing, followed by features of intestinal obstruction. Patient is toxic, dehydrated, febrile. - Mulholland & Greenfield's Surgery
Q: Is intestinal obstruction always present in strangulation? A: No. Intestinal obstruction may NOT be present in:
  • Omentocele (only fat content)
  • Richter's hernia (only part of bowel wall strangulated)
  • Littre's hernia (Meckel's diverticulum involved)
Q: Which hernia has the highest risk of strangulation? A: Femoral hernia - because of its narrow, rigid neck bounded by the lacunar ligament. All femoral hernias should be repaired electively. - Bailey & Love

5. SPECIAL/EPONYMOUS HERNIAS

Q: What is Richter's hernia? A: Only a portion of the circumference (antimesenteric wall) of the bowel is strangulated in the hernial sac. Intestinal obstruction is absent until >50% of circumference is involved. Most commonly complicates femoral hernia. Dangerous because it mimics gastroenteritis and diagnosis is delayed. - S. Das; Yamada's GI
Q: What is Littre's hernia? A: A hernia containing a Meckel's diverticulum in the sac.
Q: What is Maydl's hernia (Hernia-en-W)? A: Two loops of bowel lie in the sac with the connecting loop remaining inside the abdomen. The connecting loop undergoes retrograde strangulation first ("W" shape). The danger is that the abdominal loop is strangulated even though the loops in the sac appear viable - this is missed unless the abdomen is opened and the connecting loop inspected.
Q: What is a sliding hernia (hernia-en-glissade)? A: A portion of extraperitoneal bowel (usually caecum on right, pelvic colon on left, or bladder on either side) slides down to form the wall of the hernial sac. The sac is not completely lined by peritoneum - the bowel forms part of the posterior wall. Important surgically: do not excise the sac without identifying this.
Q: What is a pantaloon hernia? A: Both a direct and indirect hernia are present simultaneously on the same side, straddling the inferior epigastric vessels.
Q: What is Spigelian hernia? A: A hernia through the linea semilunaris (lateral border of rectus), usually below the level of the umbilicus at the arcuate line. It is an interparietal hernia - between layers of the abdominal wall - and can be difficult to diagnose clinically.
Q: What is an obturator hernia? A: Protrusion through the obturator canal. More common in elderly, thin women. Classic sign is Howship-Romberg sign - pain on the inner aspect of the thigh radiating to the knee due to compression of the obturator nerve.

6. FEMORAL HERNIA

Q: Why do femoral hernias have a higher risk of strangulation? A: Because the femoral ring has rigid, unyielding boundaries - especially the sharp medial boundary formed by the lacunar (Gimbernat's) ligament.
Q: Where does a femoral hernia emerge superficially? A: Through the saphenous opening (fossa ovalis), situated 1.5 inches below and lateral to the pubic tubercle. It then expands into the loose subcutaneous tissue and takes a retort shape.
Q: How do you distinguish a femoral hernia from an inguinal hernia clinically? A:
  • Femoral hernia lies below and lateral to the pubic tubercle
  • Inguinal hernia lies above and medial to the pubic tubercle
Q: Why is femoral hernia more common in women? A: Women have a broader pelvis, giving a larger femoral ring. - Thieme Atlas

7. EXAMINATION

Q: How do you examine for an inguinal hernia? A:
  1. Inspect in standing position - visible swelling with cough impulse
  2. Reduce hernia if possible
  3. Invaginate scrotum to reach superficial inguinal ring; ask patient to cough - a hernia impulse is felt
  4. Press finger at deep inguinal ring (just above midpoint of inguinal ligament) - if hernia is controlled, it is indirect; if not, it is direct
  5. Assess tone of abdominal muscles (Malgaigne's bulgings test)
  6. Percussion: resonant = enterocele; dull = epiplocele
Q: What is Zieman's test? A: The three fingers of the right hand are placed on the right inguinal region with:
  • Index finger on the superficial inguinal ring
  • Middle finger on the femoral canal
  • Ring finger on the obturator foramen Ask the patient to cough - impulse felt against index finger = inguinal hernia; middle finger = femoral hernia; ring finger = obturator hernia.

