Gastrointestinal

disease

Oral medicine
Dr. Fahed Habash

6th lect. 1st semester

25.10.21

Jouman ALQawasmi.
 Introduction
The oral cavity is a part of the upper GI tract so any systemic disease in the GI may have an oral
manifestation

A problem in absorption will cause a nutritional deficiency

Chronic blood loss → peptic ulcer and duodenal ulcer → anemia

Anatomy of GI

Start with the oral cavity and salivary glands → esophagus → stomach →
a sphincter BWN the stomach and the esophagus prevent the acids and
food reflux → the lower part of the stomach called pylorus → small
intestine “duodenum, jejunum, ileum” → large intestine “ascending,
transverse, descending, sigmoid colon → rectum → anal canal

The liver, spleen and gallbladder are a part of the GI.

GASTRO-OESOPHAGEAL REFLUX

Gastro-esophageal reflux and consequent esophagitis are a common cause of the symptoms of dyspepsia
and ‘heart burn’. Smoking, excessive alcohol consumption, obesity, frequent stooping and overlarge meals
are frequent precipitating factors. If persistent, the esophageal lining may undergo metaplasia to a more
resistant gastric-type mucosa (Barrett’s esophagus). Acid rarely reaches the mouth in any quantities and,
unless severe, reflux alone is not a potent cause of dental erosion, though it may contribute. Inhibition of
acid secretion by protein pump inhibitors, such as omeprazole, is highly effective in controlling it.

A relaxation in the sphincter” muscles” as a result of genetics, life style end with a reflux of stomach
content → a condition called hiatus hernia.

Signs & symptoms:

• Heart burn or chest burn

• Esophagitis

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 • Burning sensation on oral mucosa
• Ulcerations
• Erosions of palatal surface of upper anterior
• Metaplasia in the esophageal epithelium “premalignant”
• Hoarseness due to larynx irritation and respiratory system.
• altered taste and burning sensation in the tongue

an erosion of the palatal surface of the upper is seen in pyloric stenosis ‫المسلز الموجودة بالثلث األخير من المعدة‬
.‫بتصير كتير قوية وبصير فيها تديق هاد بيخلي األكل ما يروح عاإلنتستن وبيضل بالمعدة وبصير فومتنج‬

Diagnosis:

• Gastroscope “endoscope”
• Radiological exam by barium meal ‫الصورة األولى وهو واقف التانية وهو قاعد في أسماء للبوسيشنز‬

In some cases, a sliding of the stomach into the esophagus

Management:

Diet advise ‫ عند النوم ينام رافع رأسه‬,‫ بعد وقت معين ممنوع األكل‬,‫وجبات صغيرة بالحجم مقسمة على عدد مرات كبير‬

Antacids:
1. H2 blocker like: famotidine, cimetidine, nizatidine “older group”

2. protein pump inhibiter: omeprazole, lansoprazole, pantoprazole, esomeprazole “Nexium 20 mg or

40mg” ‫ ولكن ممكن في بعض األحيان حبتين باليوم وحدة الصبح ووحدة المسا التنتين‬,‫بنعطوا صباحا ً حبة وحدة قبل الفطور باألغلب‬
‫قبل األكل‬

3. surgery: in sever cases, by gastroscope ‫درجة‬270 ‫بيدخلوا جوا المعدة وبيعملوا أربع ثقوب وبيجو عالمعدة وبيقلبوها‬
‫ درجة‬360‫أو‬

Peptic ulceration:

:‫المعدة بتفرز الكثير من األسدز فبصير الجدار تاعها ضعيف ممكن يؤدي ل‬

Hemorrhage → blood loss

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If it was in the duodenal region, it is called duodenal ulcer, if it is in the stomach, it is called gastric
ulcer “two types of peptic ulcer”

Chronic blood loss → nutritional deficiency →anemia “iron deficiency anemia” so the signs and
symptoms and the oral manifestations are all related to the anemia

Signs and symptoms:

Recurrent oral ulcerations

Angular cheilitis

Atrophic glossitis

Causes:

