BDS13048 Gastrointestinal and Hepatic Disease I PDF

BDS13048 Gastrointestinal and hepatic disease I  AIM: To describe the potential impact of gastrointestinal or hepatic disease upon oral health and oral health care (dentistry) INTENDED LEARNING OBJECTIVES: On completion of this lecture, the student should have an understanding of: 1....

BDS13048 Gastrointestinal and hepatic disease I  AIM: To describe the potential impact of gastrointestinal or hepatic disease upon oral health and oral health care (dentistry) INTENDED LEARNING OBJECTIVES: On completion of this lecture, the student should have an understanding of: 1. The oral disease that may arise in patients with gastrointestinal or hepatic disease 2. The impact of gastrointestinal or hepatic disease upon the delivery of oral health care  The gastrointestinal tract Oesophagus Small bowel Stomach Duodenum Jejunum Ileum Large bowel Rectum  The gastrointestinal tract: Function Small bowel Duodenum Oesophagus: Passage to stomach (site of initial food break down; site of entry of pancreatic enzymes and bile salts (for later fat absorption) Stomach: Acid generation (essential for later absorption of iron) Jejunum Intrinsic factor generation (essential for later (breakdown and a major site for absorption of vitamin B12) absorption) Commencement of physical break down of food Ileum (breakdown and major site for absorption; terminal ileum is site of Large bowel: absorption of vitamin B12) Water absorption Rectum: Faecal storage  The gastrointestinal tract: Disorders Oesophagus: Dysphagia Small bowel Gluten sensitive enteropathy Stomach: (Coeliac disease) Gastro-oesophageal reflux/hiatus hernia Pancreatic disease (and Gastric erosion/ulceration malignancy) Autoimmune destruction of Parietal cells (lack of intrinsic factor and autoimmune pernicious anaemia) Malignancy Large bowel: Inflammatory bowel disease (Crohn’s disease and ulcerative colitis) Malignancy Anus: Rectum: Haemorrhoids Malignancy  Dysphagia - difficulty swallowing food or liquid Causes Oral Long standing oral dryness Disease affecting the tongue and/or soft palate structure and/or movement Pharyngeal Painful disease Pharyngeal pouch (rare) Malignancy Loss of motor function (e.g. bulbar palsy (with stroke) or pseudobulbar palsy (e.g. with motor neuron disease) or myasthenia gravis Oesophageal Physical obstructions e.g. strictures, malignancy or web (e.g. with iron deficiency) Altered peristalsis (e.g. scleroderma; achalasia, others)  Dysphagia - difficulty swallowing food or liquid Causes Oral Long standing oral dryness Disease affecting the tongue and/or soft palate structure and/or movement Pharyngeal Painful disease Pharyngeal pouch (rare) Malignancy Loss of motor function (e.g. bulbar palsy (with stroke) or pseudobulbar palsy (e.g. with motor neuron disease) or myasthenia gravis Oesophageal Physical obstructions e.g. strictures, malignancy or web (e.g. with iron deficiency) Altered peristalsis (e.g. scleroderma; achalasia, others) Dysphagia: Implications Aspiration risk: – Hence upright positioning – High velocity suction – Rubber dam if appropriate – VERY good lighting Anaesthesia: Risk of anaemia (hence GA risk): Poor nutrient intake will cause an eventual reduction in folate and iron Inability to swallow medication Any implications associated with the causative disease “Globus syndrome” – the sensation of a lump in the throat (that has no physical cause) May be a feature of patients with burning mouth syndrome  The gastrointestinal tract: Disorders Oesophagus: Dysphagia Small bowel Gluten sensitive enteropathy Stomach: (Coeliac disease) Gastro-oesophageal reflux/hiatus hernia Pancreatic disease (and Gastric erosion/ulceration malignancy) Autoimmune destruction of Parietal cells (lack of intrinsic factor and autoimmune pernicious anaemia) Malignancy Large bowel: Inflammatory bowel disease (Crohn’s disease and ulcerative colitis) Malignancy Anus: Rectum: Haemorrhoids Malignancy Hiatus hernia and Oesophagitis Hiatus hernia Part of stomach herniates through the diaphragm. Oesophagitis/gastro-oesophageal reflux disease (GERD) Due to reflux of gastric acid. Pain radiating to the back, worse on stooping. Hiatus hernia and oesophagitis: Implications Risk of pain when in the supine position (unlikely) – Hence upright positioning Risk of anaemia (hence GA risk) – Gradual bleeding will cause an eventual reduction in iron and folate Inability to swallow medication due to pain – (unlikely) Dental erosion is a rare possibility – (but it will not be as severe as that associated with eating disorders and may affect lower posterior rather than upper anterior teeth) Omeprazole has been reported to cause oral dryness  Upper gastrointestinal erosion/ulceration Causes May affect the lower oesophagus, stomach or upper small bowel Risk factors - Stress, smoking, NSAID’s, corticosteroids, H.pylori infection, Zollinger-Ellison syndrome. Upper GIT erosion/ulceration: Implications Risk of anaemia (hence GA risk) – Gradual bleeding will cause an eventual reduction in iron and folate Inability to swallow medication due to pain – (unlikely) Worsened by non-steroidal anti- inflammatory drugs (NSAIDs) Worsened by systemic corticosteroids  The gastrointestinal tract: Disorders Oesophagus: Dysphagia Small bowel Gluten sensitive enteropathy Stomach: (Coeliac disease) Gastro-oesophageal reflux/hiatus hernia Pancreatic disease (and Gastric erosion/ulceration malignancy) Autoimmune destruction of Parietal cells (lack of intrinsic factor and autoimmune pernicious anaemia) Malignancy Large bowel: Inflammatory bowel disease (Crohn’s disease and ulcerative colitis) Malignancy Anus: Rectum: Haemorrhoids Malignancy  Small bowel disease – “malabsorption” Malabsorption probably best describes what happens when there is disease of the small bowel (especially the jejunum and ileum) Features include: abdominal pain, diarrhoea, fatty stools, vitamin deficiencies (e.g. K leading to bleeding tendency) and hypocalcaemia Causes Gluten sensitive enteropathy (Coeliac disease) Post gastrectomy or vagotomy Chronic pancreatitis Others  Small bowel disease – “malabsorption” Gluten sensitive enteropathy Gluten intolerance leads to villus atrophy and malabsorption. Occurs at any age. Complications - GI lymphoma, neuropathies, hyposplenism. Small bowel disease – “malabsorption”:IMPLICATIONS Anaemia – Fe, folate deficiency Bleeding tendency – Due to Vitamin K deficiency Possible delayed dental eruption and enamel defects – Due to Calcium deficiency Possible oral ulcers – secondary to anaemia Possible ulcers/blisters – due to associated dermatitis herpetiformis Possible risk of methaemoglobinaemia – with dapsone-treated dermatitis herpetiformis  Pancreatic disorders of relevance Chronic pancreatitis Alcohol-induced or idiopathic (calcified protein plugs of the duct); also cystic fibrosis Epigastric pain, anorexia, weight loss, steatorrhoea, diabetes Implications based upon:  Pancreatic disorders of relevance Pancreatic cancer 1-2% of all malignancies; risk factors – tobacco, alcohol; 60% are adenocarcinomas of the head of pancreas Poor outcome, especially non- head lesions (2% survival at 5 years) Pancreatic disorders: IMPLICATIONS Alcohol misuse Malabsorption (thus anaemia, bleeding tendency) Diabetes mellitus Possible risk of malabsorption post surgically (hence anaemia etc)  The gastrointestinal tract: Disorders Oesophagus: Dysphagia Small bowel Gluten sensitive enteropathy Stomach: (Coeliac disease) Gastro-oesophageal reflux/hiatus hernia Pancreatic disease (and Gastric erosion/ulceration malignancy) Autoimmune destruction of Parietal cells (lack of intrinsic factor and autoimmune pernicious anaemia) Malignancy Large bowel: Inflammatory bowel disease (Crohn’s disease and ulcerative colitis) Malignancy Anus: Rectum: Haemorrhoids Malignancy Large bowel disease - Inflammatory bowel disease Inflammation of the bowel Most commonly ages 20-45 Combined prevalence of 1 in 10,000 Comprises Crohn’s disease or ulcerative colitis Inflammatory bowel disease: Implications Crohn’s disease Ulcerative colitis  Inflammatory bowel disease: Implications Crohn’s disease Ulcerative colitis Granulomatous inflammation of Non-granulomatous inflammation any part of the gut – typically the of the mucosa of the entire colon, ileocaecal junction especially the rectum Inflammation affects all layers of Clinical picture akin to that of gut (transmural) Crohn’s but reduced risk of fistulae Involved sites of gut can be and abcesses distant (i.e.”skip lesions”) Risk of colonic adenocarcinoma Causes abdo pain (lower right), with longstanding total colonic UC altered bowel