Gastroenterology

Dr Niamh Coakley
Dept of Medicine
CUH
 Plan

Oral manifestations of GI disease

Gastro oesophageal reflux

Peptic Ulcer Disease

Coeliac Disease

Inflammatory Bowel Disease

Irritable Bowel Syndrome

 Gastroenterology

Branch of Medicine dealing with disorders of the Digestive System

Oral Cavity

Pharynx

Oesophagus

Stomach

Small Intestine (with Liver/Pancreas)

Large Intestine
GI Tract
 GI symptoms

Dyspepsia
Heartburn/Water brash/Acid regurgitation
Dysphagia
Abdominal Pain
Appetite and/or weight change
Nausea and/or vomiting
Diarrhoea
Constipation
Bleeding – upper or lower GI tract
Jaundice
Pale Stools/Dark Urine
Abdominal swelling
Pruritus
Fever
 Points to note in History

GI symptoms\diagnoses

Gastro oesophageal reflux

PUD current\past

Inflammatory Bowel Disease

Gastric Surgery

Pancreatic\Liver Disease

Full list of Meds including OTC

 Common GI Diseases

Gastro-Oesophageal Reflux (GORD)

Peptic Ulcer Disease including H. pylori infection

Coeliac disease

Inflammatory Bowel Disease

Ulcerative colitis and Crohn’s
 Common GI diseases

Diverticular disease

Malignancy

Hepatobiliary
Hepatitis/Gallstones/Hepatoma

Pancreatic
Pancreatitis/Cancer
 ‘Functional’ GI Diseases

Irritable Bowel Syndrome

Functional Dyspepsia

Functional swallowing problems

Clinical aspects
 Aphthous Ulcers

GI Causes-

Food\medications

Coeliac Disease

Inflammatory Bowel Disease

Vitamin\Nutritional Deficiencies

• Management-

oral hygiene\topical agents\treat infection\underlying cause if persistent

Oral Ulceration
 Angular Cheilitis

Inflammation at angles of mouth

Example of GI cause- nutritional def

(also eg dentures, infection, meds..)

Can get infection-candida\staph\strep

 Angular Cheilitis

Underlying GI disorder?

Stability of current condition?

Meds

Nutritional Def

Infection

Maintain good oral hygiene\Topical treatment\Underlying cause\treat infection\Refer?

 Atrophic Glossitis

Atrophy of filiform papillae

Smooth glossy appearance, pink\red background, sore tender swollen tongue

Causes- Nutritional def(folate, iron), xerostomia, Coeliac, Crohns

Atrophic Glossitis
 Oesophagus

Dysphagia
Mechanical Obstruction
Intrinsic – stricture/Carcinoma
Extrinsic – goitre/mediastinal tumours

Neuromuscular motility disorders

Achalasia/Diffuse spasm/Scleroderma
Neurological disorders – post stroke
 Gastro-oesophageal reflux disease
GORD

Gastric contents refluxing into the oesophagus- prolonged contact with mucosa

Symptoms-Heartburn/Regurgitation/Dysphagia/Cough/
Wheeze/Hoarseness/Sore throat/Non-cardiac chest pain/Enamel erosion etc

Predisposing factors
GI – pH of refluxate/Mucosal defences/G–O motility/Hiatus Hernia
Obesity/Smoking/Alcohol/Drugs/Large meals
GORD
 Management of GORD

Antacids\Alginates

H2 receptors

Proton pump inhibitors

Pro-motility agents

Surgery
 GORD

Complications- stricture\aspiration\airways disease\Barretts -squamous metaplasia

DENTAL ASPECTS-

oral pH<5.5

Enamel erosion- palatal surfaces of maxillary dentition

Exposure of dentin

Discomfort in supine position

S\E of meds used to treat

 Oesophageal carcinoma

Squamous or Adenocarcinoma

Symptoms
Pain and dyspepsia
Progressive dysphagia for solids then liquids
Weight loss
Vomiting
Endoscopic appearance – Oesophageal carcinoma
Stomach
 Peptic Ulcer Disease

Symptoms – epigastric pain/Vomiting/weight loss/haemorrhage

Red flags
Bleeding/Anaemia/Early satiety/Unexplained weight loss/Progressive
dysphagia/Odynophagia/ Family history of gastric carcinoma

Causes – H. pylori/Drugs –NSAIDs,

Steroids/Smoking/C2H5OH/Physiological stress
Peptic Ulcer Disease
Peptic ulcer disease
 Peptic Ulcer Disease
Helicobacter pylori

Gram neg urease producing bacterium

Assoc with- chronic active gastritis, peptic ulcer disease, gastric cancer, gastric
b-cell lymphoma

Most asymptomatic

Diagnosis- C13 Urea breath test, Stool antigen test, Serology (non invasive)
-Rapid urease test (CLO test)- (endoscopy)
 Peptic Ulcer Disease
helicobacter pylori

Eradication-

Proton pump inhibitor,

Antibiotics- eg. metronidazole, clarithromycin, amoxicillin

 Peptic Ulcer Disease

Treat precipitating factors

PPI

Eradication of H pylori

Surgery

Complications – Perforation/Haemorrhage/Pyloric stenosis/Malignancy

 Peptic Ulcer Disease – dental aspects

Care – Beware of NSAIDs +/- Corticosteroids (Consider Paracetamol, COX2

inh+ PPI/Misoprostol)

