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DENT :D > Gastrointestinal Disease > Flashcards

Gastrointestinal Disease Flashcards

1
Q

What are the three GI topics covered

A

Peptic Ulcer
Crohn’s disease/Ulcerative Colitis
Pseudomembranous Colitis

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2
Q

Peptic Ulcer

- location

A

Definition: a well-defined break in the GI mucosa (at least 0.5m min diameter) that results from chronic acid or pepsin secretions and the destructive effects of and host response to Helicobacter pylori

  • Location: Any part proximal to acid and pepsin secretions
  • 2/3 in men
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3
Q

What are the two most common causes of Peptic Ulcers?

A
  1. H. Pylori ( > 80%): associated with the development of a low-grade gastric mucosa–associated lymphoid tissue
    (MALT) lymphoma
  2. NSAIDs (15%, stomach ulcer)
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4
Q

Name 4 groups of medications causing peptic ulcer***

A

Drugs That Increase the Risk of Peptic Ulcer Disease

NSAIDS, 
Anticoagulants
Corticosterids
Oral Bisphosphnates
(and Amphetamines: cocaine or crack, or serotonin reuptake inhibitors)

Risk with NSAIDS, is very common, the rest^ “less common”

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5
Q

***Risk of Peptic Ulcer formation with NSAID use increases with…

A

Risk with NSAID use increases with
• age older than 60 years;
• high-dosage long-term therapy
• use of NSAIDs with long plasma half-lives (e.g., piroxicam)
rather than those with short half-lives (i.e., ibuprofen)
• concomitant use of alcohol, corticosteroids, anticoagulants,
or aspirin

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6
Q

What are main treatments for peptic ulcers

A

Use:

  • Eradication of H.Pylori: triple” therapy: 2 AB + antisecretory drugs
  • Anti-secretory drug, such as a proton pump inhibitor ( H. Pylori negative)

AVOID:
Withdraw of offending and contributing factors: Avoid NSAIDs, smoking cessations, diet modification, limit alcohol intake

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7
Q

What are the three Anti-Secretory drugs taken for peptic ulcers

A

Class:

Histamin H2 receptor antagonists
Proton pump inhibitors PPIs
Prostaglandins

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8
Q

Histamine H2 Recetor Antagonists
Drug
(Trade name)
Dental Considerations

A

Drug: Cimetidine
Dental Considerations: Delayed liver metabolism of benzodiazepines; reversible joint symptoms with preexisting arthritis

Drug: Ranitidine
Dental considerations: N/A

Drug: Famotidine
Dental considerations: Anorexia, DRY MOUTH

Nizatidine: Potentially increased serum salicylate levels with concurrent aspirin use

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9
Q

PPI
Drug
Dental Considerations

A

(all the ones ending in -azole)
Omeprazole
Lansoprazole
Rabeprazole

PPIs can reduce absorption of ampicillin, ketoconazole, and intraconazole (you may prescribe this for fungal infections in the mouth, make sure their not already on PPIs as it ); may increase the concentration of benzodiazepines, warfarin, and phenytoin. Dental providers should check drug interaction resources BEFORE prescribing anti-infective drugs in these patients.

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10
Q

Prostaglandins

Drug
Dental considerations

A

Misoprostol

Dental considerations: Diarrhea, cramps

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11
Q

Dental Peptic Ulcer Risk Assessment:

A

Identify the severity and stability of the patient

Signs of Poor control: ongoing pain, blood in the stool, anemia, or recent physician visits or hospitalization

Usually no problem with tx, but be watchful
check drug interactions

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12
Q

Dental Management of Peptic Ulcers

A

Avoidance of actions that increase the production of acid
• lengthy dental procedures should be avoided or spread out over shorter appointments to minimize stress.
• To avoid aspirations, patients should not be left in a supine or subsupine (horizontal) position for lengthy periods during dental appointments.

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13
Q

Pt with Peptic Ulcers comes to your office complaining of a severe toothache on area of left posterior mandible pointed to 3.7. She also has swollen submandibular area.

• What analgesics or Analgesics would you prescribe?
- what are safe vs avoid

A

SAFE:
Acetaminophen (tylenol) and compounded acetaminophen

If NSAIDs necessary; COX-2–selective inhibitor (e.g., celecoxib (Celebrex]) + PPI or misoprostol (Cytotec)

AVOID
prescribing aspirin, aspirin-containing compounds, and other NSAIDs

  • Corticosteroids
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14
Q

**Dental Management of Peptic Ulcer Disease (PUD) when prescribing AB

A

Be aware of recent use of antibiotics for PUD; Contact patient’s physician if necessary
Some AB increase the risk of intestinal flare-up in patients with IBD. (clindamycin, cephalosporins, ampicillin)
Avoid long-term use of antibiotics, especially in older and debilitated persons, to minimize the risk of pseudomembranous colitis (diarrhea, GI distress)

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15
Q
  • *Dental Management of Peptic Ulcer Disease (PUD) when prescribing Antacids
  • drug interactions
  • consequence
  • How to avoid this problem
A

Antacids also impair the absorption of tetracycline, erythromycin, oral iron, and fluoride, thereby preventing attainment of optimal blood levels of these drugs.

