Gastroenterology: Inflammatory Bowel Disease (IBD) - 5. Gastroenterology - iii. PDF

**[GASTROINTESTINAL DISORDERS]** **Inflammatory Bowel Disease (IBD)** - *[Frequent]* **Oral Manifestations** - *[Higher]* *[incidence]* in **Young Patients** - *[Important]* to *[understand]* other features of the **Disease** **IBD** is *[different]* to **Inflammatory Bowel Syndro...

**[GASTROINTESTINAL DISORDERS]** **Inflammatory Bowel Disease (IBD)** - *[Frequent]* **Oral Manifestations** - *[Higher]* *[incidence]* in **Young Patients** - *[Important]* to *[understand]* other features of the **Disease** **IBD** is *[different]* to **Inflammatory Bowel Syndrome**! - IBS is diagnosis of exclusion Excluded all the others **[IBD Types]** - **Ulcerative Colitis**: *[Affects]* **Mucosa** of the **Colon**, **Intra-Mural** *[Confined]* to the **COLON** - **Mucosal disorder** - **Crohn's Disease**: *[Can **affect any** part of the]* **GI Tract**; **Transmural**, with **Fistulae** as a *[feature]*; often has \"**Skip Lesions**\" *[Some]* **parts** are **affected** then *[some are]* **Normal** *[then some]* **Ain't** - **TRANSMUCOSAL DISORDER** **Gender Prevalence** - **Crohn's Disease**: *[More common]* in **Females** (excluding pediatric cases) - **Ulcerative Colitis**: *[More common]* in **Males** **Familial Patterns in IBD** - **10-25%** **concordance** - **Influences**: **Genetic** and **Environmental** **Factors**, *[more common]* in \"**Westernized**\" *[societies] -* **Suggested Dietary Influence** - **Genetic** and **Environmental** **Influences** *[still not fully resolved]* **Causes of IBD --** - **Infections** - **Immunological origins** - **Genetic** **Predisposition** - **Dietary** and **Environmental** factors - **Vascular**/**Neuromotor** factors - **Allergenic** - \[Psychogenic factors considered\] - *[Big difference between]* **Irritable Bowel Syndrome (tends to be linked to Mental)** **[Drug Therapies for IBD]** - **Symptomatic Agents**: **Anti-diarrheal, anti-spasmodics** - **Short-term Steroids**: **Prednisolone -** *[only used]* **SHORT TERM** - **Amino-salicylic acid derivatives** - **5-ASA compounds**: **Sulphasalazine** - **Corticosteroids and Immunosuppressives** - **Antibiotics**: **Metronidazole (anerobics in gut)** - **Biologic Agents**: Medications ending in "-**mab**" **Crohn's Disease Presentation** - **Symptoms** *[vary depending on the]* **Affected** **Part** of the **GI TRACT**: - **Small Intestine** can sometimes be more affected - **Chronic pain** and **Diarrhea** - **Abdominal** **pain** - **Intestinal** **obstruction** - *[Potential]* **Malabsorption** - *[Periods]* of **Remission** and **Flare-Ups** - Can go months without flare ups **[Systemic Complications of IBD (related to inflammatory activity)]** - **Aphthous Ulceration -- *due to lots* *of* blood loss** - **Episcleritis** and **Uveitis** (eye) - **Uveal Tract Inflammation** **Irregular** **Shaped** **Pupil** - **Red** **Sclera** - **Arthritis** - **Erythema** **Nodosum - Pattern** on the **SHINS** - **Pyoderma** **Gangrenosum --** *[Side of]* **ANKLE** - *[Usually]* on the **Lateral Side** of the **Ankles** - *[If on the]* **Medial Side** *[Typically]* **Varicose Veins** **[Extra-GI Signs in IBD (particularly Crohn's Disease)]** **[Systemic Complications of Crohn's Secondary to small bowel involvement ]** - **Malabsorption** - **Gallstones** - **Renal** **Stones** - **Fistulae** - **Hydronephrosis - Fluid Accumulation** *[Around]* The **Kidney** - **Amyloidosis -- Protein** *[like]* **substance** that *[gets]* **deposited** (big thing in **Alzheimer's** were they find it in the brain) **Pediatric Potential Complications** - **Fever** - **Anemia** - **Arthritis** - *[Failure]* of **Growth** and **Development** *[due to]* **MALABSORPTION** **Blood Tests for IBD** - **FBC**: **Hemoglobin (Hb), White Cells, Platelets Microcytic RBCs Check