Anaemia with anaesthesia

Dental erosions if they develop pyloric stenosis with reflux

Dental caries - dry mouth secondary to drugs (note some sialogogues- increase
acid prod)
 Gastric cancer

Adenocarcinoma

Usually present late – hence poor prognosis

Dyspepsia/Epigastric pain/Anorexia/Weight loss/Early

satiety/Anaemia/Haematemesis/Melaena/Metastases – eg to jaw

Risk factors – Pernicious anaemia/Atrophic gastritis/partial gastrectomy/diet

Gastric cancer
 Upper GI haemorrhage- causes

Common
DU/GU/Gastric Erosions/Mallory-Weiss tear

5% or less
Duodenitis/Oesophageal varices/Oesophagitis

Rare – 1% or less
Angiodysplasia/HHT/Portal hypertensive gastropathy/Aortoduodenal fistula

Management – urgent medical referral

 Small Intestine

 Malabsorption
Lassitude/Weakness/Weight loss/Failure to thrive/Vitamin deficiency – eg
Vitamin K/Anaemia/Diarrhoea/Steatorrhoea/Abdo discomfort
Oral manifestations – glossitis/chelitis/stomatitis/oral candidiasis/gum
bleeding
 Coeliac disease

Gluten sensitive enteropathy (wheat,rye, barley)

Autoimmune. (DM type 1,Thyroid)
1/100 European derived pop
Damaged intestinal mucosa with villous atrophy-malabsorbtion
Symptoms\Complications
Diarrhoea/Steatorrhoea/Flatulence/Bloating/ Cramps/Borborygmi/Weight
loss/Fatigue/Abdo pain/Malabsorbtion/Neurological symptoms(B
vits)/Anaemia/Osteopaenia/Osteoporosis(Vit D, Ca) /Skin – dermatitis
herpetiformis/Malignancy
Coeliac disease
 Coeliac disease
Dental\Oral Aspects

Anaemia/Aphthae/Glossitis/Burning mouth/Angular stomatitis

Small stature + Enamel defects – suggests early onset coeliac disease

Oral mucosal lesions\dental enamel defects- may be only presenting feature

Bleeding problems-Vit K def(fat soluble)

NB- to establish diagnosis-oral symptoms helpful tool in diagnosis

 Inflammatory Bowel Disease
Crohn’s Disease

Idiopathic chronic inflammatory lesions – from mouth to anus

Transmural granulomatous – ‘skip lesions’, fibrosis, strictures, obstruction, sinus
tracts/fistulae
Symptoms- Abdo pain/Diarrhoea/Fistulae/Obstruction/Fever/Weight
loss/Anorexia/Nausea/Vomiting/Malabsorption/Fatigue/Bone Loss

Extra intestinal manifestations – Eye/Skin/Joints/Liver…

 Crohn’s disease

Oral – 8-29%

May precede intestinal involvement

Extraintestinal involvement more common if oral cavity involved

Important in diagnosis and can parallel disease course

 Crohn’s Disease

Diffuse labial-Gingival mucosal swelling

Cobblestoning of the buccal mucosa and gingiva

Aphthous ulcers

Mucosal Tags

Angular cheilitis

Non-caseating granulomas on biopsy

Crohn’s Disease
 Inflammatory Bowel Disease
Ulcerative Coilitis

Recurring Inflammation, Rectum moving proximally.

Uniform with mucosal and submucosal involvement
Symptoms
Rectal bleeding/Increased frequency of defaecation/mucous
PR/Tenesmus/Lower Abdo Pain
Severe cases – severe diarrhoea/abdo cramps/ fever/abdo distension – (Toxic
megacolon)
Extraintestinal involvement
 Ulcerative colitis

Oral aspects- relatively rarer in UC

Aphthous ulceration/superficial haemorrhagic lesions
Relapse and remit
Pyostomatitis Gangrenosum
Pyostomatitis vegetans
TMJ arthritis- 10%
Severity of oral lesions correspond to disease act, usually respond to rx
Pyostomatitis vegetans (UC)
Pyostomatitis gangrenosum (UC)
 Management of Inflammatory Bowel Disease

1. Aminosalicylates\Antibiotics

2. Corticosteroids

3. Immune modifying agents

4 Others

4. Surgery
 Inflammatory Bowel Disease

General principles – beware of complications of treatment as well as disease

Anaemia
Risk of bleeding
Corticosteroid use
Immunosuppressive drugs- FBC before surgery
 Large intestine

UC

Bowel cancer

Polyposis

Diverticular disease

Haemorrhoids
 Irritable Bowel Syndrome

Symptoms- absence of specific unique organic pathology

Abdo pain\altered bowel habit

10-20% of pop

Rome 111 Criteria

Theories

Inconsistent symptoms eg bleeding, wgt loss, fever, nocturnal symptoms, sig family hx

Management-Dietary\Psychological\Pharmacology
 GI Disease and the Dentist

Recognise

Diagnose

Treat\Refer

Safe and appropriate care

Oral adverse effects of meds

Interactions with meds prescribed during dental care

 Drug Treatment of GI Diseases

Drug history- GI drugs- esp corticosteroids\immunosuppressants, use of

antibiotics, doses of all meds, potential for adverse effects. additional\change in
meds for dental treatment.