Gastrointestinal Problems
Claire Nowlan MD
Peptic Ulcers
Ulceration of either the gastric or duodenal mucosa
Risk factors for Peptic Ulcers H. Pylori (cause of 70%-90% of ulcers) NSAIDs (Steroids and Bisphosphonates) Alcohol Smoking Ages 30-50 Stress Medical conditions
– Hyperparathyroidism– Zollinger Ellison Syndrome– Renal Dialysis
Etiology
Imbalence of Aggressive/protective factors H. Pylori produces urease
– urea > ammonia and CO2– This invokes immune response and starts
inflammation cascade– infection increases with age and poor
socioeconomic conditions– only 20% of infected develop disease
Etiology
NSAIDs– reduced mucosal prostaglandin
production, resulting in impaired prostaglandin dependent mucosal defense and repair mechanisms
Inflammation cascade
ca ta lyzed b y cox-2
L eu ko trien es
A rach id on ic ac id p ros tag lan d in s
P h osp h o lip id s
d is tu rb an ce o f ce ll m em b ran es
S tim u lu s
Complications
Depends on depth of ulcer More common in the elderly
– Perforation– Hemorrhage - more serious if patient on
anticoagulants– Pyloric stenosis– Carcinomatous transformation
Signs and Symptoms
Variable Red flags - vomiting, bloody or tarry
stools, new ab pains in an elderly person, signs of blood loss (pale, lightheaded, orthostatic hypotension)
Lab findings
Serology or 13C 14C urea breath tests for H. Pylori
Barium swallow Endoscopy
Medical treatment
Eradication of H. Pylori usually cures ulcer Regiments – 7 to 14 days of:
– PPI (Omeprazole/Lansoprazole/Pantoprazole)– PLUS 2 antibiotics
(Clarithromycin/Metronidazole/Amoxicillin/Tetracycline)
– PLUS/MINUS Pepto-Bismol
Stop NSAIDs
Dental Management If active, untreated disease - refer If possible, NSAIDs should be avoided in
patients with– Previous GI bleeding– Previous peptic ulcers– Age > 75 years
Avoid longer courses of NSAIDs in – Age 60 - 75– Patients on steroids
May use COX-2 selective inhibitors or preventive medication in above patients
Cyclo-oxygenase-2 (COX-2) inhibitors Vioxx/Celebrex(not in patients with
Sulfa allergy)/Mobicox Similar efficacy to older NSAIDs Early trials suggested decreased
endoscopic ulceration Recent trials show little if any efficacy
(1.8% rate of ulcers vs. 1.3%) No difference in dyspepsia
Medications to prevent NSAID associated peptic ulcers Misoprostol 200ug TID
– Don’t use in fertile women PPIs
– Omeprazole 20 mg od– Lansoprazole 30 mg od– Pantoprazole 40 mg od
Irritable bowel
Affects up to 30% of the population Symptoms include
• diarrhea• constipation• abdominal pain• bloating
Difficult to control symptoms Treatment includes dietary changes, stress
management, medications
Pseudomembranous colitis
A severe colitis that results from broad spectrum antibiotics killing healthy gut bacteria and allowing C. difficile to flourish (already present in 2% asymptomatic people, up to 50% of the elderly)
C. difficile binds to intestinal mucosa and alters cell permeability
Worst antibiotic – Clindamycin, amoxil and cephalosporins to a lesser extent
Symptoms usually develop 1 week later, can be as long as 8 weeks
Pseudomembranous colitis
Symptoms - Watery profuse diarrhea and low grade fever, if severe - bloody diarrhea, fever, abdominal pain and death
Diagnosis – enterotoxin A/B found in the stool sample
Medical Management• Stopping the antibiotic cures up to 25% of patients• Flagyl or Vancomycin for 7 to 10 days• Hand washing
Pseudomembranous colitis
Dental management– Use broad spectrum antibiotics wisely
especially in elderly patients or those with a previous history
Inflammatory Bowel Disease (IBD) Inflammatory disease of the GI tract Unknown origin Patient experiences diarrhea,
abdominal pain Peak age of onset 20 to 40 years Systemic findings –arthritis, iritis,
uveitis, skin manifestations
Inflammatory Bowel Disease (IBD) Ulcerative Colitis Limited to the large
intestine Limited to mucosa Continuous lesions Remissions/
exacerbations common Rectal bleeding
common
Crohn’s Disease Affects any portion
of the bowel Transmural Segmental Usually slowly
progressive Fever, weight loss
common
Inflammatory Bowel Disease (IBD) Ulcerative Colitis Complications
hemorrhage, toxic megacolon, anemia, volume depletion, electrolyte imbalance, malignancy
Crohn’s Disease Complications
anemia, malabsorption, fistulae, stricture, abscess
Operations more common
Inflammatory Bowel Disease (IBD) - lab findings May see anemia, malabsorptions
causing low B12, folate, iron, albumin, and increased ESR
Really diagnosed with colonoscopy/biopsy
Medical management
Supportive therapy– Nutritional supplementation, bowel rest, replacing
fluid and electrolytes
Antiinflammatory drugs• Sulfasalazine• 5 ASA• Steroids
Immunosupressives/Antibiotics Surgery – curative in UC
Dental management - IBD
Precautions if on steroids Immunosupressants cause pancytopenia in
5% of patients, increase risk of lymphoma and oral infections
Methotrexate can cause hypersensitivity pneumonia and hepatic fibrosis
Cyclosporin can cause renal damage Sulfsalazine associated with pulmonary,
nephrotic damage
Dental management - IBD
Analgesics acetaminophen plus
– NSAIDs OK– opioids fine, unless during acute severe
exacerbation - can cause toxic megacolon Only urgent care during exacerbation