Aspirin and NSIDS long term usage

Stress

H pylori

Diagnosis:

1. Endoscope
2. Barium meal x ray: it will reveal a perforation and ulceration

Management:

Antacids like protein pump inhibitors the most common one is Nexium 20 or 40 mg

For H pylori→ triad therapy: two antibiotic and one antacid

Antacid → omeprazole 10 to 14 days

Antibiotics→ clarithromycin 500mg 1*2*10 days and amoxicillin 1000mg 1*2*10 days

“commonest”

In the past a tetracycline or metronidazole were used rather than clarithromycin

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 10*1*1 ‫ ملغ‬500 ‫ فولكسال‬,‫أحدث اشي بيستخدموه حاليا ً هو الليفوفلوكساسين " ليفوكس‬

CROHN’S DISEASE

Granulomatous inflammatory disorder, affect any

site in the GI tract, the most common site is the
hernial ileum

The onset of disease: variations 20s and 50s

The oral lesions appear earlier than the GI

problems, these lesions are: angular cheilitis, oral
ulceration, thickening of the oral mucosa “specially
the buccal mucosa and retromolar pad area” →
cobblestone mucosa appearance “mucosal tags”
and gingivitis and lip swelling and lip fissure

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Etiology:

Autoimmune disease

‫أوتو أنتي بديز بتهاجم الجي آي تراكت‬

Environmental factor

Diet

Genetics

GI problems:

Abdominal pain

Diarrhea

Wight loss

Weakness

Perianal Fistula and perforation

‫في ببعض األحيان بتيجي األتاك قوية وبتقعد لفترة وبعدها بتخف‬

A variation in the progress is present: active phase and inactive phase

Other complications:

Malabsorption → anemia folic acid anemia with

skin rash with weakness

Diagnosis:

Biopsy from the rectal mucosa, under the

microscope we see non caseating “with no
necrosis” epithelioid cell granuloma a collection of
macrophages and multinucleated giant cells

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 RG exam:

Barium enema for any lower GI tract “barium meal for upper GI”

This will reveal ulceration in the GI

Clinically → perianal fistula may present

Treatment:

Steroids “as anti-inflammatory”

To reduce the steroids side effect an immunomodulator should be used

Any deficiency present should be corrected

Iron def. → ferrous sulphate 200mg 1*3

Folic acid def. → folic acid 5mg

New drugs ‫مش واضح اسمهم‬

Work as antagonist of action of tumor necrosis factor → reduction on interleukin IL 1and IL 6 and
leukocytes migration → reduction in epithelial permeability → reduction in inflammatory process

Surgery .‫لو كانت المشكلة باإلليم بقصو هاي المنطق الي عاملة المشكلة‬

OROFACIAL GRANULOMATOSIS

Orofacial granulomatosis is used to describe oral mucosal granulomatous inflammation without an

identifiable cause. The clinical features are very similar to oral lesions of Crohn’s disease, but this is probably
a distinct disease. However, distinguishing these conditions is difficult, and some patients considered to
have orofacial granulomatosis will subsequently prove to have Crohn’s disease after several years. The
chances of eventually developing Crohn’s disease are higher if orofacial granulomatosis is diagnosed in
childhood.

‫الليجنز والساينز كاملة الي بنشوفها بالكرونز دزيز بنشوفها هون لكن بدون مشاكل في الجي آي‬

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‫ من الحاالت الي تشخصت أول اشي أوروفيشيل جرانيلومتوسز بعد فترة تحولت وصار في مشاكل في الجي آي بتصير اسمها‬%5
‫ بكرونز بكون المرض مرتبط باألمراض المناعية هون بيكون مرتبط أكتر باألليرجيز ألنواع معينة من األكل‬, ‫كرونز ديزيز‬
)‫سينامون‬,‫(شوكوالتة مواد حافظة فيها بنزويك أسيد‬
signs:

Lip swelling

Facial swelling should be present “in one side or in both sides” (most persistent sign)

