Git And Skinnn

PROFESSOR PROFESSOR

M. YOUSRY ABDEL-MAWLA,MDM. YOUSRY ABDEL-MAWLA,MD

ZAGAZIG FACULTY of ZAGAZIG FACULTY of MEDICINE,EGYPTMEDICINE,EGYPT

Gastrointestinal disordersGastrointestinal disorders Cutaneous Cutaneous disordersdisorders

Inflammatory bowel diseaseInflammatory bowel disease

Ulcerative colitis Neutrophilic tissue Ulcerative colitis Neutrophilic tissue reactions reactions

Crohn’s disease Pyoderma Crohn’s disease Pyoderma gangrenosumgangrenosum

Bowel – bypass syndrome Sweet’s syndrome Bowel – bypass syndrome Sweet’s syndrome Pustular vasculitis Pustular vasculitis Erythema nodosumErythema nodosum Aphthous stomatitisAphthous stomatitis

MalabsorptionMalabsorption

Gluten-sensitive Gluten-sensitive enteropathyenteropathy

Alcoholic liver diseaseAlcoholic liver disease

• Acrodermatitis Acrodermatitis enteropathicaenteropathica

• Dermatogenic Dermatogenic enteropathyenteropathy

• Pancreatic Pancreatic panniculitispanniculitis

• Porphyria cutanea Porphyria cutanea tardatarda

• Dermatitis Dermatitis herpetiformisherpetiformis

Nutritional and Metabolic Nutritional and Metabolic disordersdisorders

InfectionsInfections

• Hepatitis B and CHepatitis B and C

• Helicobacter Helicobacter pyloripylori

Porphyria cutanea Porphyria cutanea tardatarda

Erosive or oral Erosive or oral lichen planuslichen planus

Sweet's syndromeSweet's syndrome

MalignanciesMalignancies

• GlucagonomaGlucagonoma

• CarcinoidCarcinoid• Esophageal carcinoma  Esophageal carcinoma  

• Nonspecific cutaneous Nonspecific cutaneous signs of gastrointestinal signs of gastrointestinal malignancymalignancy

• Necrolytic migratory Necrolytic migratory erythemaerythema

• FlushingFlushing• Bazex's syndromeBazex's syndrome• Palmar-plantar Palmar-plantar

hyperkeratosishyperkeratosis• KoilyonychiaKoilyonychia• GlossitisGlossitis• Acanthosis nigricansAcanthosis nigricans• Erythema nodosumErythema nodosum• Metastatic skin lesions Metastatic skin lesions

(eg adenocarcinoma of (eg adenocarcinoma of coloncolon

• Sister Mary Joseph's Sister Mary Joseph's nodules)nodules)

MalignanciesMalignancies

• Gastrointestinal Gastrointestinal polyposis polyposis syndromes and syndromes and gastrointestinal gastrointestinal cancercancer

• Gardner's Gardner's syndromesyndrome

• Cronkhite-Cronkhite-Canada Canada syndromesyndrome

• Peutz-Jeghers Peutz-Jeghers syndromesyndrome

• Cowden diseaseCowden disease• Muir-Torre Muir-Torre

syndromesyndrome

Gastrointestinal Gastrointestinal hemorrhagehemorrhage • Vascular disordersVascular disorders • Hereditary hemorrhagic Hereditary hemorrhagic

telangiectasia (Osler-telangiectasia (Osler-Weber-Rendu disease)Weber-Rendu disease)

• Kaposi's sarcomaKaposi's sarcoma• Necrotizing angiitisNecrotizing angiitis• Pseudoxanthoma Pseudoxanthoma

elasticumelasticum• Ehlers-Danlos syndromeEhlers-Danlos syndrome• Degos, diseaseDegos, disease• Henoch-Schönlein Henoch-Schönlein

purpurapurpura

Dermatologic Dermatologic ManifestationsManifestationsof liver diseaseof liver diseaseVascular Vascular