To avoid this problem, antibiotics and dietary supplements should be
taken 2 hours before or 2 hours after antacids are ingested.

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16
Q

Dental Management of Peptic Ulcer Disease (PUD) when prescribing Diazepam, lidocaine, tricyclic antidepressants

A

Acid-blocking drugs, such as cimetidine, decrease the metabolism of certain dentally prescribed drugs (i.e., diazepam, lidocaine, tricyclic antidepressants) and enhance the duration of action of these medications

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17
Q

Pts with persistent H pylori are at increased risk for ________
pts with Crohns disease or ulcerative colitis are at increased risk for ______

A

Patients with persistent Helicobacter pylori are at increased risk for MALT lymphoma; patients with Crohn disease or ulcerative colitis are at increased risk for colon cancer.

18
Q

Peptic Ulcer drug consideration for simultaneous use of Acid-blocking drugs and PPIs with Warfarin

  • consequence
  • how to avoid
A

Concurrent use of acid-blocking drugs and PPIs with warfarin (Coumadin) can enhance blood levels of the anticoagulant. Obtain CBC if medication profile increases patient risk for anemia, leukopenia, thrombocytopenia, or bleeding.

19
Q

PPIs may reduce absorption of _____

A

PPIs may reduce absorption of select antibiotics and antifungals.

20
Q

Median Rhomboid Glossitis

- Cause

A

red area in the middle back of the tongue

due to candidiasis, pt taking corticosteroids

21
Q

**What are the oral manifestations of Acid Reflux/Peptic Ulcers

A

Due to the disease itself
• Enamel erosion
• Vascular malformation/macule of the lip

Medication related
• Fungal infection due to AB therapy
• PPI: Altered taste** (metaformin = metallic taste)
• Cimetidine and ranitidine: anemia, agranulocytosis, or thrombocytopenia due to bone marrow toxicity ( mucosal ulcer, gingival bleeding, pallor) - send for CBC, could be drug toxicity
• famotidine and anticholinergic drugs, such as propantheline (Pro-Banthine): Xerostomia (dry mouth)

• cimetidine, ranitidine, omeprazole, and lansoprazole: Erythema multiforme

22
Q

When you see crusted lip, what should be on your DDX?

A

Two things should come to mind:

  1. Erythema Multiforme (med related: Omeprazole induced Erythema multiforme)
  2. Herpes infection
23
Q

**Oral Manifestations for IBD

A
  • Aphthous like lesions (Canker sores, also called aphthous ulcers, are small, shallow lesions that develop on the soft tissues in your mouth or at the base of your gums
    • Linear mucosal ulcers with hyperplastic margins

Pyostomatitis vegetans (raised papillary, vegetative projections or pustules on an erythematous base of the labial mucosa, gingiva, and palate )- SEARCH PICTURE

24
Q

***Oral Manifestations ONLY in Crohn’s

A

Only in Crohn’s:
I. atypical mucosal ulcerations
II. diffuse swelling of the lips and cheeks (orofacial granulomatosis).
III. Linear mucosal ulcers with hyperplastic margins or
IV. papulonodular “cobblestone” proliferations of the mucosa, often in the buccal vestibule and on the soft palate.

you’ll see little wave like layers of folds on the base of the gums near the vestibular areas

25
Q 
* What are the following for UC
Site
Extent
Risk
Epidemiology
Signs & Symptoms
Extraintestinal manifestation
A

Site : large intestine and rectum.
Extent : Diffuse
Risk : Non-smoker ( protective effect of smoking)
Epidemiology : 20-40 y (young adulthood), F=M
Carcinoma of the colon more likely

S&S : Diarrhea , rectal bleeding, abdominal cramp
Dehydration, fatigue, weight loss, and fever
No GRANULOMA

Extraintestinal manifestation: arthritis, erythema nodosum, pyoderma gangrenosum, eye disorders (iritis and uveitis), and growth failure.

26
Q 
* What are the following for Crohn's Disease
Site
Extent
Risk
Epidemiology
Signs & Symptoms
Extraintestinal manifestation
A 
* What are the following for UC
Site : Any area from mouth to anus
Extent : Skip lesion, transmural
Risk : Smokers
Epidemiology : 20-40 and 55-65, F>M
higher Granuloma formation

Signs & Symptoms : recurrent or persistent diarrhea (often without blood), right lower quadrant abdominal pain or cramping, anorexia, weight loss transmural fibrosis, intestinal fissuring, and formation of fistulas or abscesses , anemia, osteoporosis GRANULOMA

Extraintestinal manifestation : fever, malaise, arthritis, uveitis, and features related to malabsorption, osteoporosis