Gingivitis

Mucosal tags

Oral ulceration “recurrent”

Angular cheilitis

Male = female

Signs start earlier than in Crohn’s disease “start in 10 years

Etiology:

Allergies ‫القرفة مثال‬

Infections

Diagnosis:

Depends on histopathological examination

• Patch test
• Biopsy from the buccal mucosa (we see under the microscope the see non caseating “with no
necrosis” epithelioid cell granuloma a collection of macrophages and multinucleated giant
cells).
• Serological investigations antibodies against allergens

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Treatment:

‫ لو ما تحسن‬, ‫بعد ما نشوف الفحوصات بنمنع المريض ياكل المواد الي بتحسس منها لمدة تلت أشهر وبعدها بنشوف لو تحسن أو ال‬
. ‫ لكن دائما ً بننصح المرضى يبتعدو عن القرفة والبنزوك أسد‬, ‫بندور عمواد أخرى‬

‫دائما ً الزم نسأل المريض لو صار عنده إكزيما أو أزما كله مرتبط باألليرجنز‬

For short term:

Antihistamine

Short courses of steroids “intra lesion steroids can be used

Topical steroids and antiseptic mouthwash for oral ulcers (chlorhexidine)

Angular cheilitis: antifungal “daktarin daktazole” and antibiotic fusidic acid

‫ أشهر ل سنة ونص‬6 ‫بالعادة األوروفيشيل ليجنز بتختفي خالل‬

Melkersson Rosenthal syndrome

Is a part of Crohn’s disease → three F: facial and lip swelling “persistent”

facial paralysis due to granuloma ‫تضغط الفيشيل نيرف‬
fissured tongue

Male = female

Under 20 years

Signs and symptoms

Repeated attacks of facial swelling

Treatment

It is for symptoms only

Non-steroidal anti-inflammatory drugs + steroids “to reduce swelling”

We need to reduce the inflammation to avoid facial paralysis

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 Ulcerative colitis

Ulcerative colitis is an inflammatory disease of the large intestine causing ulceration and fibrosis. Patients
are typically between 15 and 50 years. The main effect is intractable diarrhea with blood and mucus in the
stools. Abdominal pain, fever, anorexia and weight loss are seen in severe cases.

Affects the colon and rectum “mostly” → result of inflammatory process is the ulcerations complicated
with hemorrhage and perforation

The most affected ages → under 30 “young”

Signs and symptoms:

Abdominal pain

Diarrhea mixed with blood

Wight loss

Etiology: fatty food, modern life style

In oral cavity:

Recurrent aphthous ulcer “aphthous like ulceration”

Angular cheilitis due to malabsorption and blood loss

Deficiencies → iron deficiency

Diagnosis:

Barium enema (shortening of colon, loss of haustral pattern of colon, ulceration)

The best test is endoscope with biopsy

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Treatment:
Anti-inflammatory drugs (sulphasalazine, sulphoinamide)

Drugs affects the tumor necrosis factor

The same with Crohn’s disease

We may go for surgery → removal of colon surgically

COELIAC DISEASE
Subtotal villous atrophy → in the jejunum

Reaction “hypersensitivity” of alpha gliadin component of wheat rye or barley

‫المريض الزم يلتزم بأكل معين وما باكل قمح‬

Common disease 1:2000

Signs symptoms:
Diarrhea

Wight loss

Weakness

The oral manifestation has a huge variation

Malabsorption of folic acid → recurrent aphthous like ulceration, angular cheilitis, atrophic glossitis

Diagnosis:
Endoscope and biopsy from the jejunum→ we see under the microscope the subtotal villous atrophy

Hematological investigations to see the iron and folic acid levels then to correct them

Serological investigations Ig A antigliadin

The patient should eat a gluten free diet

To confirm the diagnosis ‫بعد إلتزام المريض بطعام خالي من الجلوتين بنعمل كمان مرة بايوبسي بنالقي إنه تحسنت الجيجنم‬
‫بطل في أتروفي‬
Need a folic acid supplement

THE END
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