this for anaemia? IMPORTANT TO LEARN** - **C-Reactive Protein (CRP)**: Non-specific inflammation marker - **LFTs**: Liver function tests, related to complications of Crohn's, e.g., sclerosing cholangitis (**Sclerosing** of **Bile Ducts**) - **U&E**: Urea and electrolytes - **Ferritin Levels**: Iron stores - **Vitamin Levels**: B12, folate, Vitamin D - **Trace elements** **Other Tests** - **Stool/faecal tests**: *[Checks for]* **Bleeding**, **Infection (Faecal Occult - Blood Test) -** *[Checking for any]* **Blood Present** - **Faecal calprotectin levels**: Indicates inflammation **Endoscopy** - **Oral** or **Rectal**, *[depending]* on **Symptoms** (looks for polyps, strictures) - **Biopsies** in **Crohn's**: *[Characteristically]* *[shows]* **Granulomatous** **Inflammation -** lots of **GRANULOMAS** *[present]* - *[Differentiates]* from other **Granulomatous Disorders**: - **SERUM ANGIOTENSIN CONVERTING TEST** *[Diagnostic]* of *[somebody]* with **SARCOIDOSIS** - **Blood test.** **[DIFFERENTIATE] OFG** & **CROHNS BIOPSY** - *[ASK IF THERE IS ANY]* **HISTORY** OF THIS PT - **COBBLESTONE MUCOSA PRESENTATION** **[Dental Aspects in IBD]** - **OROFACIAL GRANULOMATOSIS (OFG**) *[with]* **Oral Soft Tissue** **swellings** - **APHTHOUS ULCERATION** - *[Effects]* of **Medication**, e.g., **Immunosuppressants** like **ADALIMUMAB**, **INFLIXIMAB** - [**Dental Infections** *they would not typically get **ADVANCED PERIODONTAL DISEASE***] - **ANEMIA** and *[relevant]* **Systemic Signs/Symptoms** **Ethnic and Racial Incidence of IBD** - *[Highest]* in **JEWISH PEOPLE** (10 per 100,000) - *[Second]* *[highest]* in **NON-JEWISH CAUCASIANS** (4 per 100,000) - *[Lowest incidence]* in **BLACK PEOPLE** (\~1.5 per 100,000) [**PROCTOCOLITIS** ***causes***:] - **Ulcerative coilitis** - **Crohns disease** - **Radiation** - **Ischemia** - **Infections** - **Antibiotics** - **Other causes** **ULCERATIVE COLITIS - Indications for Surgery** - **Failure** of **Medical Treatment** - **Life-Threatening Hemorrhage** - **Toxicity** (with or without perforation) - **NON-FUNCTIONAL COLON** *[increases]* *[with]* **Size** to a **Mega Colon**, *[then]* **BURSTS** - *[Suspected]* **Malignancy** or ***[severe]*** **Dysplasia** - **Growth** **Retardation** or **Systemic** **Complications** **Surgery** for **Crohns** is *[rare]* If *[removed]* a **Section**, *[next]* **Section** *[often becomes]* **Affected** **[GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)]** - **Retrograde** **Flow** of **Gastric** **Contents** into the **Oesophagus** - *[Causing]* **Heartburn** - *[Only]* **Diagnosed** when **Reflux** *[causes]* *[frequent]*, *[severe]* **Symptoms** or **mucosal** **damage** - *[Common disorder,]* *[typically]* **Chronic** and **Relapsing**, *[impacting]* **Quality Of Life** **Epidemiology of GORD** - \~25% of **Adults** in **WESTERN SOCIETIES** *[experience]* **Symptoms** at *[least monthly]* - 5% experience **Daily Symptoms** - *[Incidence]* **Increases** *[with]* **age** - *[Relaxed muscles ]* *[Goes through]* **T10** **Pathophysiology of GORD** - **[Multifactorial]** - **Anti-Reflux Barrier**: - **Diaphragm** *[serves]* as an \"**External Sphincter\"** - **Refluxed material**: **Acid** and **Pepsin** **Damage** the **Oesophageal Mucosa**, **Damage** *[proportional]* to **Acid Exposure** - *[If **L**]***ong Term** *[can develop]* **Barrett's Oseophagus** *[Can become]* **Malignant** **[Oesophageal Defence Mechanisms]** - **Oesophageal** *[clearance]* via **Gravity** and **Peristalsis** (dysfunction can impair clearance) - **PERISTALTIC DYSFUNCTION** - **Hiatus Hernia** *[can impact]* **Clearance** - **Stomach** *[goes into the]* **Thorax** *[through the]* **T10** - *[Name]* *[varies]* **dependent** **Upon Location** - **Saliva** *[contains]* **Bicarbonate** to *[neutralize]* **Acid** (important for patients with dry