• a. Spider telangiectasia,a. Spider telangiectasia,• b. Palmer erythema, b. Palmer erythema, • c. Corkscrew scleral vessels, c. Corkscrew scleral vessels, • d. Caput medusae, d. Caput medusae, • e. Plethoric facies, e. Plethoric facies, • f. Flushing, f. Flushing, • g. Unilateral nevoid telangiectasia. g. Unilateral nevoid telangiectasia. Jaundice, Jaundice, Pruritus, Pruritus, Urticaria,Urticaria,Nail changes – Nail changes – a.a. Terry’s nails, Terry’s nails, b.b. b. Red lunulae, b. Red lunulae, c.c. c. Koilonychia, Clubbing.c. Koilonychia, Clubbing.Hyperpigmentation,Hyperpigmentation,Skin cancer,Skin cancer,Lichenoid dermatitis,Lichenoid dermatitis,Oral Changes – Oral Changes – a.a. Black hairy tongue, Black hairy tongue, b.b. b. Glossitisb. Glossitis

SKIN MANIFESTATIONS OF SKIN MANIFESTATIONS OF VIRAL HEPATITISVIRAL HEPATITISHEPATITIS BHEPATITIS B• Polyarteritis nodosa (PAN)Polyarteritis nodosa (PAN) The pathogenesis :deposition of immune complexes in The pathogenesis :deposition of immune complexes in

the vessel walls including IgM, complement factors the vessel walls including IgM, complement factors (C3), and HBsAg(C3), and HBsAg

• Papular acrodermatitis of childhood (PACPapular acrodermatitis of childhood (PAC))A non-relapsing, erythemato-papular dermatitis A non-relapsing, erythemato-papular dermatitis

localized to the face and limbs, lymphadenopathy, , localized to the face and limbs, lymphadenopathy, , acute hepatitis (mostly anicteric), and HBsAg acute hepatitis (mostly anicteric), and HBsAg antigenaemiaantigenaemia

• Serum sickness-like syndrome (SSLP)Serum sickness-like syndrome (SSLP)ItIt is associated with the prodromal phase of the is associated with the prodromal phase of the

disease .disease .Manifestations: urticaria, angioedema, arthropathy, Manifestations: urticaria, angioedema, arthropathy,

proteinuria or hematuria, and rash. proteinuria or hematuria, and rash. The pathogenesis : deposition of immune complexes: H The pathogenesis : deposition of immune complexes: H

BsAg, IgG, IgM, and C3BsAg, IgG, IgM, and C3

SKIN MANIFESTATIONS OF SKIN MANIFESTATIONS OF VIRAL HEPATITISVIRAL HEPATITISHEPATITIS CHEPATITIS C • Mixed cryoglobulinemiaMixed cryoglobulinemia Cryoglobulins are anti-immunoglobulin immunoglobulins (Igs) that Cryoglobulins are anti-immunoglobulin immunoglobulins (Igs) that

precipitate at temperatures less than 37°C.precipitate at temperatures less than 37°C.Mixed cryoglobulins : rheumatoid factors (RF) (usually IgM) Mixed cryoglobulins : rheumatoid factors (RF) (usually IgM)

complexed with IgG which form immune complexes.complexed with IgG which form immune complexes.Mixed cryoglobulinemia : considered essential if it is not associated Mixed cryoglobulinemia : considered essential if it is not associated

with any disease other than Sjogrens syndromewith any disease other than Sjogrens syndrome• Porphyria cutanea tardaPorphyria cutanea tarda Porphyria cutanea tarda (PCT) is characterized by an abnormal Porphyria cutanea tarda (PCT) is characterized by an abnormal

porphyrin metabolism secondary to decreased activity of porphyrin metabolism secondary to decreased activity of uroporphyrinogen decarboxylase (URO-D). uroporphyrinogen decarboxylase (URO-D).

