1. Gastrointestinal Problems Claire Nowlan MD

2. Peptic Ulcers Ulceration of either the gastric or duodenal mucosa

3. 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

4. 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

5. Etiology NSAIDs –reduced mucosal prostaglandin production, resulting in impaired prostaglandin dependent mucosal defense and repair mechanisms

6. Inflammation cascade

7. Complications Depends on depth of ulcer More common in the elderly –Perforation –Hemorrhage - more serious if patient on anticoagulants –Pyloric stenosis –Carcinomatous transformation

8. 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)

9. Lab findings Serology or 13 C 14 C urea breath tests for H. Pylori Barium swallow Endoscopy

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. Pseudomembranous colitis Dental management –Use broad spectrum antibiotics wisely especially in elderly patients or those with a previous history

18. 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

19. Inflammatory Bowel Disease (IBD) Ulcerative Colitis Limited to the large intestine Limited to mucosa Continuous lesions Remissions/ exacerbations common Rectal bleeding common Crohn’s Disease Affects any portion of the bowel Transmural Segmental Usually slowly progressive Fever, weight loss common

20. 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

21. Inflammatory Bowel Disease (IBD) - lab findings May see anemia, malabsorptions causing low B12, folate, iron, albumin, and increased ESR Really diagnosed with colonoscopy/biopsy

22. Medical management Supportive therapy –Nutritional supplementation, bowel rest, replacing fluid and electrolytes Antiinflammatory drugs Sulfasalazine 5 ASA Steroids Immunosupressives/Antibiotics Surgery – curative in UC

23. Dental management - IBD 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

24. Dental management - IBD Analgesics acetaminophen plus –NSAIDs OK –opioids fine, unless during acute severe exacerbation - can cause toxic megacolon Only urgent care during exacerbation