8. SURGICAL REPAIR

Q: What are the principles of hernia repair? A:
  1. Reduce contents
  2. Excise sac (herniotomy)
  3. Repair/reinforce the defect (herniorrhaphy / hernioplasty)
Q: What is the Lichtenstein repair? A: Tension-free flat polypropylene mesh repair of inguinal hernia, described by Lichtenstein in the 1980s. The mesh is sutured to the inguinal ligament inferiorly and to the conjoint tendon/internal oblique above, creating a tension-free reinforcement of the posterior wall. Currently the most widely performed open inguinal hernia repair globally. - Bailey & Love; Sabiston
Q: Why is tension-free repair preferred? A: Tension at the repair site is a primary contributor to recurrence. Mesh bridges the defect without bringing tissues together under tension.
Q: What are the laparoscopic approaches for inguinal hernia? A:
  • TAPP - Transabdominal Preperitoneal Repair (enters peritoneal cavity, dissects preperitoneal space)
  • TEP - Totally Extraperitoneal Repair (works entirely in preperitoneal space, does not enter peritoneum)
Q: When is surgery MANDATORY for hernia? A: All femoral hernias, obstructed hernias, and strangulated hernias require surgery. Symptomatic or irreducible inguinal hernias should also be repaired.
Q: What is watchful waiting in inguinal hernia? A: In asymptomatic inguinal hernias, watchful waiting is safe - approximately 10% per year cross over to surgery due to developing symptoms. - Bailey & Love

9. UMBILICAL & INCISIONAL HERNIA

Q: Define umbilical, paraumbilical and incisional hernia.
  • True umbilical hernia: congenital, through the umbilical ring, common in infants - most close spontaneously by age 2-3 years
  • Paraumbilical hernia: in adults, occurs just above or below the umbilicus through a weakness in the linea alba; more common in obese, multiparous women
  • Incisional hernia: hernia through a previous surgical incision; caused by wound infection, poor closure, obesity, malnutrition, steroids
Q: What is the most common cause of incisional hernia? A: Wound infection. Other causes: poor suture technique, malnutrition, obesity, chronic cough, steroids.

10. HIGH-YIELD MNEMONICS

Sac contents - common to rare: Omentum > Small bowel > Large bowel (caecum/sigmoid) > Bladder > Ovary/Fallopian tube
Femoral canal mnemonic (NAVY - lateral to medial): Nerve, Artery, Vein, Y-fronts (empty space = femoral canal)
Strangulation triad: Irreducible + No cough impulse + Tense & Tender
Sources: S. Das - Manual on Clinical Surgery 13th ed.; Bailey & Love's Short Practice of Surgery 28th ed.; Thieme General Anatomy & Musculoskeletal Atlas; Mulholland & Greenfield's Surgery 7e; Sabiston Textbook of Surgery; Yamada's Textbook of Gastroenterology

Ulcer all viva question given

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I now have very comprehensive textbook material. Let me compile the complete ulcer viva answer.

ULCER - Complete Viva Q&A

(Sources: S. Das - Manual on Clinical Surgery 13th ed.; Bailey & Love's 28th ed.; Schwartz's Surgery 11th ed.; Maingot's Abdominal Operations; Katzung's Pharmacology 16th ed.)

SECTION 1: DEFINITION & CLASSIFICATION

Q: Define an ulcer. A: An ulcer is a break in the continuity of a covering epithelium (skin or mucous membrane) that does not heal within the expected time period. It may be on the surface of the skin or on the mucous membrane.
Q: What are the parts of an ulcer? A: Every ulcer has five parts:
  1. Margin - the junction between normal epithelium and the ulcer (boundary)
  2. Edge - the area between the margin and the floor; activity is maximum here
  3. Floor - the exposed surface inside the ulcer (what you see)
  4. Base - the tissue on which the ulcer rests (felt between finger and thumb, not seen)
  5. Surrounding area - the skin/tissue around the ulcer
Q: Classify ulcers.
(A) Non-specific ulcers:
  1. Traumatic - mechanical, physical, chemical
  2. Arterial (ischaemic) - atherosclerosis, Buerger's, Raynaud's
  3. Venous - varicose/post-thrombotic ulcer
  4. Neurogenic (trophic) - bed sore, perforating ulcer (tabes dorsalis, leprosy, DM neuropathy)
  5. Associated with systemic disease - gout, diabetes, anaemia, avitaminosis
  6. Tropical ulcer (malnutrition/Vincent's organisms)
  7. Bazin's ulcer (young obese girls, calves)
  8. Martorell's ulcer (hypertensive)
(B) Specific ulcers:
  • Tuberculous, syphilitic, soft chancre (chancroid), actinomycosis, Meleney's ulcer
(C) Malignant ulcers:
  • Epithelioma (squamous cell carcinoma), Marjolin's ulcer, Rodent ulcer (basal cell carcinoma), Malignant melanoma