mouth) - **Oesophageal** **Mucosa** *[provides]* *[protection]* via **Mucus**, **Bicarbonate**, and **Prostaglandins** **[Risk Factors for GORD]** - **Genetic Predisposition** - **Smoking** - **Diet**, particularly large meals or high-fat foods - **Obesity** - **Caffeine** and *[excessive]* **alcohol** - **Pregnancy** - **Hiatus Hernia** - *[Certain]* **Medications**, e.g., **Tricyclic Antidepressants** (TCAs), **Anticholinergics**, **Nitrates**, **Calcium Channel Blockers** - **Nitrates** *[can affect the]* **Lower Oesophageal Sphincter** - *[Relaxes]* **Hiatus Hernia** *[Can relieve]* **Pain** in **MI** (caused by GI) **[Symptoms of GORD]** - **Heartburn** - *[Triggered]* by **Meals**, **Lying Down**, **Stooping**, **Straining**; *[relieved]* by **Antacids** - **Retrosternal Discomfort** - **Acid Brash** (regurgitation of acid or bile) - **Water Brash** (excessive salivation) - **Odynophagia** (pain on swallowing, possibly due to severe oesophagitis or stricture) - **MUST BE FOLLOWED UP** **[Dental Erosion]** **"Alarm Symptoms" - Refer Immediately** - **Acute** **Gastrointestinal** **Bleeding - *[If]* Vomiting Blood\-\-- IMMEDIATE REFERRAL** - **URGENT ENDOSCOPY!** - *[Urgent]* **Endoscopy** *[referral]* for **Patients** with **Dyspepsia** *[presenting with:]* - **Chronic Gastrointestinal Bleeding** - *[Progressive Unintentional]* **Weight Loss** - *[Difficulty]* **Swallowing** - *[Persistent]* **Vomiting** - **Iron** **Defic*[i]*ency** **Anemia** - **Epigastric** **Mass** **[Management of GORD]** - *[Reduce]* **Risk Factors** - *[Initial]* **Treatment** *[with]* **Medications** *[unless]* **Alarm Symptoms** *[are present]* - **Proton pump inhibitors (PPIs)** like **Omeprazole, Lansoprazole** **[Upper Gastrointestinal Bleeding]** - **[Causes]**: - **Peptic Ulcer Disease** - **Gastritis** - **Varix Rupture** - **VARICOSE VEINS Rupture** - **Oesophagitis** - **Duodenitis** **Signs and Symptoms of Upper GI Bleeding** - *[General]* **Abdominal** **Discomfort** - **Hematemesis** and **Melena** - **Hematemesis Vomiting blood** - **Melena Blood passed rectally** - **If Stool is BLACK Blood** *[from the]* **STOMACH** - **Fresh blood** *[In]* **Inflammatory Bowel Disease** - *[Classic]* *[signs]* of **Shock** (e.g., orthostatic changes) **Treatment** - *[Differentiate]* *[between]* **Life-Threatening** and **Chronic Cases** - *[General]* **Treatment** **Guidelines** *[established]* **[Peptic Ulcers]** **Pathophysiology**: **Erosions** *[caused]* by **Gastric Acid -** *[Includes]* **STOMACH & INTESTINE ULCERATION** - *[**Common causes**:]* - **NSAID** use - **Alcohol** and **Tobacco** use - **Helicobacter Pylori Infection** **[Helicobacter Pylori]** - *[Diagnosed]* with a **Urea** **Breath** **Test** (converts urea to ammonia and carbon dioxide) - *[PT TAKES **UREA** HY PYLORI CONVERTS IT ]* - *[Sometimes]* **Diagnosed** via **Biopsy** - **Micro-Aerophilic**, **Gram-Negative**, **Helical-Shaped Bacteria** **Treatment for H. Pylori Infection** - [**Triple Therapy**:] - **Lansoprazole** (PPI) - **Clarithromycin** and **Amoxicillin** (or **Metronidazole**) *[for one week]* **[Coeliac Disaease]** A **GI** **Malabsorption** *[disorder]* due to **Intolerance** to **Alcohol-Soluble Proteins** in **Barley**, **Wheat**, **Rye** (*[sometimes]* **oats**) - *[Leads]* to **Villous** **Atrophy** and **Malabsorption** - *[Can occur at any]* **Age**, *[often]* in **Children** and **Adults** **aged 50-60,** with a *[slight]* **Female Predominance** **[Associations with Coeliac Disease]** - **HLA DR3 gene** - **Autoimmune** **Diseases** - **Dermatitis Herpetiformis** **[Symptoms of Coeliac Disease]** - **Abdominal** **Pain**, **Steatorrhea**, **Bloating**, **Weight Loss**, **Fatigue** - **Oral** **Symptoms**: **Aphthous Ulcers**, **Angular Cheilitis** **[Coeliac Disease Diagnosis]** - **Alpha**-**Gliadin** and **Anti-Endomysial** **Antibodies** - **Gliadin *[Found in]* Wheat Products** - **Jejunal** **Biopsy** *[showing]* **Villous** **Atrophy** (reverses on a gluten-free diet) **[Complications of Coeliac Disease]** - **Anemia** - *[Increased]* *[risk]* of **T-cell lymphoma** - *[Secondary]* **Lactose Intolerance** - *[Other]* **malignancies** **[SUMMARY]** - **IBD**: *[Consists]* of **Two Main Types** (Ulcerative Colitis and Crohn's Disease) - *[Different]* from **IBS** - *[Involves]* *[both]* **Genetic** and **Environmental** **Factors** - *[Has]* **Oral** and **Extra-Intestinal** **Manifestations** - **GORD**: Often treated with **PPIs** **[FINAL POINTS]** - *[Always]* *[inquire]* about **GI symptoms** *[when managing]* **Soft Tissue** **Lesions** or *[prescribing]* **Medications** - *[Remember]* to *[consider]* the **GI Tract** in **patient** **[\ ]** **[GASTROENTEROLOGY:]** **[Liver Function:]** Clotting Factors: - Hepatocytes are involved in the synthesis of clotting factors - Such as fibrinogen, prothrombin, factor V, VII, IX, X, XI, XII - Involved in haemostatic function Metabolism/Detoxification: - Most drugs/alcohol are metabolised in the liver - Drugs are metabolised using cytochrome P450 enzymes Bilirubin: - Bilirubin is the breakdown products of red blood cells - Bilirubin is a yellowish pigment - Bilirubin then passes into bile and is eventually excreted in the body - Build-up of bilirubin suggests the liver is not functioning properly = jaundice. Storage: - Storage of glycogen - Converts glycogen to glucose when BSL is low and vice versa Bile Production: - Liver produces bile which is then stored in the gall bladder Albumin: - Protein made by the liver - Maintenance of appropriate osmotic pressure - Transporter for hormones **[Chronic Liver Disease:]** Chronic liver disease refers to disease of the liver which lasts **over a period of six months.** It is the graduate destruction of liver tissue over time. Liver disease is caused by many different things e.g., alcohol/genetics/viral infection/non-alcoholic disease. Initially, there is hepatitis (reversible inflammation of the liver), if this is not treated it can lead to cirrhosis. Cirrhosis is end-stage liver function where the liver becomes fibrotic and there are structural changes. **[Liver Disease Risks:]** - Excessive bleeding - Due to disordered production of clotting factors - Risk of viral hepatitis - Drug toxicity - Most drugs/alcohol is metabolised in the liver **[Risk Factors:]** - Heavy alcohol use - Obesity - Type 2 diabetes - Tattoos or body piercings completely aseptically - Injecting drugs using shared needles - Blood transfusion between 1992 - Unprotected sex **Hepatitis:** - Hepatitis A: transmitted faeco-orally, 3-week incubation period - Hepatitis B: blood-to-blood contact, 6 week -- 6-month incubation period - Dental care professionals are immunised against Hepatitis B - Blood test will show hepatitis B antibodies in the blood - Hepatitis C: second biggest cause of liver disease after alcohol, 6 week -- 6-month incubation period **Alcohol-Liver Disease:** - Major cause of liver disease in Western countries - Alcohol overconsumption leads to fatty liver, alcoholic hepatitis, and eventual end-stage cirrhosis. - Alcohol is broken down in the liver but causes inflammation of the hepatocytes which them lay down fatty deposits, causing inflammation of the liver. **Non-Alcoholic Disease:** - Common in countries in which alcohol use is low - Associated with high BMI/high cholesterol and high fatty diets **Signs and Symptoms:** - Acute hepatitis often has no noticeable symptoms, chronic hepatitis more likely to have symptoms - Muscle and joint pain - Fever - Nausea/vomiting - Fatigue - Abdominal pain - Dark urine - Pale faeces - Itchy skin - Jaundiced skin - Loss of weight **Diagnosis: Liver Function Tests:** - **Albumin:** - Low albumin may indicated the synthetic