Oral Inflammatory Lesions Quiz

Oral Inflammatory Lesions

• Aphthous Ulcers (Canker Sores)
  • Common superficial mucosal ulcerations
  • More frequent in the first 2 decades of life
  • Extremely painful and often recur
  • Cause is unknown
  • Ulcers can be solitary or multiple
  • Most cases resolve spontaneously in 7 to 10 days, but can recur

Oral Candidiasis (Thrush)

• Most common fungal infection of the oral cavity
• Candida albicans is a normal component of the oral flora
• Predisposing factors:
  • Immunosuppression
  • Specific strain of C. albicans
  • Composition of the oral microbial flora (microbiota)

Esophagus

Obstructive and Vascular Diseases

• Mechanical Obstruction
  • Atresia, fistulas, and duplications
  • Discovered shortly after birth due to regurgitation during feeding
  • Most commonly at or near the tracheal bifurcation
  • Associated with a fistula connecting the upper or lower esophagus to a bronchus or trachea
  • Complications: aspiration, suffocation, pneumonia, fluid and electrolyte imbalances
• Functional Obstruction
  • Achalasia
    • Characterized by the triad of:
      1. Incomplete LES relaxation
      2. Increased LES tone
      3. Esophageal aperistalsis
    • Primary Achalasia: caused by failure of distal esophageal inhibitory neurons & degenerative changes in neural innervation (idiopathic)
    • Secondary Achalasia: caused by Chagas disease (destruction of the myenteric plexus, failure of LES relaxation, and esophageal dilation), diabetic autonomic neuropathy, etc.

Esophagitis

• Chemical Esophagitis
  • Caused by chemical irritants:
    1. Alcohol
    2. Corrosive acids or alkalis
    3. Excessively hot fluids
    4. Heavy smoking
    5. Iatrogenic (cytotoxic chemotherapy, radiation therapy, graft-versus-host disease)
• Infectious Esophagitis
  • Most frequent in immunosuppressed
  • Caused by:
    1. Herpes simplex viruses (punched-out ulcers)
    2. Cytomegalovirus (CMV), shallower ulcerations
    3. Candida, adherent, gray-white pseudomembranes
    4. Mucormycosis, aspergillosis
• Reflux Esophagitis
  • Reflux of gastric contents into the lower esophagus is the most frequent cause of esophagitis
  • Clinical condition: Gastroesophageal Reflux Disease (GERD)
  • Causes:
    1. Conditions that decrease LES tone or increase abdominal pressure
    2. Alcohol and tobacco use
    3. Obesity
    4. Pregnancy
    5. Hiatal hernia
  • Clinical Features:
    • Most common in adults, most common in those over 40 years of age
    • Heartburn, dysphagia, regurgitation of sour-tasting gastric contents

Barrett Esophagus

• Complication of chronic GERD
• Characterized by intestinal metaplasia within the esophageal squamous mucosa
• 10% of persons with symptomatic GERD
• Typically present between 40 and 60 years of age
• Confers an increased risk of esophageal adenocarcinoma
• Majority of esophageal adenocarcinomas are associated with Barrett esophagus
• Clinical Features:
  • Usually prompted by GERD symptoms and requires endoscopy and biopsy

Esophageal Tumors

• Squamous Cell Carcinoma
  • Most common esophageal tumors
  • Occurs > 45 years of age
  • Males: females ratio = 4:1
  • Half occur in the middle third
• Risk factors:
  • Tobacco and alcohol use
  • Poverty
  • Caustic esophageal injury
  • Achalasia
  • Plummer-Vinson syndrome
  • Frequent consumption of very hot beverages
• Clinical Features:
  • Dysphagia, odynophagia, and obstruction
  • Extreme weight loss
  • Hemorrhage
  • Aspiration of food through a tracheoesophageal fistula
• Adenocarcinoma
  • Men: women ratio = 7:1
• Risk factors:
  • Barrett esophagus and long-standing GERD
  • Tobacco use
  • Obesity
  • Previous radiation therapy
  • Diet low in fruits and vegetables
• Clinical Features:
  • Pain or difficulty in swallowing
  • Progressive weight loss
  • Chest pain or vomiting

