Gastroenterology II: Ulcerative Colitis and Crohn’s Disease

• Describe the anatomy of the lower GI tract.

  The lower GI tract runs from the small intestine to the large intestine to the anus

  
• What is coeliac disease?

  Gluten sensitivity/intolerance associated with HLA B8 tissue type with a prevalence of ~1 in 1800 but it is under-diagnosed in most people
• How does coeliac disease present?

  Presents with change of bowel habit (COBH):

  Pale, bulky, offensive, greasy stool

  
  

  Abdominal colic

  
  

  Weakness; weight loss

  
  

  Short stature/failure to thrive
• What are the classical GI symptoms of coeliac disease?

  Diarrhoea (45-85%)

  Flatulence (28%)

  Borborygmus (35-72%)

  Weight loss (45%)

  Weakness; fatigue (80%)

  Abdominal pain (30-65%)

  Secondary lactose intolerance

  Steatorrhea
• What are the classical extra-intestinal symptoms of coeliac disease?

  Anaemias (10-15%): especially Fe, B12

  
  

  Neurological symptoms (8-14%)

  
  

  Skin disorders (10-20%) e.g dermatitis herpetiformis-maculopapular pruritic.

  
  

  Endocrine disturbances including infertility, impotence, amenorrhea, delayed menarche

  
• What investigations should you undertake to diagnose coeliac disease?

  Serology test

  
• How is coeliac disease treated?

  Gluten restriction curative in 95%

  
  

  Refractory in 5%- so use corticosteroids (poor outcome)

  
  

  Involve dietician, support groups, on-line recipes

  
  

  Read labels including medications, cosmetics, etc.
• What is important to be aware of if someone has coeliac disease?

  Although rare, remember there is increased risk of lymphoma and adenocarcinoma of the pancreas, oesophagus, small bowel, biliary tract, including T & B cell non-Hodgkin's lymphoma
• What are some long-term effects of coeliac disease?

  People with it are more likely to be affected with problems relating to malabsorption, including:

  
  

  Osteoporosis

  Tooth enamel defects

  Central & PNS disease

  Pancreatic disease

  Internal haemorrhaging

  Organ disorders

  Gynaecological disorders
• What is the dental relevance of coeliac disease?

  Problems related tomalabsorption:

  -B12, folate, ferritin: can orally manifest as glossitis, angular cheilits, anaemia, burning mouth, smooth tongue

  -Vitamin K: bleeding tendency

  -Vitamin D:osteomalacia and rickets in children

  Enamel defects may occur in the permanent dentition if the onset is in childhood
• Contrast the epidemiology of Crohn's disease & ulcerative colitis (UC).

  Crohn's:Slightly less common (27-106/100,000)Females: 1.2:1Younger: 26

  UC:Slightly more common (80-150/100,000)Males: 1.2:1Older: 34

  
• Is the aetiology of Crohn's & UC well known?

  No, but there are concerns about genetic tissue types, polygenic inheritance patterns, & familial patterns, as well as host immunology

  
• Contrast the environmental aetiology between Crohn's & UC.

  Appendicectomy = removal of the appendix

  
• Contrast the pathology of Crohn's with UC.


  Backwash ileitis- inflammatory reaction in the distal ileum

  
• What is Crohn's disease?


  Chronic Inflammatory bowel disease, specifically chronic and recurring inflammation of the GI tract.

  
  

  Aetiology unknown - inflammatory response to intestinal microbes + environmental factors + genetic factors.
• How does Crohn's manifest?

  Patchy distribution of 'skip lesions' is quite common

  
• How do patients commonly present with Crohn's disease?

  Intermittent abdominal pain, diarrhoea, abdominal distension (90%)

  Decreased appetite- anaemia and weight loss (50%)

  Fresh blood or melaena (40%)

  Fistulae and perianal sepsis (20%)

  Episodes of flares with asymptomatic intervals
• What are some symptoms of Crohn's disease?

  Fat wrapping, cobble-stoning and thickened wall.

  
• What are the 3 phenotypes of Crohn's disease?

  Stricturing:gradual thickening of intestinal wall- leads to stenosis/ obstruction

  Penetrating:intestinal fistulas(abnormal passage from one organ to another)between GI tract and other organs (can occasionally be external fistulas-skin)

  Non-penetrating:anal fissures, abscesses
• What characterises Crohn's in terms of macroscopic changes?

