ulcers Flashcards
1
Q
how can ulcers be classified?
A
single or multiple
recurrent or persistent
2
Q
what may cause a single recurrent ulcer?
A
trauma or TUGSE
may be infective (multiple ulcers coalesce)
3
Q
what may cause multiple recurrent ulcers? (9)
A
RAS
Reiter syndrome (reactive arthritis)
MAGIC
PFAPA
smoking cessation
Behcet’s disease
erythema multiforme
recurrent herpes
idiopathic
4
Q
what may cause a single persistent ulcer? (4)
A
neoplasms
trauma
chronic infections (eg TB, syphilis, fungal)
drugs (esp nicorandil)
5
Q
what may cause multiple persistent ulcers? (5)
A
dermatological disorders (LP, vesiculobullous conditions)
GI issues
haematological issues
connective tissue disease
drugs
6
Q
which drugs may cause a single persistent ulcer? (3)
A
(often cause multiple rather than single)
aspirin chemical burn
nicorandil
methotrexate
7
Q
what is RAS? (name, types, aetiology)
A
recurrent aphthous stomatitis
three types - herpetiform, minor, major
unknown aetiology, modulated by stress
8
Q
describe herpetiform RAS (age, presentation)
A
- 20-30yo (young adult)
- non-keratinised epithelium, esp ventral tongue, soft palate, fauces
- 0.5-3mm dia, 5-40/crop
- round (but may coalesce)
- yellow base with larger erythematous border
- last 1-2 weeks with no scarring
9
Q
herpetiform RAS age group
A
young adult (20-30yo)
10
Q
herpetiform RAS sites
A
non-keratinised
esp ventral tongue, soft palate, fauces
11
Q
herpetiform RAS ulcer appearance and number per crop
A
- round (may coalesce)
- yellow base, large erythematous border
- <3mm dia, 5-40 per crop
12
Q
describe minor RAS (age, presentation)
A
- 10-20yo (teens)
- non-keratinised epithelium, esp buccal/labial mucosa
- <10mm dia, 1-5/crop
- oval
- grey base with erythematous border
- last 1-2 weeks with no scarring
13
Q
minor RAS age group
A
teens (10-20yo)
14
Q
minor RAS sites
A
non-keratinised epithelium
esp buccal/labial mucosa
15
Q
minor RAS ulcer appearance and number per crop
A
- oval
- grey base with erythematous border
- <10mm dia, 1-5 per crop
16
Q
describe major RAS (age, presentation)
A
- <10yo (children)
- any surface, esp fauces
- > 10mm dia, 2-10/crop
- oval or irregular (esp if long-standing) shape
- grey base +/- indurated edge
- last 2 weeks-3 months, with scarring
17
Q
major RAS age group
A
children <10yo
18
Q
major RAS ulcer appearance and number per crop
A
- oval/irregular
- grey base +/- indurated edge
- > 10mm dia, 2-10/crop
19
Q
major RAS site
A
any surface, esp fauces
20
Q
investigations if pt presents with ulcer (2)
A
bloods - FBC, haematinics, coeliac screen
biopsy if atypical
21
Q
management steps for RAS (5)
A
- eliminate local aggravating factors
- topical/local pain relief
- anti-inflammatory (topical or systemic)
- assess response to therapy
- maintenance
22
Q
examples of topical pain relief for RAS (7)
A
- Lignocaine 5% ointment or 2% gel
- Prilocaine 4% max in 10ml
- Benzocaine 10mg lozenges
- Bonjela = choline salicylate
- Difflam MW = benzydamine
- Cocaine MW = specialist use only (addictive, also for radiotherapy mucositis)
- Agents that cover mucosa = adhesive gels (Igloo), +/- lidocaine
23
Q
examples of topical anti-inflammatory therapy for RAS (5)
A
- Betamethasone (Betnesol) – MW QDS
- Prednisolone – 5mg MW TDS
- Fluticasone – spray or nasule MW
- Clobetasol (Dermovate) ointment mixed 50/50 with Orabase (adhesive topical steroid) OD
- “Triple” MW = betamethasone, doxycycline and nystatin; TDS (good for herpetiform ulcers but bad taste)
24
Q
examples of systemic anti-inflammatory therapy for RAS (specialist only) (6)
A
- Colchicine – 500ug OD-TDS, least potent (needs monitoring)
- Corticosteroids, prednisolone – tablet, ulcers tend to recur once stopped
- Pentoxifylline – 400mg BD, variable efficacy
- Azathioprine – serious s/e (needs monitoring)
- Thalidomide (peripheral neuropathy in most, teratogenic)
- Biologics – infliximab (IV), adalimumab (subcutaneous), various response and immunosuppression
25
colchicine action/effect (2)
- Inhibits cell-mediated responses, anti-inflammatory
- Reduces number, size, duration, pain and increases ulcer-free period
26
infliximab and etanercept drug type
anti-TNF (biologic)
27
what is in "triple" MW?
