GI presenting symptoms Flashcards
The mouth - leukoplakia
An oral mucosa white patch that will not rub off and is not attributable to any other known disease. It is a pre-malignant lesion with a transformation rate that ranges from 0.6% to 18%.
Oral hair leukoplakia is a shaggy white patch on the side of the tongue seen in HIV and caused by EBV.
The mouth - apthous ulcers
20% will get these shallow painful ulcers in the mouth that will heal without scarring.
- Causes – Crohns or coeliac disease, Behcet’s disease, trauma, erythema multiforme, lichen planus, pemphigus, pemphigoid or infections e.g. herpes simplex, syphilis or Vincent’s angina.
- Management of minor ulcers – avoid oral trauma e.g. hard toothbrushes or foods such as toast and acidic food and drinks. Hydrocortisone lozenges or antimicrobial mouthwashes may help.
- Management of severe ulcers – give systemic steroids e.g. 30-60mg oral Prednisolone for a week. Perform a biopsy on any ulcer that fails to heal within 3 weeks to exclude malignancy.
The mouth - candidiasis
- Causes white patches or erythema of the buccal mucosa. Patches may be hard to remove and bleed when scraped.
- Risk factors – extremes of age, diabetes mellitus, antibiotics or immunosuppression e.g. long term corticosteroids (including inhalers), cytotoxics, malignancy or HIV.
- Management – give 100,000U Nystatin suspension (swill and swallow) or amphotericin lozenges.
The mouth - chelitis
Angular stomatitis – fissuring of the corners of the mouth can have many causes including problems with dentures, candidiasis or a deficiency of either iron or riboflavin (aka vitamin B2).
The mouth - gingivitis
Gum inflammation ± hypertrophy occurs with poor oral hygiene, drugs (phenytoin, ciclosporin, nifedipine), pregnancy, vitamin C deficiency, acute myeloid leukaemia or Vincent’s angina.
The mouth - microstomia
The mouth is too small - from thickening and tightening of the perioral skin (after burns or in epidermolysis bullosa – destructive skin and mucous membrane blisters) or systemic sclerosis.
The mouth - oral pigmentation
- Brown – perioral brown spots characterise Peutz-Jegher’s and pigmentation anywhere in the mouth suggests Addison’s disease, drugs e.g. anti-malarials and consider malignant melanoma.
- Telangiectasia – capillary dilation occurs in systemic sclerosis or Osler-Weber-Rendu syndrome.
- Fordyce glands – creamy yellow spots at the border of the oral mucosa and the lip vermilion (the upper border of the lips). These are sebaceous cysts which are common and benign.
- Black tongue – colonisation of Aspergillus niger may cause a black tongue.
The teeth
A blue line at the border of the teeth and the gums may suggest lead poisoning and yellow brown discolouration of the teeth may be caused by childhood tetracycline (antibiotic) exposure.
The tongue
- Xerostomia – a dry, furred tongue can occur in dehydration, after tetracycline or radiotherapy, in Crohn’s disease, Sjogren’s syndrome or Mikulicz’s syndrome (parotid gland enlargement).
- Glossitis – a smooth, red, sore tongue can be caused by iron, folate or vitamin B12 deficiency.
- Macroglossia – the tongue is too big – caused by myxoedema, acromegaly or amyloidosis.
- A Ranula is a bluish salivary retention cyst on one side of the frenulum (named after frog throat).
Tongue malignancy
- Typically appears on the edge of the tongue as a raised ulcer with firm edges and environs. The main risk factors for development are smoking and alcohol.
- Spread – anterior third to the submental nodes, middle third to the submandibular nodes and posterior third to the deep cervical nodes.
- Management – radiotherapy or surgery – 5 year survival is 80%.
Dysphagia - causes
Can be divided into mechanical and motility causes:
- Mechanical block – malignant stricture (oesophageal, gastric or pharyngeal), benign stricture (oesophageal web or peptic stricture), extrinsic pressure (lung malignancy, mediastinal lymph nodes, retrosternal goitre, aortic aneurysm or left atrial enlargement) or a pharyngeal pouch.
- Motility – achalasia, diffuse oesophageal spasm, systemic sclerosis, myasthenia gravis, bulbar palsy, pseudobulbar palsy, syringobulbia, bulbar poliomyelitis or Chagas’ disease.
- Other – oesophagitis (infection – candida or HSV of reflux oesophagitis) or globus hystericus.
Dysphagia - questions to ask
- Was there difficulty swallowing solids and liquids from the start? – if yes then suspect a motility disorder or a pharyngeal cause. If no suspect a stricture either benign or malignant.
- Is it difficult to make the swallowing movement? – if yes then suspect a bulbar palsy.
- Is swallowing painful (odynophagia)? – if yes suspect malignancy, oesophageal ulcer or spasm.
- Is the dysphagia intermittent or constant and getting worse? – if it is intermittent suspect an oesophageal spasm but if constant and worsening suspect a malignant stricture.
- Does the neck bulge or gurgle on drinking? – if yes suspect a pharyngeal pouch.
Dysphagia - signs
Is the patient cachectic or anaemic? Examine the mouth and feel the supra-clavicular nodes (Virchow’s node enlargement suggests intra-abdominal malignancy) and signs of systemic disease e.g. systemic sclerosis or central nervous system disease.
Dysphagia - investigations
FBC for anaemia, U+Es for dehydration and CXR for mediastinal fluid level, absent gastric bubble or aspiration.
Upper GI endoscopy ± biopsy is usually first line investigation but a barium follow through ± video fluoroscopy is useful to diagnose high dysphagia or dysmotility e.g. achalasia.
Diffuse oesophageal spasm
Causes intermittent dysphagia and chest pain.