  -Bowel is thickened

  
  

  -Lumen is narrowed

  
  

  -Deep ulcers

  
  

  -Mucosal fissures

  
  

  -Cobblestone

  
  

  -Fistulae

  
  

  -Abscess

  
  

  -Apthoid ulceration

  
• Contrast the microscopic changes in Crohn's disease against UC.


  Crohn's:TransmuralLymphoid hyperplasiaGranulomas

  UC:Mucosal (chronic inflammatory cells: lamina propria)Goblet cell depletionCrypt abscess

  
• How do you diagnose Crohn's disease?

  Diagnosis:

  
  

  Barium enema: rose thorn, skip lesion, string sign

  
  

  Sigmoidoscopy and biopsy, colonoscopy

  
  

  Differential diagnosis includes TB and sarcoidosis
• How do you treat Crohn's disease?

  Symptomatic relief; reduction of inflammation; increase Quality Of Life

  
  

  Medical- glucocorticoids

  
  

  immunomodulators

  
  

  biologics

  
  

  Surgical- intestinal resection
• What are the specific lesions you get in Crohn's disease?

  Diffuse labial and buccal swelling

  Cobblestones

  Mucosal tags

  Linear ulcers

  Mucogingivits

  Staghorning - enhancement of submandibular ducts

  Granulomatous Cheilitis - swollen lips

  
• What are the non-specific lesions you get in Crohn's disease?

  Aphthous ulcers

  Angular Cheilitis

  Glossitis

  Dental Caries

  Gingivitis/Periodontitis

  
• What does orofacial granulomatosis (OFG) have similar signs & symptoms to?

  Crohn's disease (concurrent Crohn's occurs in ~40% of children diagnosed with OFG)
• Who is OFG more prevalent in?

  Children & young adults
• What benefits 70% of people with OFG?

  Avoiding cinammon & benzoates
• What is UC (ulcerative colitis)?

  Chronic inflammatory bowel disease where there is diffuse mucosal inflammation of the colon with backwash involvement of the terminal ileum: rectum always involved
• What is the hypothesis behind the aetiology of UC?

  Dysregulated interaction mucosal immunology & intestinal microflora, and genetic predisposition
• How do patients with UC commonly present?

  Painless, bloody diarrhoea with mucus

  
  

  Associated fevers and remission periods where the patient returns to near normal

  
• Visually compare UC and Crohn's disease:

  UC = Ulceration, surviving mucosa (pseudo-polyps), loss of haustra.

  
• Visually compare a normal colon and a colon affected by ulcerative colitis:

  Absence of goblet cells

  
  

  Crypt distortion and abscess

  
  

  Affects mucosal layer only

  
• What is the risk with UC?

  Chronic inflammation leading to colorectal cancer

  
• How do you diagnose UC?

  Colonoscopy and biopsy- findings include exudates, ulcerations, loss of vascular pattern, friability , continuous granularity (very fragile, bleeding)

  
  

  Superficial inflammation with loss of haustration
• What do extra GI manifestations of UC look like?


  It can include these issues:

  Occular(uveitis, episcleririts, conjunctivitis)Renal(Gall stones, fat liver, hepatitis, sclerosing cholangitis)Dermatological(erythema nodosum, pyoderma gangrenosum)ORALHepato-billiaryVascularSkeletal

  
• How do you treat UC?

  High protein, high fibre diet

  
  

  5-ASA (5- amino salicyclic acid), sulphasalazine & mesalazine, thioprines, corticosteroids

  Surgery
• What is the dental relevance of UC?

  Oral manifestations:

  Pyostomatitis vegetans (PV)-benign, multiple small white and yellow pustules, erythematous/oedematous background (‘snail track’ ulcers)

  ^Primary involved sites include labial attached gingivae, soft/hard palate, buccal mucosa, sulcus

  The intestinal symptoms usually precede PV

  
• What are some other common conditions to have alongside UC?

  Aphthous ulcers

  Tongue coating

  Gingivitis

  Periodontitis

  Halitosis

  Acidic taste

  Cutaneous manifestations

  
• If concerned about UC or Crohn's, what should you ask your patient about?

  Rashes

  Mouth ulcers

  Joint/back pain

  Eye problems

  Family history

  Smoking status