SECTION 2: CLINICAL EXAMINATION OF AN ULCER

History

Q: What do you ask in history of a patient with an ulcer? A:
  1. Onset - how did it start? spontaneously or from swelling/injury?
  2. Duration - acute vs chronic
  3. Pain - painful or painless?
  4. Discharge - character (serous, purulent, serosanguineous)
  5. Associated disease - diabetes, TB, syphilis, neurological disease

Inspection

Q: What do you look for on inspection? A:
  1. Size and shape - tuberculous ulcers are oval; syphilitic are circular/serpiginous; varicose are vertically oval; carcinomatous are irregular
  2. Number - TB, gummatous, varicose, soft chancre may be multiple
  3. Position - varicose ulcer at medial malleolus; rodent ulcer above line joining mouth angle to ear lobule (upper face); trophic ulcer on heel/ball of foot
  4. Edge - (see below)
  5. Floor - red granulation = healing; pale granulation = slowly healing; wash-leather slough = gummatous ulcer; bone in floor = trophic ulcer
  6. Discharge - scanty serous = healing; purulent = spreading/inflamed; serosanguineous = TB or malignant; greenish = B. pyocyanea

Types of Edge

Q: What are the different types of ulcer edges? Which ulcer has which edge?
Edge TypeDescriptionUlcer
Sloping/shelvingGently sloping, like a beachHealing ulcer
UnderminedEdge overhangs floor, can insinuate probeTuberculous ulcer
Punched outVertical wall, like a punch holeGummatous ulcer, Trophic ulcer
Raised & rolled/beadedPearly rolled-in edgeRodent ulcer (BCC)
Raised & everted/proliferativeEdge raised outward, cauliflower-likeSquamous cell carcinoma (Epithelioma)
Undermined + reddish-blueCharacteristic undercuttingTuberculous ulcer
(S. Das, Manual on Clinical Surgery)

Palpation

Q: What do you feel on palpation?
  1. Tenderness: Acutely inflamed = exquisitely tender; TB/syphilis = slightly tender; varicose = variable; malignant = NOT tender (neoplastic ulcers are never tender)
  2. Edge induration: Marked induration = squamous cell carcinoma; moderate = any chronic ulcer
  3. Base: Marked induration = squamous cell carcinoma or Hunterian chancre (hard chancre)
  4. Depth: Trophic ulcer can reach bone
  5. Bleeding to touch: Feature of malignant ulcer
  6. Fixity to deeper structures: Malignant infiltration; gummatous ulcer may fix to subcutaneous bone
  7. Surrounding skin: Raised temperature/tenderness = acute inflammation; eczema/pigmentation = venous; no sensation = trophic/neurogenic
  8. Peripheral pulses: Feel for absent dorsalis pedis in ischaemic ulcers

Lymph Nodes

Q: How do lymph nodes behave in different ulcers?
UlcerLymph nodes
Acute inflammatoryEnlarged, tender, may suppurate
TuberculousEnlarged, matted, slightly tender
Hard chancre (Syphilis)Enlarged, non-tender, rubbery (shotty), NOT matted
Soft chancre (Chancroid)Enlarged, tender, may form bubo
Epithelioma (SCC)Hard, fixed, matted (metastasis or secondary infection)
Marjolin's ulcerUsually NOT enlarged (lymphatics destroyed by chronic scarring)

SECTION 3: SPECIFIC ULCER TYPES (HIGH YIELD)

Varicose (Venous) Ulcer

Q: What is a venous ulcer? Where does it occur? A: Caused by chronic venous hypertension, usually from deep vein thrombosis (DVT) with valve destruction. NOT directly caused by varicose veins - hence "venous ulcer" is preferred over "varicose ulcer."
  • Site: Medial aspect of lower third of leg, just above medial malleolus (gaiter area)
  • Shape: Vertically oval
  • Surrounding skin: Eczema, pigmentation (lipodermatosclerosis)
  • Edge: Sloping or irregular
  • Pain: Present initially, settles over time
  • Main complication: Malignant change - Marjolin's ulcer (from the growing edge)

Arterial / Ischaemic Ulcer

Q: Features of arterial ulcer? A:
  • Causes: Atherosclerosis (commonest), Buerger's disease, Raynaud's disease
  • Site: Heel, tips of toes, dorsum of foot (pressure areas)
  • Edge: Punched out
  • Floor: Minimal granulation, may expose tendons/bone
  • Extremely painful, worsens with leg elevation
  • No relief at rest (cf. venous ulcer relieved by elevation)
  • Peripheral pulses: Absent or feeble dorsalis pedis
  • Arteriography: Required to define arterial disease

