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BDS2; CHHD > Gastroenterology lower GIT > Flashcards

Gastroenterology lower GIT Flashcards

1. Recall the anatomy an physiology of the lower GIT 2. Outline the clinical features of lower GIT disorders 3. Describe the special investigations used to establish a diagnosis of lower GIT diseases 4. Recognise oro-facial manifestations of lower GIT diseases 5. Recognise the impact of respective treatments of lower GIT diseases on oral health

1
Q

What makes up the lower GIT

A
  1. Small intestine
    - duodenum
    - jejunum
    - ileum
  2. Large intestine
    - colon
    - ascending, transverse, descending segments
  3. Rectum and anus
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2
Q

What are the main functions of the small intestine

A

Connects the stomach to large intestine

  1. Digestion
  2. Absorption
    - iron + folate = duodenum
    - other substances = jejunum
    - gastric intrinsic factor + B12 = terminal ileum
    - bile salts, fats, fat soluble vitamins = terminal ileum
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3
Q

What are the features of steatorrhoea

A
  • bulky stools
  • floating and difficult to flush
  • greasy, fatty or frothy appearance
  • foul smell
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4
Q

What are the causes of steatorrhoea

A
  • coeliac disease/crohn’s
  • pancreatitis
  • liver disease
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5
Q

What is coeliac disease

A

It is gluten sensitive enteropathy where the patient has a permanent intolerance/hypersensitivity/toxic reaction to alpha-gliadin component of gluten found in wheat, oats, rye and barley and this has a strong genetic background

It is a T-cell mediated autoimmune disease and is associated with other autoimmune conditions

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6
Q

What happens in coeliac disease

A
  1. Indigestion of gluten
  2. Jejunal villous atrophy and inflammation
  3. Malabsorption
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7
Q

How does coeliac disease cause other complications in the body

A

Occurs at any age affecting the GI tract or mouth

  1. Villous atrophy causes malabsorption resulting in
    - growth retardation in children
    - vitamin deficiencies (anaemia, bleeding tendencies)
    - mineral deficiencies (osteomalacia = risk factor for osteoporosis in elder patients)
    - chronic diarrhoea
  2. Inflammation
  3. Small risk of developing GI T-cell lymphomas and other malignancies
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8
Q

What are the clinical manifestations of coeliac disease

A
  1. Glossitis
  2. Burning mouth
  3. Angular chelitis
  4. Tiredness
  5. Malaise
  6. Easy bruising
  7. Steatorrhoea (fatty stools)
  8. Weight loss
  9. Crampy abdominal pain
  10. Bloating
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9
Q

What investigations are done to identify coeliac disease

A
  1. FBC; iron deficiency anaemia
  2. Haematinics screen; low B12, folate and iron
  3. Stool examination; XS fat (steatorrhea)
  4. Serology; look for IgA antibodies (antigliadin, antiendomysial and tissue transglutaminase antibodies)
  5. Endoscopy; villous atrophy
  6. Small intestine biopsy
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10
Q

Describe the oral lesions occurring in coeliac disease

A

Recurrent oral ulceration or dental hypoplasia in enamel

- this is due to reduced absorption from small bowel mucosa

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11
Q

Identify the dental aspects of coeliac disease

A
  1. Dental hypoplasia
  2. Glossitis and burning mouth
  3. Angular chelitis
    4 .Recurrent oral ulceration
  4. Exacerbation of LP
  5. Associated autoimmune diseases e.g. Sjogrens, DM
  6. Malignant disease
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12
Q

What is Sjogren’s syndrome

A

Affects fluid secreting glands and causes dry eyes, mouth, skin and lack of salivation - this is associated with rheumatoid arthritis

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13
Q

What are the less common associations of coeliac diesease

A
  1. Dermatitis herpetiformis
  2. Linear IgA disease
  3. Selective IgA deficiency
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14
Q

What is dermatitis herpatiformis

A

It is associated with coeliac disease and is an autoimmune hypersensitive gluten reaction affecting middle aged males producing a pyritic vesiculopapular rash typical at bottom and elbow; most patients will have oral lesions

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15
Q

What is dental hypoplasia

A

This can be seen in most children with coeliac disease

  • it is an enamel defect which is symmetrically and chronologically distributed
  • mostly mild defects
  • rough surface with horizontal grooves and shallow pits
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16
Q

Outline managements for coeliac disease

A

Gluten-free diet - this can be challenging; and to correct any nutritional deficiencies

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17
Q

What can happen if coeliac disease is left untreated

A

Patients may develop bleeding tendencies secondary to anaemia (this can complicate GA use) and osteomalacia

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18
Q

What are the main functions of the large intestine

A

It is between the terminal ileum and anus and is for

  • recovery of water and electrolytes
  • formation, storage and expulsion of stools
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19
Q

What is Crohn’s disease

A

Patchy full thickness ulcerations involving any part of the GIT from mouth to anus;

  • it has discontinuous involvement = skip lesions
  • the terminal ileum is the most affected area
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20
Q

Describe the histology of Crohn’s disease

A

There is transmural granulomatous inflammation (this means the whole of the gut wall is included)

21
Q

Outline the clinical features seen when Crohn’s disease affects the mouth

A
  1. Peri-oral and lip swelling
  2. Mucosa tags/ cobble-stoning
  3. Angular stomatitis
  4. Atypical ulcers
  5. Recurrent apthous stomatitis
  6. Lesions associated with nutritional deficiencies
22
Q

Outline the clinical features seen when Crohn’s disease affects the small intestine

A
  1. Abdominal pain (apendicitis)
  2. Abnormal bowel habits; diarrhoea and constipation
  3. Weight loss
  4. Malabsorption
23
Q

Outline the clinical features seen when Crohn’s disease affects the large intestine

