GI 2

Question 1

What are the three parts of the small intestine?

Answer 1

Duodenum
Jejunum
Ileum

Question 2

What is the aetiology of coeliac disease?

Answer 2

Autoimmune condition where APC in the small intestine take up undigested gliadin and display them on their surface.
T cells get activated and go on to activate B antibodies

Question 3

What are the main symptoms of coeliac disease?

Answer 3

• Pale, bulky, greasy stools
• Abdominal pain
• Weight loss
• Short stature
• Weakness
• Diarrhoea
• Tummy rumbling

Question 4

What are the main extra-intestinal symptoms of coeliac disease?

Answer 4

• Anaemia (iron and B12 malabsorption)
• Bleeding risk (malabsorption of vitamin K)
• Tingling nerves
• Skin disorders due to reaction to glucose
• Endocrine disturbances around reproduction

Question 5

What are the 2 investigations done to diagnose coeliac disease?

Answer 5

1) Blood test :
- Antibodies for gliadin, endomysium and transglutaminase
(IgA antibodies to transglutaminase is the main test)

2) Endoscopic biopsy
- Inflamed and deranged small gut lining and loss of epithelium integrity after eating gluten

Question 6

What is the treatment for coeliac disease?

Answer 6

• Avoid gluten

- Corticosteroids (Anti-inflammatory)

Question 7

What is the dental relevance of coeliac disease?

Answer 7

• Malabsorption of B12 and folate leads to oral manifestations
• Vitamin K deficiency leads to bleeding
• Enamel defects can occur during amelogenesis of the permanent dentition

Question 8

Crohns or UC?

1. Which one is more common?
2. Which one is more common in women?
3. Which one presents at a younger age?

Answer 8

1. UC
2. Crohns
3. Crohns

Question 9

What is the tissue type that is most likely to lead to UC and Crohn’s?

Answer 9

HLA DRB

Question 10

What is the difference in pathology between UC and Crohn’s?

Answer 10

Crohns: Entire bowel is affected UC: only affects the colon (mainly the rectum)

Crohns : skip lesions, affected the terminal ileum mainly and ascending colon
UC: mainly affects the anal ring and descending colon

Crohns : causes a deeper inflammation with granulomas forming UC : superficial inflammation with goblet cell depletion

Question 11

What are the main symptoms of Crohns disease?

Answer 11

• Abdominal pain
• Diarrhoea
• Decreased appetite
• Anaemia and weight loss
• Fresh blood passed through rectum

Question 12

How does Crohns appear on an endoscope?

Answer 12

• Thickened walls with deep fissures
• Fat wrapping around bowel
• Cobble stoning of mucosa
• Excess mucus secretion
• Lumen narrowed
• Mucosal fissures
• Deep ulcers
• Fistulae

Question 13

What are the 3 main Crohn’s phenotypes?

Answer 13

• Stricturing (gradual thickening of the intestinal wall leading to stenosis / obstruction)
• Penetrating (intestinal fistulas form between the gut and other organs (perforation out the bowel forming abnormal connections of the intestine with other organs such as bladder, vagina or skin)
• Non penetrating

Question 14

What do we do to diagnose Crohns?

Answer 14

Biopsy
Endoscopy 
Barium enema (skip lesions, string sign)

Question 15

How do we treat Crohn’s disease?

Answer 15

Medical (glucocorticoids such as prednisolone) (immunomodulators such as azathioprine)

Surgically (intestinal resection if too much obstruction has occurred)

Question 16

What is the dental relevance of crohn’s?

Answer 16

Oral manifestations including ulcers, facial and labial swelling, mucosal tags
Malabsorption of b12 leading to oral complications (glossitis, ulcers, angular chelitus, burning mouth, itch)
Immunosuppressants (methotrexate) increases infection risk)

Question 17

Name some of the specific and nonspecific oral manifestations of Crohn’s?

