Download GI-

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
Stimulus
disturbance of cell membranes
Phospholipids
catalyzed by cox-2
Arachidonic acid
Leukotrienes
prostaglandins
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/Tetracyc
line)
– 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)

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Ulcerative Colitis
Limited to the large
intestine
Limited to mucosa
Continuous lesions
Remissions/
exacerbations
common
Rectal bleeding
common
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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
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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