bethamethasone (topical steroid)
doxycycline
nystatin
28
which type of RAS is triple MW best for?
herpetiform
29
how might smoking be related to ulcers?
smoking cessation may allow ulcers to form (multiple recurrent)
30
what is in Difflam MW?
benzydamine
31
describe Behçet’s disease (what, demographic, genetic links)
- chronic, relapsing, inflammatory multisystem disease
- 20-40yo, often more severe in males
- Silk Road distribution around equator (Turkey, Europe)
- HLA-D51 and HLA-B21 links
32
pathophysiology of Behçet’s disease (4)
Multifactorial
- inflammation set off by infection (eg HSV, Streptococcus) or antigen (eg heat shock protein)
- genetically predisposed individuals
- Th17, IL-17 pathways very active
- Increased PMN activity, significant PMN and lymphocyte infiltration in affected organs
33
features of Behcet's disease (7)
- oral and genital aphthous-like ulcers
- uveitis (blurring, pain, floaters) – blindness if untreated (retinal vein occlusion)
- skin = papulopustular, acne-like and/or erythema nodosum
- headaches (migraines, brain fog)
- superficial phlebitis, DVT, PE, aortic aneurysm
- non-erosive, non-deforming swelling/inflammation of joints
- IBS-like symptoms (diarrhoea, constipation, bloating, pain)
34
types of Behcet's disease
- Mucocutaneous = oral, genital + skin lesions
- Arthritic = oral ulcers + inflamed joints
- Neurological = ulcers + neurological signs
- Ocular = ulcers + ocular signs
35
management of Behcet's disease (3)
- referral to centre of excellence
- MDT approach
- oral ulcers treated as per RAS (eg colchicine)
36
describe Reiter syndrome/reactive arthritis (what, cause, demographic) and triad of symptoms
- autoimmune, inflammatory
- 2-4 weeks after GI infections (Shigella, Salmonella, Campylobacter) or GU infections (esp Chlamydia trachomatis)
- often adult men
- triad = non-infective urethritis, arthritis, conjunctivitis with mouth ulcers
- often circinate lesions on tongue (resembles geographic tongue)
37
management of Reiter syndrome (5)
based on symptom severity, 65% self-limiting, 30% needing treatment for chronic symptoms
- NSAIDs mainly
- Corticosteroids – topical, intra-articular or systemic
- Antibiotics for the initiating infection
- DMARDs if NSAIDs ineffective/contraindicated
38
examples of DMARDs (3)
- sulfasalazine
- methotrexate
- anti-TNF (etanercept, infliximab)
39
what does MAGIC stand for?
Mouth And Genital ulceration
with Inflamed Cartilage
40
describe MAGIC syndrome and symptoms
- relapsing polychondritis and Behcet’s disease (vasculitis)
- orogenital aphthous ulcers and chondritis
41
what is erythema nodosum?
