W16 56 gastroenterology for dentists Flashcards
What is GORD?
Gastro-oesophageal reflux disease (GORD) is the retrograde flow of gastric contents into the oesophagus
When does GORD present?
When the reflux of gastric contents causes frequent, severe symptoms or mucosal damage.
What factors can cause GORD (multi factorial)?
Due to a retrograde slow up the gastrooesophageal sphincter up into the gullet, pushing into the oral cavity
Sometimes due to acidity
GORD usually has lower LOS pressures
Diaphragm acts as an ‘external sphincter’
Acid and pepsin damage the oesophageal mucosa, damage proportional to acid exposure
Bile acids and pancreatic enzymes probably have a limited role
Symptoms don’t necessarily relate to amount of oesophageal damage. But what are the symptoms of GORD?
Heartburn - related to meals, lying down, stooping and straining, relived by antacids
Retrosternal discomfort
Acid brash
Regurgitation acid or bile
Water brash
Excessive salivation
Odynophagia
Pain on swallowing (from severe oesohagitis)
Dental erosions
Acute gastrointestinal bleeding should be referred immediately. How does GI bleeding present?
Haematemesis
Melaena
Weakness/sweating
Postural dizziness/fainting
Collapse/shock
(Chest pain or palpitations)
Upper GI alarm symptoms - when should you send for an urgent referral for endocarditis or assessment?
When patients present with:
Chronic gastrointestinal bleeding
Progressive unintentional weight loss
Progressive difficult swallowing (dysphagia)
Persistent vomiting
Iron deficiency anaemia
Epigastric mass
New dyspepsia in those greater than 50 years
What are the causes of peptic ulcer disease?
NSAIDs/Coxib/aspirin/antithrombotics
Helicobacter pylori
How do you treat peptic ulcer disease?
Endoscopy allows visualisation of bleeding site acutely and therapy
Treatment with PPI
What is the effect of NSAIDs on symptomatic upper GI events?
Naproxen is the most gastrotoxic
Ibuprofen is associated with 2 fold risk of gastric ulceration
What are gastroprotectants?
Proton pump inhibitors (PPI) Eg omeprazole, lansoprazole
Histamine antagonists eg ranitidine
They act on the ATPase pump
What are some lower gastrointestinal alarm features that should be tested to exclude cancer?
Age >=50
Rectal bleeding
Recent change in bowel habit
Nocturnal symptoms
Unexplained or unintentional weight loss
Iron deficiency anaemia
Family history of colorectal cancer or IBD
What is Coeliac disease?
A chronic autoimmune GI disorder from infancy. Characterised by anaemia, weight loss and abdominal pain or discomfort. It is caused by an intolerance to gluten eg wheat, oats, rye. Treatment is a gluten free diet.
Can be associated with aphthous ulceration.
Diagnosed with blood serology (TTG) but confirmed by duodenal biopsy.
How do you diagnose IBS (irritable bowel syndrome)?
Routine blood tests, including coeliac serology
Avoid exhaustive investigation
Rome III criteria
What is the Rome III criteria?
At least three months, with onset at least six months previously, of recurrent abdominal pain or discomfort associated with two or more of the following:
Improvement with defecation; and/or
Onset associated with a change in frequency of stool; and/or
Onset associated with a change in form (appearance) of stool.
How can you subdivide IBS patients by stool pattern?
Diarrhoea-predominant (IBS-D)
Constipation-predominant (IBS-C)
Mixed (IBS-M)
Post-infectious (IBS-P)
What is treatment of IBS dependent on?
Stool form, but this might fluctuate over time.
What is the suggested treatment algorithm in IBS? PG552 TABLE!
Diarrhoea - 1st line: antispasmodics (preferable hyoscine), 2nd line: TCAs
Constipation - 1st line: ispaghula, 2nd line linaclotide
Pain - 1st line: antispasmodics or peppermint oil, 2nd line TCAs or SSRIs, psychological therapy
Bloating - 1st line: dietary manipulation (eg low FODMAP), 2nd line probiotics
What are the 3 types of inflammatory bowel disease (IBD)?