A
  1. Non-blood diarrhoea lasting more than 6 weeks
  2. Bleeding and pain related to defecation
  3. Intestinal obstruction due to structuring disease (scar tissue formation in areas of inflammation)
24
Q

Outline the clinical features seen when Crohn’s disease affects perianal areas

A
  1. Anal tags
  2. Anal fissure, fistula
  3. Anal abscess formation
25
Q

Outline the extra-intestinal features of Crohn’s disease

A
  1. Musculoskeletal system
    - arthritis
    - ankylosing spondylitis (spine)
  2. Skin
    - erythema nodosum
    - psoriasis (red crusty patches of skin with silver scales)
    - pyoderma gagrenosum
26
Q

What is erythema nodosum

A

Associated with Crohn’s = swollen fat under skin causing red raised, itchy and tender bumps

27
Q

What is pyoderma gangrenosum

A

Infected tissue breakdown causing painful ulcers which have characteristic borders of blue loose skin

28
Q

What investigations are carried out to determine Crohn’s disease

A
  1. FBC; anemia, microcytosis, thrombocytosis
  2. Inflammatory markers; ESR, CRP increase
  3. Haematinic screen; folate, ferritin, iron, B12, potassium, zinc decrease
  4. Faecal calprotectin increase
  5. Stool microscopy to exclude infective diarrhoea
  6. Radiology; endoscopy, MRI, CT, barium follow through
  7. Mucosal biopsy; non-caesating granuloma
29
Q

Outline management for Crohn’s disease (non-drug)

A
  1. Diet; exclude benzoate’s, cinnamonaldehyde, E-preservatices
  2. Lifestyle; stop smoking, avoid stress, exercise, hydration
  3. Correct nutritional deficiencies
  4. Surgery to drain abscesses, repair fistulae and fissures
30
Q

Outline drug therapies for Crohn’s disease

A
  1. Anti-inflammatory drugs = sulfasalazine, mesalazine
  2. Immunomodulators = prednisolone, methotrexate
  3. Biological therapies = anti-TNFa-Infliximab/Adalimumab
31
Q

How should patients with Crohn’s be treated in dentistry

A
  • avoid stress as this can cause flare-ups
  • avoid antibiotics as this aggravates diarrhoea
  • evaluate corticosteroid history
  • delay routine dentistry in fare-ups
  • oro-facial granulomatosis may precede GI manifestations
32
Q

What is ulcerative colitis

A

Diffuse inflammation in the superficial layers of mucosa affecting the whole or part of the large intestine; it can be persistent or relapse and remitting and cause ‘backwash ilieitis’

33
Q

What are the clinical features of ulcerative colitis

A
  • abdominal pain
  • bloody diarrhoea
  • pus
  • intermixed mucus with/without systemic toxicity
  • joint pain
  • conjunctivitis
  • finger clubbing
  • erythema nodosum, pyoderma gangrenosum

Specific oral manifestations are rare

34
Q

What systemic toxicity can arise from ulcerative colitis

A
  • fever
  • anorexia
  • weight loss
  • anaemia
  • raised ESR and CRP inflammatory markers
35
Q

What is the risk of colon carcinoma increased by

A

Patients with early onset ulcerative colitis and those that have had the chronic disease for > 10years

36
Q

What is pseudomembranous colitis and when does it arise

A

This is associated with proliferation of clostridium difficile in elderly or debilitated patients and occurs after high doses or prolonged antibiotic use (lincomycin, clindamycin)

It manifests as painful diarrhoea and mucus passage in stool

37
Q

What is pseudomembranous colitis treated with

A
  1. Oral metronidazole

2. Vancomycin

38
Q

What is irritable bowed syndrome

A

A functional bowel disorder more common in females that has an unknown cause but is linked to

  • infection
  • stress
  • anxiety
39
Q

What are the clinical features of IBS

A
  1. Patient looks healthy so examination is usually normal
  2. Crampy abdominal pain relived by defecation or flatulence
  3. Bloating or abdominal distension
  4. Altered bowel habit
40
Q

How is IBS managed

A

Anti-spasmodics e.g. mebeverine

Stress reduction through CBT and anti-depressants

High-fibre diet

41
Q

What are the dental aspects of IBS

A

Psychogenic oral symptoms such as

  • burning mouth syndrome (nerve dysfunction)
  • persistent idiopathic facial pain
  • sore tongue
42
Q

What is Peutz-Jegher’s syndrome

A

Autosomal dominant mucocutaneous hyperpigmentation and gastrointestinal harmatomatous polyps (benign growths causing bleeding and obstruction)

43
Q

What complications can arise with Peutz-Jegher’s syndrome

A
  • intestinal obstruction
  • abdominal pain
  • gastrointestinal bleeding
44
Q

What is appendicitis

A

inflammation of the appendix usually causing pain that starts in the middle of your tummy before moving towards the lower right side and this is treated by surgical removal of the appendix

45
Q

What is diverticular disease

A

Diverticular disease and diverticulitis are related digestive conditions that affect the large intestine they are small bulges or pockets that can develop in the lining of the intestine

46
Q

What is familial polyposis coli

A

Familial adenomatous polyposis (FAP) is a rare, inherited condition caused by a defect in the adenomatous polyposis coli (APC) gene

47
Q

What is Gardener’s syndrome

A

Gardner syndrome is a form of familial adenomatous polyposis (FAP) that is characterised by multiple colorectal polyps and various types of tumours, both benign and malignant

Requires regular colonoscopy and flexible sigmoidoscopy to monitor polyps

48
Q

What is linear IgA disease

A

Bullous pemphigoid like gluten-enteropathy which is less commonly associated with coeliac disease

BDS2; CHHD (32 decks)

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