The cutaneous findings: skin fragility, blister formation, The cutaneous findings: skin fragility, blister formation, hyperpigmentation and hypertrichosis, by the photosensitizing hyperpigmentation and hypertrichosis, by the photosensitizing action of accumulated porphyrinsaction of accumulated porphyrins

• Lichen planusLichen planus Lichen planus is a chronic inflammatory mucocutaneous disease Lichen planus is a chronic inflammatory mucocutaneous disease

process. It usually presents as small, pruritic, purple, planar, process. It usually presents as small, pruritic, purple, planar, polygonal papules with superimposed fine, reticulated white lines polygonal papules with superimposed fine, reticulated white lines called Wickham's striae. called Wickham's striae.

Mucous membrane lesions are typically lacy white or ulcerative.Mucous membrane lesions are typically lacy white or ulcerative.

Other cutaneous Other cutaneous associationsassociations of HCVof HCV• Erythema multiforme, Erythema multiforme, • Erythema nodosum , Erythema nodosum , • Henoch-Schonlein purpuraHenoch-Schonlein purpura• Bechet's syndrome Bechet's syndrome • Necrolytic acral erythema Necrolytic acral erythema • Polyarteritis nodosa , Polyarteritis nodosa , • Prurigo nodularis , Prurigo nodularis , • Pyoderma gangrenosum , Pyoderma gangrenosum , • Urticaria , and Urticaria , and • Urticarial vasculitisUrticarial vasculitis

Inflammatory bowel Inflammatory bowel diseasesdiseases• Inflammatory disorders of the bowel Inflammatory disorders of the bowel

discussed here include ulcerative colitis discussed here include ulcerative colitis (UC), Crohn's disease, and bowel bypass (UC), Crohn's disease, and bowel bypass syndromesyndrome

• Both UC and Crohn's disease (the Both UC and Crohn's disease (the traditional inflammatory bowel diseases traditional inflammatory bowel diseases [IBD]) can present with abdominal pain, [IBD]) can present with abdominal pain, GI bleeding, or diarrhea.GI bleeding, or diarrhea.

• Bowel bypass syndrome : a bacterial Bowel bypass syndrome : a bacterial overgrowth in the blind loop associated overgrowth in the blind loop associated with a dermatosis-arthritis syndromewith a dermatosis-arthritis syndrome

Inflammatory bowel Inflammatory bowel diseasesdiseases

Inflammatory disorders of the bowel Inflammatory disorders of the bowel discussed here include ulcerative discussed here include ulcerative colitis (UC), Crohn's disease, and colitis (UC), Crohn's disease, and

bowel bypass syndromebowel bypass syndromeBoth UC and Crohn's disease (the Both UC and Crohn's disease (the traditional inflammatory bowel traditional inflammatory bowel

diseases [IBD]) can present with diseases [IBD]) can present with abdominal pain, GI bleeding, or abdominal pain, GI bleeding, or

diarrhea.diarrhea. Bowel bypass syndrome : a bacterial Bowel bypass syndrome : a bacterial

overgrowth in the blind loop overgrowth in the blind loop associated with a dermatosis-arthritis associated with a dermatosis-arthritis

syndromesyndrome

Pathogenesis of extraintestinal Pathogenesis of extraintestinal manifestations of inflammatory bowel manifestations of inflammatory bowel syndromesyndrome

• Immunologic mechanisms Immunologic mechanisms • The mucosa from the underlying bowel disease The mucosa from the underlying bowel disease

provides associated immune responses for the provides associated immune responses for the inflammatory process in the extraintestinal sites.inflammatory process in the extraintestinal sites.

• Autoimmune response increases with the Autoimmune response increases with the presence of foreign proteins or bacterial presence of foreign proteins or bacterial products in the intestinal mucosa.products in the intestinal mucosa.

• Shared epitopes between bacterial proteins and Shared epitopes between bacterial proteins and host self-antigens.host self-antigens.