Answer 17

Specific:

• Labial and buccal swelling
• Cobblestones
• Mucosal tags (sticking out mucosa)
• Linera (slit like) ulcers
• Inflammation of the gingiva (mucogingivits)
• Granulomatous cheilitis (lip swelling)
• Staghorning

Non specific conditions:

• Typical ulcers (aphthous ulcers - small shallow lesions on the soft tissues in the mouth)
• Angular chelitits (corners of the mouth are inflamed)
• Glossitis (inflammation of tongue)
• Dental caries (typically due to dry mouth)
• Gingivitis / periodontitis

Question 18

What is orofacial granulomatosis?

Answer 18

Orofacial granulomatosis = a slightly different condition to Crohns presenting ORALLY only

• Similar symptoms to Crohns orally
• Unknown aetiology

Question 19

What are the main symptoms for UC?

Answer 19

• Painless and bloody diarrhoea with excess mucus
• Fevers
• Remissions to near normal

Question 20

How do Crohns and UC compare endoscopically?

Answer 20

UC has a lot less fat wrapping around the bowel
UC has a thinner bowel wall
UC has loss of striations
UC can lead to bumpy mucosa (pseudo polps) compared to Crohns where cobble stoning occurs

UC: ulcers are far more superficial, loss of micro vascular pattern with red mucosa, inflamed and bleeds easily

Question 21

What is the treatment of UC?

Answer 21

High protein and high fibre diet

NSAIDS taken or injected through colon and into rectum

MEDICATION : Corticosteriods (anti-inflammatory), sulphasalazine, mesalazine = anti-rheumatic drug, mesalazine (anti-inflammatory), thriopurines (immunosupressive drug)

Surgery may be required partially if this is long term as there is a risk of chronic inflammation leading onto colorectal cancer

Question 22

What is the dental relevance of UC?

Answer 22

Oral manifestations:

SPECIFIC TO UC : Pystomatitis vegetans = Benign small white and yellow pustules
Erythematous ulcers
Snail track ulcers (painless white irregular white patch)
Labial attached gingiva, soft/hard palate, buccal mucosa and sulcus are the main sites involved here

General:

• Periodontitis
• Gingivitis
• Aphthous ulcers
• Glossitis
• Angular cheilitis
• Halitosis
• Acidic taste

Question 23

What indications in UC suggest for us to do surgery?

Answer 23

Acute:
Failure of medical treatment for 3 days 
Toxic dilatation = large bowel is obstructed and inflating 
Haemorrhage 
Perforation

Chronic:
-  Poor response to medical treatment 
Excessive steroid use over a long time risking addisonian dependance 
Non compliance with medication 
Risk of cancers

Question 24

Is Crohn’s or UC more of a risk of colon cancer?

Answer 24

UC

Question 25

What site of the colon is cancer most common?

Answer 25

Rectum

Question 26

What is the difference in presentation of a colon cancer of the left colon and right colon?

Answer 26

``` Left colon (descending part dealing with harder faeces that gets stuck) = bleeding rectum, tenesmus (feeling the need for a poo but there is an empty rectum) Right colon (ascending colon dealing with liquid food) = anaemia, weight loss and abdominal pain ```

Question 27

What are the symptoms for colon cancer?

Answer 27

``` Bleeding rectum Blood in stool Abdominal bloating Weight loss Abdominal pain Change in bowel habits including diarrhoea or constipation Weakness and fatigue Secondary affects : loss of appetite, symptoms of anaemia (shortness of breath, headaches) due to loss of blood ```

Question 28

What is diverticular disease?

Answer 28

Due to herniation of the bowel mucosa through the bowel wall at a weak point Mimics many other conditions Inflammation results in pain and discomfort Treatment is high fibre diet May need surgery if small deposits have calcified is eroding the mucosal surface risking peritonitis Example = Killian's dehiscence through Zenerkers diverticulum

Question 29

What are the main symptoms of irritable bowel syndrome?

Answer 29

- Intermittent diarrhea - Abdominal pain - Bloating