function - **Alanine aminotransferase (ALT):** - Leaks from damaged liver - Most sensitive marker for hepatic damage - **Aspartate aminotransferase:** - Leaks from damaged liver, heart or muscle - **Bilirubin** - Increased in liver damage - Both conjugated and unconjugated - **APTT/PT:** - Time is increased - As decrease in clotting factor production - **Thrombocytopenia** **Cirrhosis:** - This is last-stage liver failure, not curable - May need to consult hepatologists - Patients will have serious bleeding problem - Clotting screen may be required - Extra-care when prescribing medications - Consult BNF for hepatic doses **Treatment:** - Lifestyle changes: decreasing alcohol intake - May cause withdrawal symptoms - Treatment depends on cause of liver disease - Diuretics - Vitamin K - Blood products - Antibiotics - Nutritional therapy - Liver transplant eventually **Dental Considerations:** - Avoid LA that metabolises in the liver - Articaine preferred as it metabolises in plasma - Patient with liver disease/high alcohol consumption will need liver function tests and clotting studies prior treatment - Vitamin K IV may be needed prior oral surgery, to correct any bleeding tendancy - Dental sedation should be carried out in secondary care - Cancer risk is increased - Consent? - Bleeding/clotting studies **[\ ]** **[Oesophageal Disease GORD:]** Gastro-oesophageal reflux disease (GORD) is backflow of acid from the stomach into the oesophagus. Commonly known as heart burn and acid reflux. **[Signs and Symptoms:]** - Heartburn: burning sensation behind the sternum - Often after a meal - Acid sour taste in the mouth - Due to backflow of acid - Cough or hiccups - Hoarse voice - Bad breath - Bloating and feeling sick **[Diagnosis:]** - **[Spechler Test ]** - Similar to diet chart - 7-day diary - Times of heartburn - Severity of discomfort - Difficulty swallowing - Coughing/wheezing - **[Endoscopy ]** - Confirm that there is acid damage to the stomach - **[Smart Pill transmitter ]** - Patient swallow the pill - Pill measures pH of the stomach and sends signals to a receiver **Differential Diagnoses:** - Candida oesophagitis - Chemical burns from acids or alkalines, NSAIDs, tetracyclines **Causes/Pre-disposing factors:** - Certain foods - Fatty/spicy foods - Overweight - Smoking - Pregnancy - Stress and anxiety - Medications e.g., NSAISs - Hiatus hernia **[Treatment]:** Lifestyle advice: - Eat smaller, more frequent meals - Raising head of the bed by 10cm at night - Relaxation - Losing weight if overweight **[Medications]:** - **PROTON PUMP INHIBITORS** - Block gastric acid secretion by irreversibly binding to and inhibiting hydrogen-potassium ATPase pumps in stomach - Omeprazole - Lansoprazole - **H2 ANTAGONISTS:** - H2 blockers, reduce amount of acid produced in stomach - Ranitidine, cimetidine - **ANTACIDS** - Neutralise acid in stomach to relieve pain - Sodium alginate **Dental Considerations:** - As the gastric contents have a low pH, backflow into the oesophagus and oral cavity can cause dental erosion - Dental erosion often found on: - Palatal surfaces of upper anterior teeth and premolars - Lower teeth often protected by tongue and pooling of saliva - Other causes of erosion: - Undiagnosed epilepsy - Bulimia - Anorexia - Increased risk of gastro-oesophageal cancer **[\ ]** **[Irritable Bowel Syndrome:]** IBS affects up to the 30% of population. IBS is gastrointestinal/digestive disorder categorised by a group of symptoms which include changes in bowel movements and abdominal pain. **Causes:** - Unclear, but may be associated with: - May begin after an infection - May have a family history of IBS - Anxious personality type - History of migraines - Psychogenic symptoms - Slight female pre-deposition **Symptoms:** - Crampy abdominal pain - Flatulence - Bloating - Changes in bowel habit - Nausea - Tiredness/lack