Trophic (Neurogenic) Ulcer

Q: What is a trophic ulcer? What are its causes? A: Develops from repeated trauma to an insensitive area of the body. Begins as callosity under which suppuration occurs.
  • Causes: Leprosy, tabes dorsalis, diabetic neuropathy, syringomyelia, transverse myelitis, peripheral nerve injury
  • Site: Heel, ball of foot (ambulatory) or sacrum/back of heel (non-ambulatory)
  • Edge: Punched out, corny (callous)
  • Floor: Offensive slough, tendons/bone may be exposed
  • Absolutely painless (due to loss of sensation)
  • Surrounding skin: Loss of sensation

Tuberculous Ulcer

Q: Features of a tuberculous ulcer? A:
  • Common sites: Neck, axilla, groin (where TB lymphadenopathy is common)
  • Edge: Undermined (pathognomonic) - probe can be insinuated under the edge; thin, reddish-blue, undermined
  • Floor: Pale granulation tissue with scanty serosanguineous discharge
  • Base: Slight induration
  • Slightly painful
  • Lymph nodes: Matted, slightly tender
  • Surrounding skin: May show scar/wrinkling from old TB

Syphilitic Ulcers

Q: Describe syphilitic ulcers at different stages.
(i) Hard Chancre (Primary syphilis):
  • Appears 3-4 weeks after infection on external genitalia
  • Edges regular, base indurated (hard) - pathognomonic
  • Painless
  • Lymph nodes: Enlarged, non-tender, rubbery, NOT matted (shotty)
  • Discharge: Scanty, serous
(ii) Gummatous Ulcer (Tertiary syphilis):
  • Site: Subcutaneous bones (tibia, sternum, skull)
  • Edge: Punched out (vertical walls, like a punch hole)
  • Floor: Wash-leather slough (wet chamois leather appearance) - pathognomonic
  • Base: Indurated, may be fixed to bone (tibia, sternum)
  • Painless

Rodent Ulcer (Basal Cell Carcinoma)

Q: Describe a rodent ulcer. A:
  • Commonest skin malignancy
  • Site: Upper part of face, above line joining angle of mouth to ear lobule, frequently near inner canthus
  • Edge: Rolled/beaded/pearly - the classic "rolled edge"
  • Very slow-growing, locally invasive - "rodent" because it gnaws slowly but does NOT metastasize (BCC very rarely metastasizes)
  • Floor: Covered with small blood vessels
  • Bleeds easily

Epithelioma (Squamous Cell Carcinoma)

Q: Describe features of epitheliomatous ulcer. A:
  • Onset: 40+ years, begins as nodule, center becomes necrotic and sloughs
  • Shape: Oval or circular, size variable
  • Edge: Raised and everted (proliferative) - pathognomonic
  • Floor: Necrotic tumour, serum, blood; pale unhealthy granulation
  • Base: Marked induration - pathognomonic
  • Bleeds easily to touch
  • Lymph nodes: Hard, matted, fixed (metastatic or infected)
  • Fixed to deeper structures in late stage

SECTION 4: EPONYMOUS ULCERS (HIGH YIELD VIVA)

Q: What is Marjolin's ulcer? A: A squamous cell carcinoma arising from a long-standing benign ulcer or scar.
  • Commonest ulcer to become malignant = long-standing venous ulcer
  • Commonest scar to undergo malignant change = scar of old burn
  • Features making it different from typical SCC:
    • Edge not always raised/everted
    • Painless (lymphatics destroyed)
    • No lymph node metastasis usually (lymphatics already occluded by chronic scarring)
    • Radioresistant (relatively avascular, extensive fibrosis)
    • Slower growing, less malignant than typical SCC
Q: What is Meleney's ulcer? A: A synergistic gangrene caused by a combination of microaerophilic Streptococcus and Staphylococcus aureus. Causes progressive undermining and necrosis of skin. Typically post-operative.
Q: What is Bazin's ulcer? A: Occurs in fatty adolescent girls on the calves; starts as purplish nodules followed by indolent ulcers; associated with erythema induratum (hypersensitivity to TB).
Q: What is Martorell's ulcer? A: A hypertensive ulcer; occurs in hypertensive patients on the leg (patches of skin necrosis); NOT due to atherosclerosis.

