Gastrointestinal Disease Flashcards
What are the three GI topics covered
Peptic Ulcer
Crohn’s disease/Ulcerative Colitis
Pseudomembranous Colitis
Peptic Ulcer
- location
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
What are the two most common causes of Peptic Ulcers?
- H. Pylori ( > 80%): associated with the development of a low-grade gastric mucosa–associated lymphoid tissue
(MALT) lymphoma - NSAIDs (15%, stomach ulcer)
Name 4 groups of medications causing peptic ulcer***
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”
***Risk of Peptic Ulcer formation with NSAID use increases with…
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
What are main treatments for peptic ulcers
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
What are the three Anti-Secretory drugs taken for peptic ulcers
Class:
Histamin H2 receptor antagonists
Proton pump inhibitors PPIs
Prostaglandins
Histamine H2 Recetor Antagonists
Drug
(Trade name)
Dental Considerations
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
PPI
Drug
Dental Considerations
(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.
Prostaglandins
Drug
Dental considerations
Misoprostol
Dental considerations: Diarrhea, cramps
Dental Peptic Ulcer Risk Assessment:
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
Dental Management of Peptic Ulcers
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.
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
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
**Dental Management of Peptic Ulcer Disease (PUD) when prescribing AB
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)
- *Dental Management of Peptic Ulcer Disease (PUD) when prescribing Antacids
- drug interactions
- consequence
- How to avoid this problem
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.
Dental Management of Peptic Ulcer Disease (PUD) when prescribing Diazepam, lidocaine, tricyclic antidepressants
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
Pts with persistent H pylori are at increased risk for ________
pts with Crohns disease or ulcerative colitis are at increased risk for ______
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.
Peptic Ulcer drug consideration for simultaneous use of Acid-blocking drugs and PPIs with Warfarin
- consequence
- how to avoid
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.
PPIs may reduce absorption of _____
PPIs may reduce absorption of select antibiotics and antifungals.
Median Rhomboid Glossitis
- Cause
red area in the middle back of the tongue
due to candidiasis, pt taking corticosteroids
**What are the oral manifestations of Acid Reflux/Peptic Ulcers
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
When you see crusted lip, what should be on your DDX?
Two things should come to mind:
- Erythema Multiforme (med related: Omeprazole induced Erythema multiforme)
- Herpes infection
**Oral Manifestations for IBD
- 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
***Oral Manifestations ONLY in Crohn’s
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