- tender red bumps, usually found symmetrically on the shins
- often a sign of another disease, infection or drug sensitivity
42
management for MAGIC syndrome (2)
immunosuppressant therapy
topical therapy as per RAS
43
what does PFAPA stand for?
Periodic Fever
Aphthous stomatitis
Pharyngitis
Adenitis
44
describe PFAPA syndrome (demographic, s/s)
- Mediterranean and young adolescents (90% present before 5yo)
- Periodic fevers >40ºC every 3-8 weeks which resolve within a few days, AND: aphthous stomatitis, pharyngitis or adenitis
(may be related to recurrent infection of tonsil/adenoid)
45
possible treatment for PFAPA syndrome
Adenotonsillectomy or tonsillectomy may to lead to complete resolution
46
who manages persistent multiple ulceration secondary to haematological and CT/GI conditions (referral)
haematological = via GP
connective tissue or GI = refer to specialist centre
47
examples of dermatological disorders which may cause multiple persistent ulceration (7)
- Lichen planus (relapse + remission)
- Oral lichenoid lesions
- Immunobullous (pemphigus, pemphigoid) – no healing between episodes
- Linear IgA disease
- Dermatitis herpetiformis
- Erythema multiforme
- Epidermolysis bullosa
48
what may ulcers look like if caused by GI issues/IBD?
slit-like/linear ulcers in buccal sulci
with hyperplastic folds of mucosa at periphery
49
what haematological conditions may cause multiple persistent ulceration? (4)
anaemia (esp haematinic deficiency), dysmenorrhoea
malignancy, leukaemia
other deficiencies (eg vit C)
cyclic neutropenia
50
what may ulcers look like if caused by chronic discoid lupus?
linear ulcers with keratotic striae
51
histology of an ulcer (3)
- break in epithelium
- fibrinous slough
- granulation tissue in connective tissue
52
describe TUGSE (name, presentation, histology)
- Traumatic Ulcerative Granuloma with Stromal Eosinophilia
- deep traumatic ulcer, usually on tongue
- deep inflammation into muscle, leading to degeneration and eosinophil presence
53
what does TUGSE stand for?
traumatic ulcerative granuloma with stromal eosinophilia
54
TUGSE common site
tongue
55
typical appearance/presentation of traumatic ulcer (2)
- keratotic halo
- adjacent to cause (eg sharp tooth, occlusal plane)
56
syphilitic ulcer histology (3)
- primary/secondary = dense plasma cell infiltrate
- tertiary = granulomas
- antibody stain for Treponeme in intact epithelium
57
herpes virus ulcer histology (3)
- cells appear swollen/ballooned with marginated chromatin, clear centre
- multinucleated cells (fusion of infected cells)
- clusters of cell lysis from viral replication = epithelial breakdown
58
what is epidermolysis bullosa? (3)
- group of congenital disorders with skin/mucosal fragility
- gene mutations
- many subtypes affecting different layers of skin/mucosa
59
different subtypes of epidermolysis bullosa group (4)
- EB simplex (mildest, keratin mutation)
- dominant dystrophic EB (mild, type VII collagen in sub-lamina densa)
- junctional EB (moderately severe, BP180 in lamina lucida)
- recessive dystrophic EB (severe, type VII collagen)
60
briefly describe EB simplex (3)
- mildest form of EB
- keratin gene mutation
- more superficial separation (basal cell layer)
61
briefly describe dominant dystrophic EB (what, age)
- mild form of EB affecting type VII collagen (sub-lamina densa)
- more in adulthood
62
briefly describe junctional EB (3)
- moderately severe form of EB affecting BP 180 (lamina lucida)
- widespread involvement
- normal life expectancy
63
briefly describe recessive dystrophic EB (what, 5 s/s)
- severe form of EB affecting type VII collagen (sub-lamina densa)
- shortened life expectancy
- short stature
- skin cancers, malabsorption
- severe scarring - oral, hands, feet (mitten deformity)
- loss of teeth