habit, fistula formation (e.g. peri-anal), risk of abcess formation Inflammation will cause Fe deficiency anaemia (and B12 if at the terminal ileum)  Inflammatory bowel disease: Implications Crohn’s disease Ulcerative colitis Possible anaemia (Fe, B12) (GA Possible anaemia (Fe, B12) (GA risk) risk) Corticosteroids Corticosteroids Immunosuppression? Immunosuppression? Oral aspects - swelling of face, Oral aspects - superficial ulceration lips, buccal mucosae, mucosal and pustule formation (pyostomatitis tags, chronic and superficial vegetans) ulceration, gingival enlargement Possible corticosteroid-associated Possible corticosteroid- thrush associated thrush Possible immunosuppression related Possible immunosuppression oral hairy leukoplakia (OHL) related oral hairy leukoplakia (OHL) Access may be limited if disease is Access may be limited if disease severe is severe  Irritable bowel syndrome Common – may affects 20%+ of adult populations of any Implications age: Possible associated TMJ – Altered bowel habit (loose or dysfunction or idiopathic “rabbit-dropping” stools) facial/oral pain – Bloating – “Colic” – pain in right iliac fossa with relief on defaecation – “Morning rush” defaecation  Implications based upon: Colorectal carcinoma Common; almost always is Anaemia (GA and adenocarcinoma unexplained oral ulcers in a middle to late aged adult) Causative associations: high Access issues (post-surgical animal fat, low fibre diet; colostomy – don’t lean on longstanding ulcerative the patient!) colitis Possible association of Gardner’s syndrome Altered bowel habit, rectal bleeding, weight loss, tenesmus, anaemia  Eating disorders* Anorexia nervosa and bulimia nervosa Implications based upon: Youngish adults, often female Anaemia (GA risk) Oral manifestations: Avoidance of foods, or binge+vomiting Erosion (there is often a mixed picture of both AN and BM). There is an overall decrease Haematinic deficiency oral in intake of food and calories. ulcers Necrotising sialometaplasia Sialosis (bilateral painless * In addition there is also “disordered eating” in which salivary gland enlargement) individuals have a preoccupation with ‘healthy eating’ or significant attention to caloric or nutritional parameters of most foods eaten but intake remains acceptable. Overuse of energy drinks may cause dental erosion Implications of gastrointestinal disease disease – summary access to care Malignancies and inflammatory bowel disease communication Alcohol (chronic pancreatitis) Alcohol (chronic pancreatitis) consent education Patients with enamel hypocalcification secondary to gluten sensitive enteropathy (of early childhood) may have an increased risk of caries) Implications of gastrointestinal disease disease – summary surgical Anaesthesia: LA – little risk unless severe bleeding tendency (e.g vitamin K deficiency – theoretical rather than real); corticosteroid cover may be needed if IBD is being managed with long term corticosteroids) GA – complicated if there is anaemia RA – OK IV sedation – possibly compromised by anaemia Drug interactions: Prescribing – remember that NSAIDs and systemic corticosteroids will worsen any gastric erosion Orofacial manifestations: Orofacial features may occur with some of the disorders spread No risk Gastrointestinal and hepatic disease – key points Anaemia is probably the most common complication of gastrointestinal disease to potentially impact upon oral health care – and only when a general anaesthetic is required A bleeding tendency and altered drug metabolism are the most likely factors that require consideration when managing patients with chronic liver disease  Reading material Students are advised to review any relevant teaching provided in the second and fourth years. In addition a useful textbook is: Scully C, Diz Dios, P, Kumar N. Special Care Dentistry: handbook of oral healthcare. Churchill Livingstone 2007  AIM: To describe the potential impact of gastrointestinal or hepatic disease upon oral health and oral health care (dentistry) INTENDED LEARNING OBJECTIVES: On completion of this lecture, the student should have an understanding of: 1. The oral disease that may arise in patients with gastrointestinal or hepatic disease 2. The impact of gastrointestinal or hepatic disease upon the delivery of oral health care Thank you