Ulcerative colitis (UC), Crohn’s disease, and indeterminate
UC affects large bowel, crohn’s affects small bowel and colon but can affect anywhere along the GI tract
How do you treat IBD?
5-ASAs (masalamine) are the mainstay of UC therapy. Can be given to treat flares and maintain remission.
Glucocorticoids used for moderate to severe UC flares.
Immunomodulators for those who fail 5-ASAa
Crohn’s more complex - 5ASA not proven benefit and immunomodulators are normally required
What are some presenting features of UC?
Bloody diarrhoea
Abdominal pain
Urgency
Tenesmus
Extra-intestinal manifestations
How does severity of UC activity differ with symptoms?
Mild - =<4 stools per day (with or without blood), absence of systemic illness and normal inflammatory markers
Moderate - >4 stools per day, but minimal signs of systemic toxicity
Severe - >=6 stools per day, pulse >=90bpm, temperature >=37.5°C, haemoglobin <105g/L, or erythrocyte sedimentation rate >=30 in first hour
What are the classifications of Crohn’s disease? (Pg 554 img)
L1 - terminal ileum
L2 - colon
L3 - ileocolon
L4 - upper GI tract
What are the presenting features of Crohn’s disease?
Variable clinical presentation - depends to some extent on disease location
Colonic disease similar features to UC
Onset can be more insidious: weight loss, anaemia, chronic abdominal pain
Extra-intestinal manifestations
So what is the overall management for UC and Crohn’s?
UC - 5ASAs are the main treatment. Higher doses achieve lower relapse rates and higher remission rates. Glucocorticoids use should be minimised but warranted if continued activity despite 5ASAs.
Crohn’s is more complex - refer early for consideration of immunomodulators.
Suggest all patients stop smoking in the longer term (but esp Crohn’s disease patients).
What are some common causes of liver disease?
Alcohol-related
Viral hepatitis (B&C)
Non-alcoholic fatty liver disease (NAFLD)
What is NAFLD?
NAFLD is the liver manifestation of metabolic syndrome involving: obesity, dyslipidaemia, insulin resistance and hypertension
How do you determine the cause of liver disease?
Take a detailed history including alcohol consumption
Abdominal ultrasound scan
Blood tests to exclude other causes of liver disease
READ THE SUGGESTED REFERRAL PATHWAY PG555
Read!
What is the alcohol guideline?
14 units for men and women
Is alcohol linked to mouth cancer?
Alcohol is linked with increased risk of mouth cancer
How much is 14 units of alcohol?
About 6 pints of beer (4%) OR 7 glasses of wine (11.5% 175ml) OR 14 single shots of spirits (40%)
What are some oral manifestations of Crohn’s disease? PICS OF ALL THESE PG556/7
Diffuse labial, gingival or mucosal swelling
‘Cobblestoning’ of buccal mucosa and gingiva
Aphthous ulcers
Mucosal tags
Angular cheillitis
Oral granulomas
What are some oral manifestations of ulcerative colitis?
Aphthous ulceration or superficial haemorrhage ulcers
Angular stomatitis
Pytostomatitis vegetans
What are some oral manifestations of GORD?
Reduction of pH of oral cavity below 5.5, so enamel damage
Dentine damage, so more sensitive
Caries
What are some oral manifestations of chronic liver disease?
Jaundice
Petechiae or gingival bleeding (haemostasis disorder)
What are some oral manifestations of anaemias?
(Folate and vit B12 deficiency or iron deficiency)
Glossitis - red colour, athrophic papillae, recurrent aphthae
Candida infection
Angular stomatitis
Oral pain
GO TO PG 557 AND READ THE SUMMARY OF ORAL MANIFESTATIONS OF GASTROINTESTINAL AND ANAEMIC DISEASES!
Go read!