SECTION 5: PEPTIC ULCER (SURGICAL ASPECTS)

Q: Define peptic ulcer. A: An ulcer in any part of the GI tract exposed to acid-pepsin secretion. Common sites are the first part of the duodenum and the lesser curvature of the stomach. Also occurs at gastrojejunal stoma, oesophagus, and in Meckel's diverticulum (ectopic gastric epithelium). - Bailey & Love
Q: What are the causes of peptic ulcer? A: The two most important causes are:
  1. Helicobacter pylori infection (>90% of duodenal ulcers, ~70-80% of gastric ulcers)
  2. NSAIDs (including aspirin)
  3. Rare: Zollinger-Ellison syndrome (gastrinoma - high acid, multiple ulcers), stress ulcers, Cushing's ulcer (head injury), Curling's ulcer (burns)
Q: How does duodenal ulcer differ from gastric ulcer?
FeatureDuodenal UlcerGastric Ulcer
FrequencyMore commonLess common
Acid levelHighNormal or low
Pain timing2-3 hours after meals, relieved by foodBrought on by food, not relieved
Night painCommonLess common
H. pylori>90%~70-80%
Malignancy riskVery rareMust always exclude malignancy
SiteD1 (first part), anterior wallLesser curvature
Q: What are the complications of peptic ulcer? A: Three main complications (mnemonic: BOP):
  1. Bleeding - most common complication; anterior duodenal ulcer bleeds from gastroduodenal artery
  2. Obstruction (stenosis) - pyloric stenosis from scarring
  3. Perforation - most serious; anterior duodenal wall most common site; causes peritonitis
Q: What is Zollinger-Ellison syndrome? A: A gastrin-secreting tumour (gastrinoma) of the pancreas or duodenum causing very high acid secretion, multiple peptic ulcers in unusual sites (post-bulbar, jejunum), and diarrhoea.
Q: Medical treatment of peptic ulcer? A:
  • H. pylori eradication: Triple therapy - PPI + Clarithromycin + Amoxicillin x 14 days
  • PPIs (proton pump inhibitors) - mainstay of acid suppression
  • H2 blockers (ranitidine, famotidine) - second line
  • Avoid NSAIDs, smoking, alcohol
Q: When is surgery indicated for peptic ulcer? A: Elective surgery for peptic ulcer is now very rare. Surgery is indicated for:
  1. Emergency: Perforation, uncontrolled bleeding, obstruction
  2. Failure of medical therapy
  3. Suspicion of malignancy in gastric ulcer
Q: What surgical procedures are done for peptic ulcer? A:
  • Perforated ulcer: Graham's omental patch repair (primary closure + omental patch) + H. pylori eradication
  • Bleeding ulcer: Underrunning/oversewing of the vessel (gastroduodenal artery for DU)
  • Obstruction: Gastrojejunostomy
  • Elective: Truncal vagotomy + drainage (pyloroplasty/gastrojejunostomy) OR vagotomy + antrectomy; Proximal gastric vagotomy - Maingot's

SECTION 6: INVESTIGATIONS

Q: What investigations do you do for an ulcer?
For a general ulcer:
  • Swab for bacteriology
  • Biopsy (mandatory for any chronic/malignant ulcer)
  • FNAC of lymph nodes
  • Blood: CBC, blood sugar, VDRL/TPHA (syphilis), Mantoux test
  • Arteriography/Duplex Doppler for vascular ulcers
For peptic ulcer:
  • Upper GI endoscopy - gold standard; allows biopsy (for gastric ulcer - always biopsy to exclude malignancy)
  • H. pylori testing: Rapid urease test (CLO test), urea breath test, stool antigen, serology
  • Barium meal (if endoscopy not available)
  • Serum gastrin (if ZE syndrome suspected)
  • CT scan for perforation/complication assessment

SECTION 7: QUICK COMPARISON TABLE

FeatureVenousArterialTrophicTuberculousSCC (Epithelioma)Rodent (BCC)
SiteMedial malleolusHeel/toesHeel/pressure areasNeck/axillaAnywhereUpper face
EdgeSloping/irregularPunched outPunched out, cornyUnderminedRaised, evertedRolled/beaded
PainMild initiallySevereAbsentMildAbsent initiallyAbsent
PulseNormalAbsentNormal/absent (DM)NormalNormalNormal
NodesNormalNormalNormalMatted, tenderHard, fixedAbsent (no mets)
BleedNoNoNoNoYes (to touch)Yes (to touch)
SensationNormalReducedAbsentNormalNormalNormal

KEY MNEMONICS

Parts of ulcer: My Edge Falls Below Deeply = Margin, Edge, Floor, Base, Depth/Discharge
Peptic ulcer complications: BOP = Bleeding, Obstruction, Perforation
Painless ulcers: STMG = Syphilitic (hard chancre), Trophic, Malignant (early), Gummatous
Edge types mnemonic (SUPER P): Sloping = healing; Undermined = TB; Punched out = gumma/trophic; Everted = SCC; Rolled = BCC
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