27
Q

**Identification and Risk assessment for IBD patients

A

Identification and Risk Assessment.
• GI sign and symptoms (diarrhea,blood)
• Severity and level of control
•Poor candidate for dental treatment: six or more bowel movements per day with blood, fever, anemia, and a sedimentation rate higher than 30 mm/hr
• Acute exacerbation: only provide urgent treatment

28
Q

Dental AB Drug Concerns for pt with IBD

A

Drugs
• AB: Maybe immunosuppressive due to medications they take
• Some AB causes Pseudomembranouscolitis (Clindamycin and penicillin’s)
• May cause thrombocytopenia( sulfasalazine); checkCBC
• If patient taking corticosteroid: check dosage and consider supplement if necessary
• Azithromycin and 6-mercaptopurine: Pancytopenia

29
Q

Which drugs are Safe vs AVOID for dental pts with IBD?

A

SAFE:
- Acetaminophen alone or in combination with opioids
• COX-2inhibitor (celecoxib) and a PPI

AVOID
• Aspirin and NSAIDs
• Clindamycin ( risk of PC)

30
Q

General Dental Management of pt with IBD

A

because these patients are taking immunosuppressive meds they prone to develop lymphoma so …

Comprehensive head and neck examination should be performed in patients who take immunosuppressants because of their increased risk for lymphoma and infection (e.g., infectious mononucleosis, recurrent herpes).

31
Q 
****INSERT NOTES ON TABLE FOR 
Analgesics
Antibiotics 
Bleed 
BP 
chair position etc*****
A
32
Q

Drug related Oral Manifestations for PUD/IBD

A
  • Corticosteroid use can result in osteopenia, which may involve the alveolar bone

• Methotrexate: Oral ulcer. the healing doesn’t go in the right way which is what keeps the ulcer presistant.

33
Q
  • *****Systemic Corticosteroid therapy Adverse side effects
  • you will be tested on this
A 
- Increased appetite. And Weight gain.
• Changes in mood/ Nervousness, restlessness/Difficulty sleeping. • Muscle weakness.
• Blurred vision.
• Increased growth of body hair.
• Easy Bruising
• Lower resistance to infection (prone to infection)
• Swollen, "puffy" face.
• Osteoporosis (bone weakening disease).
• Onset of, or worsening of, diabetes.
• Onset of, or worsening of, high blood pressure.
• Peptic ulcer
• Cataracts or glaucoma.
34
Q

Pseudomembranous Colitis

A

severe and sometimes fatal form of colitis results from the overgrowth of C. difficile in the large colon
• commonly through the use of broad-spectrum antibiotics, but it also can result from heavy metal intoxication, sepsis, and organ failure
• Increase risk by obesity, concurrent irritable bowel disease, and use of PPIs
• AB: Clindamycin, ampicillin or amoxicillin

35
Q

*** List the three AB associated with pseudomembranous Colitis

A

AB: Clindamycin, ampicillin or amoxicillin

tell patient: if they develop diarrhea 4-10 days after taking AB
- watery and loose stool or bloody on sever cases
• abdominal pain, cramping, and fever.
• Serious complications: Severe dehydration, metabolic acidosis, hypotension, peritonitis, and toxic megacolon

tell them to call you*

36
Q

**Dental Management for pt with pseudomembranous Colitis

A

Identify patient at risk such as older patient, patient with IBD or history of PC
• Oral Manifestations due to dehydration and AB:
• Fungal infection (opportunistic attacks)
• Metronidazole can cause peripheral neuropathy, nausea and a metallic taste.

37
Q 
Question 1
Which of the following is the most likely cause of osteoporosis, glaucoma, hypertension and peptic ulcers in a 65 year old with Crohn’s disease?
1. Uncontrolled diabetes.
2. Systemic corticosteroid therapy. 
3. Chronic renal failure.
4. Prolonged NSAID therapy.
5. Malabsorption syndrome
A

Cortico steroid therapy

38
Q

Question 2
• A 24-year old patient complains of abdominal pain, frequent diarrhea and weight loss. The oral clinical examination shows linear mucosal ulcers with hyperplastic margins in the buccal vestibule. What is the most likely diagnosis?

  1. Crohn’s disease
  2. Leukemia
  3. AIDS
  4. Diabetes mellitus
A

Crohn’s Disease

* linear mucosal ulcers is a give away*

39
Q 
Question 3
Which of the following would you prescribe for an anxious dental patient with a peptic ulcer?
1. Reserpine.
2. Scopolamine.
3. Silica gel.
4. Diazepam.
5. Calcium carbonate.
A

Diazepam

side note: Calcium carbonate: calcium supplement.
• Calcium carbonate also is used as an antacid to relieve heartburn, acid indigestion, and upset stomach.

40
Q

Question 4
Which of the following analgesics can exacerbate peptic ulcers?

  1. Acetaminophen
  2. Ibuprofen.
  3. Codeine.
  4. Tramadol
A

Ibuprofen (NSAIDs in general unless they’re cox2 selective)

DENT :D (7 decks)

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