Ulcerative Diseases Flashcards
What is needed to establish diagnosis of an ulcer?
HPC
MH
Social history
Family history
Systems review of GI, GU system & skin
Examination
Special investigations
History to take to work out whether a patient is at risk of cancer?
Age
Other malignant disease
Smoking - work out pack years
Alcohol - units per week
Smoking & alcohol = risk of oral cancer x40
Areca nut/betel nut
Questions to ask in regard to ulcer history?
What does the pt mean by an ulcer?
Age of onset?
Length of time to heal?
Frequency of attacks?
How long is the ulcer-free period?
Which sites are common & which are never affected?
Size?
Shape?
Coalesce?
Prodrome before ulcer appears?
Pain?
Relation to menstruation/ smoking/ other factors?
Change in degree of ulceration over time?
What types of ulcers are recurrent? (heal completely then come back)
Aphthae
Erythema multiforme
What types of ulcers are recurrent/persistent?
Secondary to systemic disease
What types of ulcers are single episode?
Infective
Traumatic
Drug reaction
What type of ulcer is single persistent?
Neoplastic
3 types of recurrent aphthous stomatitis?
Major
Minor
Herpetiform
Characteristics of major RAS?
Size: >10mm in diameter
Shape: oval/irregular
Colour: grey base +/- indurated edge
Duration: 2 weeks - 3 months, scar on
healing
Site: keratinised & non-keratinised surfaces (mostly at back of mouth)
Number: Up to 10 ulcers
Age: 1st decade
Characteristics of minor RAS?
Size: <10mm in diameter
Shape: oval
Colour: grey base, erythematous border, no scarring
Duration: 1-2 weeks
Site: non-keratinised surfaces, especially buccal mucosa
Number: 1-5
Age: 2nd decade
Characteristics of herpetiform RAS?
Size: 0.5-3mm in diameter
Shape: round - may coalesce to form irregular bigger ulcer
Colour: yellow base, erythematous border
Duration: 1-2 weeks
Site: non-keratinised surfaces, especially central of tongue & floor of mouth
Number: 1-20, sometimes more
Age: 3rd decade
Management of RAS?
Establish diagnosis
Eliminate local aggravating factors (e.g. sharp tooth)
Control infection (mouthwashes/medications):
- Topical antimicrobials
- Systemic antimicrobials
Control pain - topical/systemic steroids
Maintenance/prevent recurrence
Assess response to therapy & assess if pt is adhering to tx/review diagnosis
What investigations are needed for diagnosing RAS?
Blood tests
- FBC
- Haematinics - B12/folate/ferritin
- LFTs
Biopsy
- If suspected malignancy
Scans
Summary of RAS therapy?
Relief of pain
Healing of ulcers
Prevention of new ulcers
What are the first line drugs for RAS?
Analgesics (topical/systemic)
Control of infection (antibiotics/antiseptics)
Anti-inflammatory (with analgesia/ immunosuppression)
What are second line drugs for RAS?
Immunosuppressants (azathioprine/ steroids)
Immunostimulants (levamisole)
Sedatives (thalidomide)
Which topical analgesics can be used for RAS?
Lignocaine 5% ointment
Lignocaine 2% gel
Prilocaine
Benzocaine lozenges
Bonjela (choline salicylate)
Which systemic analgesics can be used for RAS?
Aspirin
Paracetamol
Dihydrocodeine
Ibuprofen
Which topical steroids can be used for RAS?
Triamiconolone paste
Hydrocortisone pellets
Betamethasone valerate inhaler
Betamethasone sodium phosphate tabs as mouthwash (takes long time to work)
Questions to consider if treatment fails?
Is the patient taking the drug?
Is the drug being absorbed?
Is the dose adequate?
Is the drug reaching the lesion/ disease?
Is surgical intervention needed?
Has super infection with another organism occurred?
Aetiology of erythema multiforme?
Medications - sulphonamides, penicillin, barbiturates & phenytoin
Infections/illness - ~90% of EM cases associated with herpes simplex/ mycoplasma infections
Pathogenesis of erythema multiforme?
Damage to blood vessels with subsequent damage to skin tissues leading to a classic skin lesion
Mainly in children & young adults
In which patients would you see a nicorandil ulcer?
Angina patients
Write to GP/cardiologist
What is Behcet’s disease characterised by?
Chronic autoimmune disorder
- Recurrent oral & genital ulceration
- Eye lesions & skin lesions
(Triad of aphthous-like oral ulcers, genital lesions & recurrent eye inflammation)
Epidemiology of Behcet’s disease?
Rare in UK, more common in Mediterranean countries - Turkey, Middle East, Japan & South-East Asia
3rd & 4th decade
Symptoms of Behcet’s disease?
Mouth ulcers (most common symptom)
Genital ulcers
Skin sores - spots, boils, red patches, ulcers & lumps under or in skin
Eye problems - uveitis, retinal vasculitis => ‘floaters’, haziness or loss of vision, pain & redness in eye
Inflammation of joints causing pain & swelling
Clinical features of squamous cell carcinoma?
On high risk area
Necrotic black centre
Indurates
Mixed red & white
Not always painful
Will not heal of own accord