• Microbial peptides cross-reactive to the cellular Microbial peptides cross-reactive to the cellular autoantigenic epitope may initiate the autoantigenic epitope may initiate the autoimmune responseautoimmune response

Skin findingsSkin findings

• Erythema nodosum Pyoderma gangrenosum Erythema nodosum Pyoderma gangrenosum Angular stomatitis Aphthous stomatitis Angular stomatitis Aphthous stomatitis Pyostomatitis vegetans Psoriasis Erythema Pyostomatitis vegetans Psoriasis Erythema multiforme Epidermolysis bullosa acquisita multiforme Epidermolysis bullosa acquisita Sweet's syndrome Metastatic Crohn's diseaseSweet's syndrome Metastatic Crohn's disease

• Nonspecific skin findingsNonspecific skin findings• Fistulas and fissures, are found commonly in Fistulas and fissures, are found commonly in

Crohn's disease.Crohn's disease.• Painless anal fissures occur. Painless anal fissures occur. • Crohn's disease oral findings:cobblestoning, Crohn's disease oral findings:cobblestoning,

ulcerations, and nodules.ulcerations, and nodules.• Pustular reactions including pustular vasculitisPustular reactions including pustular vasculitis

Nutritional and metabolic Nutritional and metabolic disordersdisordersALCOHOL ABUSE AND SKINALCOHOL ABUSE AND SKIN  • 1-  Nutritional 1-  Nutritional

deficiencies a-  Marasmus  b- Kwashiordeficiencies a-  Marasmus  b- Kwashiorkor  c- Pellagra  d- Scurvy  kor  c- Pellagra  d- Scurvy  

• 2- Endocrine 2- Endocrine diseases  a- Hypogonadism  b- Hyperesdiseases  a- Hypogonadism  b- Hyperestrogenism  c- Pseudo-Cushing's trogenism  c- Pseudo-Cushing's syndrome  syndrome  

• 3- Porphyria cutanea tarda  3- Porphyria cutanea tarda  • 4- Infections  4- Infections  • 5- Acquired purpura fulminans5- Acquired purpura fulminans• 6-Exacerbations of skin disease6-Exacerbations of skin disease  • a-  Psoriasis  a-  Psoriasis  • b- Rosacea b- Rosacea • c-Discoid eczemac-Discoid eczema

Cutaneous eruptions Cutaneous eruptions associated with malabsorptionassociated with malabsorption

• NonspecificNonspecific• Acquired ichthyosisAcquired ichthyosis• Hair changesHair changes• Nail changesNail changes• HyperpigmentationHyperpigmentation• Altered skin Altered skin

texturetexture• Eczematous Eczematous

eruptionseruptions

• SpecificSpecific• Zinc deficiencyZinc deficiency• Acrodermatitis Acrodermatitis

enteropathicaenteropathica

• Vitamin B deficiencyVitamin B deficiency• Dermatogenic Dermatogenic

enteropathyenteropathy• Dermatitis Dermatitis

herpetiformisherpetiformis

SOME SKIN MANIFESTATIONS SOME SKIN MANIFESTATIONS OF MALIGNANCY IN G ITOF MALIGNANCY IN G ITAcanthosis nigricans Acanthosis nigricans This appears as a brown-to-black, smooth, This appears as a brown-to-black, smooth,

velvety plaque found in areas of skin velvety plaque found in areas of skin folds, most commonly the neck, axillae, folds, most commonly the neck, axillae, and groin.and groin.

Possibility of an intra-abdominal malignancy Possibility of an intra-abdominal malignancy should be considered especially if there should be considered especially if there isis

1.1. large number of plaques, large number of plaques, 2.2. Weight loss, Weight loss, 3.3. Rapid progression of lesions, Rapid progression of lesions, 4.4. The discovery of plaques in unusual The discovery of plaques in unusual

locations( lips, oral mucosa, hands, and locations( lips, oral mucosa, hands, and genitalia)genitalia)

SOME SKIN MANIFESTATIONS SOME SKIN MANIFESTATIONS OF MALIGNANCY IN G ITOF MALIGNANCY IN G IT

• Pancreatic panniculitisPancreatic panniculitis

• Pancreatic Pancreatic panniculitis(inflammation of panniculitis(inflammation of subcutaneous fat) : predominately subcutaneous fat) : predominately in alcoholic ,pancreatitis and in alcoholic ,pancreatitis and pancreatic cancer.pancreatic cancer.

