Ulcerative Diseases

Question 1

What is needed to establish diagnosis of an ulcer?

Answer 1

HPC
MH
Social history
Family history
Systems review of GI, GU system & skin
Examination
Special investigations

Question 2

History to take to work out whether a patient is at risk of cancer?

Answer 2

Age
Other malignant disease
Smoking - work out pack years
Alcohol - units per week
Smoking & alcohol = risk of oral cancer x40
Areca nut/betel nut

Question 3

Questions to ask in regard to ulcer history?

Answer 3

What does the pt mean by an ulcer?
Age of onset?
Length of time to heal?
Frequency of attacks?
How long is the ulcer-free period?
Which sites are common & which are never affected?
Size?
Shape?
Coalesce?
Prodrome before ulcer appears?
Pain?
Relation to menstruation/ smoking/ other factors?
Change in degree of ulceration over time?

Question 4

What types of ulcers are recurrent? (heal completely then come back)

Answer 4

Aphthae
Erythema multiforme

Question 5

What types of ulcers are recurrent/persistent?

Answer 5

Secondary to systemic disease

Question 6

What types of ulcers are single episode?

Answer 6

Infective
Traumatic
Drug reaction

Question 7

What type of ulcer is single persistent?

Answer 7

Neoplastic

Question 8

3 types of recurrent aphthous stomatitis?

Answer 8

Major
Minor
Herpetiform

Question 9

Characteristics of major RAS?

Answer 9

Size: >10mm in diameter

Shape: oval/irregular

Colour: grey base +/- indurated edge

Duration: 2 weeks - 3 months, scar on
healing

Site: keratinised & non-keratinised surfaces (mostly at back of mouth)

Number: Up to 10 ulcers

Age: 1st decade

Question 10

Characteristics of minor RAS?

Answer 10

Size: <10mm in diameter

Shape: oval

Colour: grey base, erythematous border, no scarring

Duration: 1-2 weeks

Site: non-keratinised surfaces, especially buccal mucosa

Number: 1-5

Age: 2nd decade

Question 11

Characteristics of herpetiform RAS?

Answer 11

Size: 0.5-3mm in diameter

Shape: round - may coalesce to form irregular bigger ulcer

Colour: yellow base, erythematous border

Duration: 1-2 weeks

Site: non-keratinised surfaces, especially central of tongue & floor of mouth

Number: 1-20, sometimes more

Age: 3rd decade

Question 12

Management of RAS?

Answer 12

Establish diagnosis

Eliminate local aggravating factors (e.g. sharp tooth)

Control infection (mouthwashes/medications):
- Topical antimicrobials
- Systemic antimicrobials

Control pain - topical/systemic steroids

Maintenance/prevent recurrence

Assess response to therapy & assess if pt is adhering to tx/review diagnosis

Question 13

What investigations are needed for diagnosing RAS?

Answer 13

Blood tests
- FBC
- Haematinics - B12/folate/ferritin
- LFTs

Biopsy
- If suspected malignancy

Scans

Question 14

Summary of RAS therapy?

Answer 14

Relief of pain
Healing of ulcers
Prevention of new ulcers

Question 15

What are the first line drugs for RAS?

Answer 15

Analgesics (topical/systemic)

Control of infection (antibiotics/antiseptics)

Anti-inflammatory (with analgesia/ immunosuppression)

Question 16

What are second line drugs for RAS?

Answer 16

Immunosuppressants (azathioprine/ steroids)

Immunostimulants (levamisole)

Sedatives (thalidomide)

Question 17

Which topical analgesics can be used for RAS?

Answer 17

Lignocaine 5% ointment
Lignocaine 2% gel
Prilocaine
Benzocaine lozenges
Bonjela (choline salicylate)

Question 18

Which systemic analgesics can be used for RAS?

Answer 18

Aspirin

Paracetamol

Dihydrocodeine

Ibuprofen

Question 19

Which topical steroids can be used for RAS?

Answer 19

Triamiconolone paste

Hydrocortisone pellets

Betamethasone valerate inhaler

Betamethasone sodium phosphate tabs as mouthwash (takes long time to work)

Question 20

Questions to consider if treatment fails?

Answer 20

Is the patient taking the drug?

Is the drug being absorbed?

Is the dose adequate?

Is the drug reaching the lesion/ disease?

Is surgical intervention needed?

Has super infection with another organism occurred?

Question 21

Aetiology of erythema multiforme?

Answer 21

Medications - sulphonamides, penicillin, barbiturates & phenytoin

Infections/illness - ~90% of EM cases associated with herpes simplex/ mycoplasma infections

Question 22

Pathogenesis of erythema multiforme?

Answer 22

Damage to blood vessels with subsequent damage to skin tissues leading to a classic skin lesion

Mainly in children & young adults

Question 23

In which patients would you see a nicorandil ulcer?

Answer 23

Angina patients

Write to GP/cardiologist

Question 24

What is Behcet’s disease characterised by?

Answer 24

Chronic autoimmune disorder

1. Recurrent oral & genital ulceration
2. Eye lesions & skin lesions

(Triad of aphthous-like oral ulcers, genital lesions & recurrent eye inflammation)

Question 25

Epidemiology of Behcet’s disease?

Answer 25

Rare in UK, more common in Mediterranean countries - Turkey, Middle East, Japan & South-East Asia

3rd & 4th decade

Question 26

Symptoms of Behcet’s disease?

Answer 26

Mouth ulcers (most common symptom)

Genital ulcers

Skin sores - spots, boils, red patches, ulcers & lumps under or in skin

Eye problems - uveitis, retinal vasculitis => ‘floaters’, haziness or loss of vision, pain & redness in eye

Inflammation of joints causing pain & swelling

Question 27

Clinical features of squamous cell carcinoma?

Answer 27

On high risk area

Necrotic black centre

Indurates

Mixed red & white

Not always painful

Will not heal of own accord