of energy **Types of IBS:** - IBS-C - IBS-D - IBS-M - IBS-U -- undefined subtype, symptoms vary **Diagnosis:** - IBS is diagnosed by exclusion - Investigations to rule out IBD, colonic cancer, coeliac disease - Blood tests: - Full blood count - Haematinics - Inflammatory markers (ESR -- erythrocyte sedimentation rate) **Treatment:** - Stress reduction - High fibre diet - Probiotics may have a role - CBT/antidepressants may be of benefit to patients with clinical depression **Dental considerations:** - LA is acceptable - Conscious sedation may be needed due to patients' anxious personalities **[Hiatus Hernia:]** A hiatus hernia is a type of hernia in which the stomach slip through the diaphragm into the middle compartment of the chest. Often referred to as the 'great mimic' because its symptoms can resemble many disorders This may result in GORD/**S&S:** - Heartburn - Acid taste in the mouth - Bad breath - Feeling bloated - Feeling sick - Bad breath **Risk Factors:** - Obesity - Older age - Major trauma - Scoliosis **Classification:** **Diagnosis**: - Confirmed with endoscopy or medical imaging **Treatment**: - Similar to treatment of GORD - Laparoscopy if the hernia is unusually large or is causing severe discomfort **[Dental Implications:]** - Same as GORD **[Gastritis:]** Gastritis is inflammation of the lining of the stomach. It is a common condition with a wide range of causes. Symptoms may come on very suddenly (acute) or last a long time (chronic gastritis) **Causes**: - H. Pylori bacterial infection - Excessive use of alcohol / cocaine - Smoking - Excessive use of NSAIDs - Autoimmune disorder **Signs + Symptoms:** - Indigestion - Burning stomach pain - Nausea - Vomiting **Diagnosis**: - Complete history of the problem **H. Pylori:** - Helicobacteria pylori bacteria can cause stomach/duodenum ulcers - Common bacterial infection to have - Most people with the infection do not have symptoms **NSAIDs**: - Excessive use of NSAIDs cause gastritis and peptic ulcers - This is because NSAIDs decrease prostaglandin secretion which is cytoprotective in the gastric mucosa - Increases risk of mucosal injury in the stomach **Treatment**: - Depends on the cause of the gastritis - Antacids to neutralise acid - **H2 Blockers** - Blocks action of histamine on h2 receptors in the stomach, decreasing acid production - Ranitidine - **Proton Pump Inhibitor** - Omeprazole - Lansoprazole - **H. Pylori Infection**: triple therapy - PPI - Clarithromycin - Amoxicillin/metronidazole - For 14 days **[Dental Implications:]** Gastric acid reflux can cause severe dental erosion, typically palatal aspects of maxillary anterior teeth and premolars - Intrinsic acid - H. Pylori may be transmitted in saliva but dentists do not seem to be at risk - There may be an association between H. Pylori and halitosis - NSAIDs that cause gastric inflammation/bleeding should not be given to patients with gastritis/ulcrs - PPIs: may cause dry mouth **[Coeliac Disease:]** Coeliac disease is a chronic auto-immune disorder where patients develop intolerance to gluten, present in foods such as wheat, rye and barely. It primarily affects your small intestine. Small intestine has a toxic reaction to the **gliadin** component of gluten. This causes villus atrophy and crypt hyperplasia **[Signs and Symptoms:]** - Many patients are asymptomatic - Diarrhoea - Stomach aches - Bloating - Flatulence - Indigestion - Constipation - Fatigue - Dermatitis herpetiformis - Infertility - Peripheral neuropathy - Unexplained weight loss - Oral ulceration, glossitis, angular cheilitis - malnutrition **[Complications of Coeliac Disease:]** - **Osteoporosis** - Malabsorption due to small intestine damage - Minerals such as calcium can lead to osteoporosis - **Anaemia** - Malabsorption due to small intestine damage - Iron/B12/folate deficiency - *[Increased]* **Risk** of **Intestinal Lymphomas** **[Diagnosis:]** - Full blood count - Anaemia is present in 50% of CD patients - Anti-gliadin antibodies (IgG and IgA) is used for coeliac screening (serum) - 24 hour weight of stool - Over 300g is abnormal - Small intestinal endoscopic biopsy - Shows villous atrophy/flattening of the villous - UK: biopsy and endoscopy **Treatment:** - If anaemic/low minerals: take as needed - Treated excluding gluten-containing products from diet - This is a lifelong treatment; patients must avoid gluten for the rest of their life - By law, gluten-free labelled food cannot have more than 20ppm of gluten - Dermatitis herpetiform should cure after cutting out gluten - Later symptoms to resolve **Dental Complications:** - Anaemia cause by CD may pre-dispose patients to ulcers, glossitis and angular stomatitis - Enamel defects -- poor enamel formation - Anaemia can complication GA **[Inflammatory Bowel Disease:]** IBD is a group of disorders that causes chronic inflammation in the intestines and includes **Crohn's disease** and **Ulcerative colitis.** [**Crohn's Disease:** ] An inflammatory bowel disease that can affect any part of the GI tract. The inflammation is **transmural** (affects all layers) **Symptoms:** - Diarrhoea - Abdominal pain - Fatigue - Rectal bleeding - Weight loss - Ulceration **Causes:** - Unknown - Genes, family history - Autoimmune - Smoking **Diagnosis:** - Full blood count: anaemia is common - Erythrocyte sedimentation rate: inflammation - C-reactive protein: inflammation - Colonoscopy to visualise pattern of disease involvement - Mucosal biopsy: often shows granulomas **Dental Considerations:** - Anaemia can cause ulceration - Aphthous ulcers, mucosal tags, cobblestone mucosa, glossitis, angular chelitis - Antibiotics (clarithromycin) may trigger antibiotic induced colitis - Anaemia may cause an issue for GA **Orofacial Granulomatosis:** oral features of Crohn's disease without gastrointestinal features [**Ulcerative colitis:** ] An inflammatory bowel disease that only affects the large intestine and rectum. Autoimmune in nature. Inflammation does not go beyond the lamina propria **Symptoms:** - Diarrhoea - Abdominal pain - Needed to go to the loo often **[Diagnosis]:** - **Full Blood Count** to check to anaemia - **Inflammatory** **Markers**: ESR and CRP - **Colonoscopy**: check the extent of the colitis - **Biopsy**: needed to differentiate between UC and Crohn's - **UC**: inflammation limited to mucosa - **Crohn's**: transmural inflammation (all layers) **[Dental Considerations:]** - Anaemia can cause ulceration - Aphthous ulcers, mucosal tags, cobblestone mucosa, glossitis, angular chelitis - Antibiotics (clarithromycin) may trigger antibiotic induced colitis - Anaemia may cause an issue for GA **[Jaundice:]** Jaundice (icterus) is a condition where the skin and the whites of the eyes are yellow-ish in colour due to high bilirubin levels. After 120 days, red blood cells are engulfed by macrophages and a product of this breakdown is unconjugated bilirubin. Unconjugated bilirubin is lipid soluble. Albumin carries unconjugated bilirubin to the liver where it is then converted into conjugated bilirubin (water soluble). It is then stored in the bile. If liver is damaged, there can be increased bilirubin (both conjugated and unconjugated) in the blood -- gives yellow skin/eye colour. **Causes:** - Hepatitis - Alcoholic induced liver disease - Increased breakdown of red blood cells - Gall stones **Signs and symptoms:** - Yellow skin - Yellow sclera - Pale faeces - Dark urine - Itchiness **Diagnosis:** - Full blood count - Bilirubin test: measure amount of bilirubin in blood - Will be increased - Liver function tests - ALT - AST **Treatment:** - Depends on the cause of the jaundice - Gall stones: remove gall stones - Alcohol induced: reduce alcohol intake - Hepatitis: anti-vitals