• Erythematous painful plaques and Erythematous painful plaques and nodules on the extremities or trunknodules on the extremities or trunk

Cutaneous syndromes and the GI Cutaneous syndromes and the GI TractTract

Cutaneous syndromes associated with gastrointestinal diseases and Cutaneous syndromes associated with gastrointestinal diseases and malignancymalignancyAbbreviationsAbbreviations: AD, autosomal dominant; BCC, basal cell : AD, autosomal dominant; BCC, basal cell carcinoma; GI, gastrointestinal; MEN, multiple endocrine neoplasia; carcinoma; GI, gastrointestinal; MEN, multiple endocrine neoplasia; MSH.MSH.

SyndromeSyndrome InheritanceInheritance CutaneousCutaneous findingsfindings InternalInternal AssociationsAssociations

WithWithincreased DEFECT increased DEFECT risk of risk of malignancymalignancy

Gardner’sGardner’sSyndromeSyndrome AD Osteoma, desmoid Intestinal AD Osteoma, desmoid Intestinal polyposis, polyposis, (familial Chromosome 5 tumors epidermoid colon (familial Chromosome 5 tumors epidermoid colon cancer, thyroidcancer, thyroidPolyposis cysts, dental cancers, Polyposis cysts, dental cancers, retinalretinalSyndrome) anomalies Syndrome) anomalies abnormalitiesabnormalities

SyndromeSyndrome InheritanceInheritance CutaneousCutaneous findingsfindings InternalInternal AssociationsAssociations

CronkhiteCronkhite Acquired Alopecia, nail GI polyps, Acquired Alopecia, nail GI polyps, coloncolonCanadaCanada dystrophy; macular carcinoma, dystrophy; macular carcinoma, diarrheadiarrhea Syndrome hyperpigmentation abdominal Syndrome hyperpigmentation abdominal painpain

Cowden’sCowden’s AD Hamartomas of Hamartomas AD Hamartomas of Hamartomas andanddiseasedisease Mutation PTEN mucous membranes malignancy of Mutation PTEN mucous membranes malignancy of colon,colon,(multiple Gene / facial breast, (multiple Gene / facial breast, thyroid, thyroid, Hamatoma chromosome tricholemmonas, renal and Hamatoma chromosome tricholemmonas, renal and bladderbladderSyndrome) 10 papillomas Palmar- colon polypsSyndrome) 10 papillomas Palmar- colon polyps plantar keratoses,plantar keratoses, scrotal tongue scrotal tongue

Muir – Torre Muir – Torre ADMutation in Sebaceous gland tumors, Nonpolyposis ADMutation in Sebaceous gland tumors, Nonpolyposis coloncolon cancercancer BCC with sebaceousBCC with sebaceous differentiationdifferentiation MSH2 gene on MSH2 gene on

SyndromeSyndrome InheritanceInheritance CutaneousCutaneous findingsfindings InternalInternal AssociationsAssociations

Peutz – Peutz – AD Periorifical and Hamartomas AD Periorifical and Hamartomas polypspolyps

JeghersJeghers mucosal lentigines, throughout GI mucosal lentigines, throughout GI tract tract

SyndromeSyndrome pigmented maculae increased pigmented maculae increased incidenceincidence hands and feet of malignancy hands and feet of malignancy

throughout GI throughout GI tract, tract,

ovarian ovarian tumors,tumors,

pancreatic pancreatic carcinomacarcinoma

gallbladder gallbladder cancer,cancer,

GI bleeding,GI bleeding,

pancreatic pancreatic carcinoma carcinoma

Cutaneous syndromes associated with Cutaneous syndromes associated with gastrointestinal diseases and malignancygastrointestinal diseases and malignancy

SyndromeSyndrome InheritanceInheritance CutaneousCutaneous findingsfindings InternalInternal AssociationsAssociations

Howell-Howell- Palmer - plantar Esophageal Palmer - plantar Esophageal carcinoma carcinoma Evans’Evans’ hyperkeratosis hyperkeratosis syndromesyndrome

