Gastrointestinal Problems 1

Gastrointestinal Problems 1

Gastrointestinal Problems 1

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Mouth Ulcers

  • Aphthous ulcers small, round or ovoid oral ulcers with well-defined margins
  • Typically first present in childhood adolescence
  • Minor aphthous ulcers
    • Up to 5mm in diameter
    • Appear in small groups (6 at a time)
    • Heal in 7-10 days
  • Major aphthous ulcers
    • Around 1cm in diameter
    • Occur in groups of up to 6 at a time
    • Heal slowly in 10-40 days and often leave scarring
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Mouth Ulcers

  • Herpetiform aphthous ulcers (uncommon)
    • Present as multiple pinhead sized discrete ulcers that increase in size and coalesce leaving large area of ulceration
    • Often extremely painful
    • Heal in 10 days or longer
    • May recur frequently so that ulceration seems continuous
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Mouth Ulcers: Possible Causes

  • Genetic predisposition - positive family history in up to 40%
  • Smoking cessation
  • Iron, folic acid or vitamin B12 deficiency
  • Hormonal factors - in some women ulcers coincide with (after ovulation) luteal phase of menstrual cycle
  • Local trauma
  • Anxiety
  • Exposure to certain foods, e.g. chocolate, coffee, peanuts and/or gluten products
  • Medication, e.g. Nicorandil, oral NSAIDs, oral nicotine replacement therapy
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Mouth Ulcers: When to Refer

  • Duration longer than 3 weeks - rule out oral malignancy
  • Other unexplained gastrointestinal symptoms
  • Immunodeficiency 
  • Medication related, e.g. carbimazole
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Mouth Ulcers: Management

  • Dentist
  • Chlorhexidine mouthwash
  • Hydrocortisone oromuscosal tablets
  • Local analgesics
  • Local anaesthetics
  • Saline mouthwash
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Cold Sores

  • Infection caused by Herpes Simplex Virus (HSV1)
  • Estimated more than 50% adults in Western world have been infected with HSV1
  • Around 20-50% of people will experience a cold sore at some time
  • Symptoms
    • Prodromal symptoms of itching, burning, tingling pain
    • Occur a few hours to a couple of days before lesion
    • Lesion appears as blister and associated redness
    • These crust over within 24 hours
  • Resolve in 7-10 days
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Cold Sores: Trigger Factors and When to Refer

  • Triggers
    • Stress
    • Ill health
    • Sunlight
    • Viral infection, e.g. cold
  • Refer
    • Over 14 days duration
    • Cold sores located within the mouth
    • Severe and widespread lesions
    • Immunocompromised patients
    • Lesions that spread from the lips to the face
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Cold Sores: Management

  • Antivirals
    • Aciclovir - applied 5 x daily for 5 days
    • Peniciclovir - applied 8 x daily for 5 days
      • Both applied during prodromal phase
  • Ammonia and Phenol (Blistex)
  • Urea (Cymex)
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Heartburn

  • More common in patients over 55
  • Not normally experienced in childhood
  • Symptoms
    • Burning discomfort experienced in the upper part of the stomach
  • Aggravating factors
    • Bending or lying down
    • Obesity
    • After a large meal
    • Medication related
      • Alpha blockers, anticholinergics, NSAIDs, nitrates, theophyllines and tricyclic antidepressants
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Heartburn: When to Refer

  • ALARM symptoms
    • Anaemia
    • Loss of weight
    • Anorexia
    • Recent onset of progressive symptoms
    • Melaenia, dysphagia and haematemesis (blood in faeces, difficulty swallowing, vomiting blood)
  • Severe pain
  • Persistent vomiting
  • Pain radiating to arm, neck and jaw
  • Failure to respond to antacids - 1 week
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Heartburn: Management

  • Antacids - neutralise acid - rennie, pepcid
  • Alginates - raft formin - Gaviscon Advance
  • H2 antagonists - ranitidine
  • Proton Pump Inhibitors - most effective
  • Advice
    • Food - small meals eaten frequently
    • Weight reduction
    • Posture - bending, stooping and slumping should be avoided
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