Stomach

• Divided into four major anatomic regions: cardia, fundus, body, and antrum
• Cardia lined mainly by mucin-secreting foveolar cells
• Antral glands similar, but also contain endocrine cells, such as G cells, that release gastrin to stimulate luminal acid secretion
• Gastric lumen strongly acidic (pH: one)
• Mechanisms that protect the gastric mucosa:
  • Mucus layer protects the epithelium
  • Mucosa has a neutral pH due to bicarbonate ion secretion
  • Rich vascular supply to the gastric mucosa delivers oxygen, bicarbonate, and nutrients while washing away acid
  • Protective effects of prostaglandins, which include enhanced bicarbonate secretion and increased vascular perfusion

Stress-Related Mucosal Disease

• Stress-related gastric injury occurs in patients with severe trauma, extensive burns, intracranial disease, major surgery, serious medical disease, and other forms of severe physiologic stress
• Ulcers appear in the first 3 days of disease
• Ulcers are given specific names based on location and clinical associations:
  • Stress ulcers affecting critically ill patients with shock, sepsis, or severe trauma
  • Curling ulcers occur in the proximal duodenum and are associated with severe burns or trauma
  • Cushing ulcers arise in the stomach, duodenum, or esophagus of those with intracranial disease and have a high incidence of perforation

Acute Peptic Ulceration

• Causes:
  • NSAIDs
  • Stress ulcers (critically ill patients with shock, sepsis, or severe trauma)
  • Curling ulcers (occurring in the proximal duodenum and associated with severe burns or trauma)
  • Cushing ulcers (intracranial disease, have a high incidence of perforation)
• Clinical Features:
  • Nausea, vomiting, and coffee-ground hematemesis
  • Perforation

Chronic Gastritis

• Symptoms are less severe but more persistent than those of acute gastritis
• Nausea and upper abdominal discomfort may occur, but hematemesis is uncommon
• Causes:
  • Helicobacter pylori
  • Autoimmune gastritis (atrophic gastritis), 10% of cases of chronic gastritis
  • Radiation injury and chronic bile reflux

Helicobacter pylori Gastritis

• Present in 90% of chronic gastritis affecting the antrum
• Increased acid secretion that occurs in H. pylori gastritis may result in peptic ulcer disease of the stomach or duodenum
• H. pylori infection causes antral gastritis with high acid production, despite hypogastrinemia
• Chronic antral H. pylori gastritis may progress to pangastritis, resulting in multifocal atrophic gastritis, reduced acid secretion, intestinal metaplasia, and increased risk of gastric adenocarcinoma
• H. pylori infection is associated with poverty, household crowding, limited education, residence in areas with poor sanitation
• Diagnosis:
  • Serologic test for anti–H. pylori antibodies
  • Fecal bacterial detection
  • Urea breath test
  • Gastric biopsy (analyzed by rapid urease test, bacterial culture, or PCR)

Complication of Chronic Gastritis

• Peptic Ulcer Disease (PUD)
  • Most often associated with H. pylori infection or NSAID
  • PUD may occur in any portion of the gastrointestinal tract exposed to acidic gastric juices
  • Most common in the gastric antrum and first portion of the duodenum

Peptic Ulcer Disease (PUD)

• Epidemiology:
  • PUD is common and is a frequent cause of physician visits worldwide
• Gastric hyperacidity is fundamental for PUD
• H. pylori infection
• Hypergastrinaemia (Zollinger-Ellison syndrome: PUD in the stomach, duodenum, and even jejunum, caused by tumor
• Cofactors in peptic ulcer:
  • Cigarette smoking (impairs mucosal blood flow and healing)
  • High-dose corticosteroids (suppress prostaglandin synthesis and impair healing)
  • Alcoholic cirrhosis
  • Chronic obstructive pulmonary disease
  • Chronic renal failure
  • Hyperparathyroid