Bazex’s Acquired Acrodermatitis, Esophageal, Bazex’s Acquired Acrodermatitis, Esophageal, laryngeal, laryngeal, syndrome nail dystrophy tongue syndrome nail dystrophy tongue carcinomacarcinoma

MEN type I AD Multiple facial Pituitary, MEN type I AD Multiple facial Pituitary, parathyroid, parathyroid, (Wermer’s Mutation in angiofibromas, pancreatic (Wermer’s Mutation in angiofibromas, pancreatic endocrineendocrine syndrome) MEN I gene collagenomas, abnormalities, syndrome) MEN I gene collagenomas, abnormalities, peptic U peptic U on chromosome lipomas, confetti-like on chromosome lipomas, confetti-like disease,Zollinger-Ellisondisease,Zollinger-Ellison 11 hypopigmented syndrome, 11 hypopigmented syndrome, gastronoma,gastronoma, macules insulinoma, macules insulinoma, carcinoid.carcinoid.

SyndromeSyndrome InheritanceInheritance CutaneousCutaneous findingsfindings InternalInternal AssociationsAssociations

MEN IIA AD Amyloidosis Medullary MEN IIA AD Amyloidosis Medullary thyroid thyroid

((Sipple’sSipple’s Mutation in Mutation in RETRET carcinoma, carcinoma,

syndrome) syndrome) gene on gene on pheochromocytoma, pheochromocytoma,

chromosome 10 chromosome 10 hyperparathyroidism,hyperparathyroidism,

Zollinger – Zollinger – EllisonEllison

syndrome, syndrome, Cushing’sCushing’s

syndrome, syndrome, malignantmalignant

melanoma, melanoma, pitutary ad. pitutary ad.

MEN IIBMEN IIB AD Multiple mucosal Hirschprung’s AD Multiple mucosal Hirschprung’s disease,disease,

Mutation in Mutation in RET RET neuromas, cervical neuromas, cervical medulloblasoma medulloblasoma

gene on marfinoid body increased risk gene on marfinoid body increased risk of of

chromosome 10 chromosome 10 habitus, nasal malignancy habitus, nasal malignancy

neuromas neuromas

Cutaneous syndromes associated with hemorrhageCutaneous syndromes associated with hemorrhage Cutaneous syndromes associated with gastrointestinal hemorrhage.Cutaneous syndromes associated with gastrointestinal hemorrhage.

Abbreviations: AD, autosomal dominant, AR, autosomal recessive; AV, Abbreviations: AD, autosomal dominant, AR, autosomal recessive; AV, arteriovenous; CNS, central nervous system; GI, gastrointestinal; GIT, arteriovenous; CNS, central nervous system; GI, gastrointestinal; GIT, gastrointestinal tract; SQ, subcutaneous.gastrointestinal tract; SQ, subcutaneous.

SyndromeSyndrome InheritanceInheritance CutaneousCutaneous findingsfindings InternalInternal AssociationsAssociations HereditaryHereditary AD Telangiectasia of skin, GI AD Telangiectasia of skin, GI

hemorrhage,epistaxishemorrhage,epistaxis hemorrhagichemorrhagic oral mucosa arterial aneurysms; oral mucosa arterial aneurysms;

AV AV telangiectasiatelangiectasia malformations in malformations in

liver,liver, lung, eye.lung, eye. Blue rubber blebBlue rubber bleb AD Compressable SQ GI vascular AD Compressable SQ GI vascular

malformationsmalformations news syndromenews syndrome hemangiomas GI hemorrhage hemangiomas GI hemorrhage Kaposi’s sarcomaKaposi’s sarcoma Violaceous papules, GI lesions, Violaceous papules, GI lesions,

hemorrhagehemorrhage nodules nodules Necrotizing angiitisNecrotizing angiitis Palpable purpura GI bleeding, Palpable purpura GI bleeding,

perforation, perforation, ischemiaischemia

SyndromeSyndrome InheritanceInheritance CutaneousCutaneous findingsfindings InternalInternal AssociationsAssociations

