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Gastrointestinal Problems

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

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Gastrointestinal Problems

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  1. Gastrointestinal Problems Claire Nowlan MD

  2. Peptic Ulcers • Ulceration of either the gastric or duodenal mucosa

  3. 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

  4. 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

  5. Etiology • NSAIDs • reduced mucosal prostaglandin production, resulting in impaired prostaglandin dependent mucosal defense and repair mechanisms

  6. Inflammation cascade

  7. Complications • Depends on depth of ulcer • More common in the elderly • Perforation • Hemorrhage - more serious if patient on anticoagulants • Pyloric stenosis • Carcinomatous transformation

  8. 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)

  9. Lab findings • Serology or 13C 14C urea breath tests for H. Pylori • Barium swallow • Endoscopy

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. Pseudomembranous colitis • Dental management • Use broad spectrum antibiotics wisely especially in elderly patients or those with a previous history

  18. 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

  19. 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)

  20. 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)

  21. Inflammatory Bowel Disease (IBD) - lab findings • May see anemia, malabsorptions causing low B12, folate, iron, albumin, and increased ESR • Really diagnosed with colonoscopy/biopsy

  22. Medical management • Supportive therapy • Nutritional supplementation, bowel rest, replacing fluid and electrolytes • Antiinflammatory drugs • Sulfasalazine • 5 ASA • Steroids • Immunosupressives/Antibiotics • Surgery – curative in UC

  23. 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

  24. Dental management - IBD • Analgesics acetaminophen plus • NSAIDs OK • opioids fine, unless during acute severe exacerbation - can cause toxic megacolon • Only urgent care during exacerbation

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