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
What makes up the lower GIT
- Small intestine
- duodenum
- jejunum
- ileum - Large intestine
- colon
- ascending, transverse, descending segments - Rectum and anus
What are the main functions of the small intestine
Connects the stomach to large intestine
- Digestion
- Absorption
- iron + folate = duodenum
- other substances = jejunum
- gastric intrinsic factor + B12 = terminal ileum
- bile salts, fats, fat soluble vitamins = terminal ileum
What are the features of steatorrhoea
- bulky stools
- floating and difficult to flush
- greasy, fatty or frothy appearance
- foul smell
What are the causes of steatorrhoea
- coeliac disease/crohn’s
- pancreatitis
- liver disease
What is coeliac disease
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
What happens in coeliac disease
- Indigestion of gluten
- Jejunal villous atrophy and inflammation
- Malabsorption
How does coeliac disease cause other complications in the body
Occurs at any age affecting the GI tract or mouth
- 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 - Inflammation
- Small risk of developing GI T-cell lymphomas and other malignancies
What are the clinical manifestations of coeliac disease
- Glossitis
- Burning mouth
- Angular chelitis
- Tiredness
- Malaise
- Easy bruising
- Steatorrhoea (fatty stools)
- Weight loss
- Crampy abdominal pain
- Bloating
What investigations are done to identify coeliac disease
- FBC; iron deficiency anaemia
- Haematinics screen; low B12, folate and iron
- Stool examination; XS fat (steatorrhea)
- Serology; look for IgA antibodies (antigliadin, antiendomysial and tissue transglutaminase antibodies)
- Endoscopy; villous atrophy
- Small intestine biopsy
Describe the oral lesions occurring in coeliac disease
Recurrent oral ulceration or dental hypoplasia in enamel
- this is due to reduced absorption from small bowel mucosa
Identify the dental aspects of coeliac disease
- Dental hypoplasia
- Glossitis and burning mouth
- Angular chelitis
4 .Recurrent oral ulceration - Exacerbation of LP
- Associated autoimmune diseases e.g. Sjogrens, DM
- Malignant disease
What is Sjogren’s syndrome
Affects fluid secreting glands and causes dry eyes, mouth, skin and lack of salivation - this is associated with rheumatoid arthritis
What are the less common associations of coeliac diesease
- Dermatitis herpetiformis
- Linear IgA disease
- Selective IgA deficiency
What is dermatitis herpatiformis
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
What is dental hypoplasia
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
Outline managements for coeliac disease
Gluten-free diet - this can be challenging; and to correct any nutritional deficiencies
What can happen if coeliac disease is left untreated
Patients may develop bleeding tendencies secondary to anaemia (this can complicate GA use) and osteomalacia
What are the main functions of the large intestine
It is between the terminal ileum and anus and is for
- recovery of water and electrolytes
- formation, storage and expulsion of stools
What is Crohn’s disease
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
Describe the histology of Crohn’s disease
There is transmural granulomatous inflammation (this means the whole of the gut wall is included)
Outline the clinical features seen when Crohn’s disease affects the mouth
- Peri-oral and lip swelling
- Mucosa tags/ cobble-stoning
- Angular stomatitis
- Atypical ulcers
- Recurrent apthous stomatitis
- Lesions associated with nutritional deficiencies
Outline the clinical features seen when Crohn’s disease affects the small intestine
- Abdominal pain (apendicitis)
- Abnormal bowel habits; diarrhoea and constipation
- Weight loss
- Malabsorption
Outline the clinical features seen when Crohn’s disease affects the large intestine
- Non-blood diarrhoea lasting more than 6 weeks
- Bleeding and pain related to defecation
- Intestinal obstruction due to structuring disease (scar tissue formation in areas of inflammation)
Outline the clinical features seen when Crohn’s disease affects perianal areas
- Anal tags
- Anal fissure, fistula
- Anal abscess formation
Outline the extra-intestinal features of Crohn’s disease
- Musculoskeletal system
- arthritis
- ankylosing spondylitis (spine) - Skin
- erythema nodosum
- psoriasis (red crusty patches of skin with silver scales)
- pyoderma gagrenosum
What is erythema nodosum
Associated with Crohn’s = swollen fat under skin causing red raised, itchy and tender bumps
What is pyoderma gangrenosum
Infected tissue breakdown causing painful ulcers which have characteristic borders of blue loose skin
What investigations are carried out to determine Crohn’s disease
- FBC; anemia, microcytosis, thrombocytosis
- Inflammatory markers; ESR, CRP increase
- Haematinic screen; folate, ferritin, iron, B12, potassium, zinc decrease
- Faecal calprotectin increase
- Stool microscopy to exclude infective diarrhoea
- Radiology; endoscopy, MRI, CT, barium follow through
- Mucosal biopsy; non-caesating granuloma
Outline management for Crohn’s disease (non-drug)
- Diet; exclude benzoate’s, cinnamonaldehyde, E-preservatices
- Lifestyle; stop smoking, avoid stress, exercise, hydration
- Correct nutritional deficiencies
- Surgery to drain abscesses, repair fistulae and fissures
Outline drug therapies for Crohn’s disease
- Anti-inflammatory drugs = sulfasalazine, mesalazine
- Immunomodulators = prednisolone, methotrexate
- Biological therapies = anti-TNFa-Infliximab/Adalimumab
How should patients with Crohn’s be treated in dentistry
- 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
What is ulcerative colitis
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’
What are the clinical features of ulcerative colitis
- 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
What systemic toxicity can arise from ulcerative colitis
- fever
- anorexia
- weight loss
- anaemia
- raised ESR and CRP inflammatory markers
What is the risk of colon carcinoma increased by
Patients with early onset ulcerative colitis and those that have had the chronic disease for > 10years
What is pseudomembranous colitis and when does it arise
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
What is pseudomembranous colitis treated with
- Oral metronidazole
2. Vancomycin
What is irritable bowed syndrome
A functional bowel disorder more common in females that has an unknown cause but is linked to
- infection
- stress
- anxiety
What are the clinical features of IBS
- Patient looks healthy so examination is usually normal
- Crampy abdominal pain relived by defecation or flatulence
- Bloating or abdominal distension
- Altered bowel habit
How is IBS managed
Anti-spasmodics e.g. mebeverine
Stress reduction through CBT and anti-depressants
High-fibre diet
What are the dental aspects of IBS
Psychogenic oral symptoms such as
- burning mouth syndrome (nerve dysfunction)
- persistent idiopathic facial pain
- sore tongue
What is Peutz-Jegher’s syndrome
Autosomal dominant mucocutaneous hyperpigmentation and gastrointestinal harmatomatous polyps (benign growths causing bleeding and obstruction)
What complications can arise with Peutz-Jegher’s syndrome
- intestinal obstruction
- abdominal pain
- gastrointestinal bleeding
What is appendicitis
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
What is diverticular disease
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
What is familial polyposis coli
Familial adenomatous polyposis (FAP) is a rare, inherited condition caused by a defect in the adenomatous polyposis coli (APC) gene
What is Gardener’s syndrome
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
What is linear IgA disease
Bullous pemphigoid like gluten-enteropathy which is less commonly associated with coeliac disease