Henoch – Henoch – Palpable purpura Abdominal cramping Palpable purpura Abdominal cramping

SchSchöenleinöenlein and pain, hmaturia, and pain, hmaturia,

purpurapurpura glomerulonephritis glomerulonephritis

Degos’ diseaseDegos’ disease atrophic Erythematous Vasculitis of GIT, atrophic Erythematous Vasculitis of GIT,

papules infarction, papules infarction, bleeding,bleeding,

CNS infarctsCNS infarcts

Ehler’s – DanlosEhler’s – Danlos AD, AR Easy bruising, thin Arterial rupture, GI AD, AR Easy bruising, thin Arterial rupture, GI

syndrome type IVsyndrome type IV translucent skin hemorrhage, translucent skin hemorrhage, uterine uterine

rupturerupture

PseudoxanthomaPseudoxanthoma AD, AR Waxy yellow papules, GI hemorrhage, AD, AR Waxy yellow papules, GI hemorrhage, Angioid Angioid

elasticumelasticum flexural areas, streaks in eyes, flexural areas, streaks in eyes,

elastosis perforans coronary heart elastosis perforans coronary heart disease,disease,

serpiginosa vascularserpiginosa vascular calcification calcification

Miscellaneous cutaneous diseases Miscellaneous cutaneous diseases associated with GI disorders;associated with GI disorders;• Scleroderma (systemic sclerosisScleroderma (systemic sclerosis The dermatologic changes: sclerotic changes The dermatologic changes: sclerotic changes

that eventually involve the entire body, that eventually involve the entire body, telangiectases, hyperpigmentation and telangiectases, hyperpigmentation and hypopigmentationhypopigmentation

• GIT Manifestations GIT Manifestations The esophageal symptoms :feeling of The esophageal symptoms :feeling of

premature fullness, reflux esophagitis, premature fullness, reflux esophagitis, dysphagia, and epigastric pain. dysphagia, and epigastric pain.

Stomach and small bowel :anorexia, early Stomach and small bowel :anorexia, early fullness, diarrhea, nausea/vomiting, and fullness, diarrhea, nausea/vomiting, and obstipation caused by impaired motility, obstipation caused by impaired motility, which, in turn, leading to chronic intestinalwhich, in turn, leading to chronic intestinal pseudo-obstruction, malnutrition, and pseudo-obstruction, malnutrition, and bacterial overgrowthbacterial overgrowth

Pemphigus vulgarisPemphigus vulgaris

• Pemphigus vulgaris (PV) : autoimmune blistering Pemphigus vulgaris (PV) : autoimmune blistering disorder involving the skin and mucous membranes that disorder involving the skin and mucous membranes that also can affect the esophagus (persistent sore throat, also can affect the esophagus (persistent sore throat, dysphagia, and odynophagia).dysphagia, and odynophagia).

• • Skin lesions: bullous lesions(1-10 cm) superficial, and Skin lesions: bullous lesions(1-10 cm) superficial, and

easily ruptured by trauma. One characteristic finding on easily ruptured by trauma. One characteristic finding on lateral palpation of these lesions is extension into lateral palpation of these lesions is extension into adjacent tissue. adjacent tissue.

• Mucosal sites also commonly are involved, including the Mucosal sites also commonly are involved, including the oral mucosa (often the presenting site), anus, cervix, oral mucosa (often the presenting site), anus, cervix, and conjunctivae. and conjunctivae.

• Antigenic confirmation of the disease correlation: the Antigenic confirmation of the disease correlation: the target cell adhesion molecule of the PV autoantibodies target cell adhesion molecule of the PV autoantibodies is strongly expressed in the is strongly expressed in the esophageal epitheliaesophageal epithelia..

SummarySummary

• Early recognition of cutaneous Early recognition of cutaneous diseases or manifestations diseases or manifestations associated with the gastrointestinal associated with the gastrointestinal tract disorders may be lifesaving tract disorders may be lifesaving at times, and may lead to early at times, and may lead to early preventive intervention to decrease preventive intervention to decrease risk of morbidity or mortality.risk of morbidity or mortality.