Poop Pourri of Oral Manifestations
of Pediatric Gastrointestinal
Disease
13th Annual Fall Pediatric Conference
Susan Maisel MD
St. Vincent PMCH Pediatric Gastroenterology
317 338-9450
Objective
• To provide an update for three pediatric
gastrointestinal diseases that can initially
manifest themselves in, and profoundly
affect the oral cavity.
Dermatitis herpetiformis
Endoscopic Findings
• Frequently normal
appearing
endoscopy
• Can be associated
with mild gastritis
Dental Enamel Defects and
Celiac Disease
• Affects 89%
• Childhood onset of disease occurs during
enamel formation
• Characterized by:
–
–
–
–
demarcated opacities
undersized teeth
yellowing
grooves and pitting
• Can occur in asymptomatic Celiacs
Dental Enamel Defects and
Celiac Disease
• Involves permanent dentition
• Symmetrical
– incisors
– Molars
• Damage is irreversible
• Treatment is cosmetic
– bonding
– veneers
Celiac Disease Histology
Normal
Partial atrophy I
Partial atrophy II
Partial atrophy III
Subtotal atrophy
Total atrophy
Oral Cavity and Celiac Disease
• Cavities
– Calcium and vitamin D deficiencies common
•
•
•
•
Aphthous stomatitis
Atrophic glossitis
Dry mouth syndrome
Squamous carcinoma
Iritis/Uveitis
Erythema Nodosum
Pyoderma Gangrenosum
Inflammatory
Bowel Diseases (IBDs)
INFLAMMATORY BOWEL DISEASE
Ulcerative Colitis (UC)
Crohn’s Disease
(CD)
Mucosal Ulceration in Colon
Transmural Inflammation
Proctitis
Left-sided Extensive
Colitis
Colitis
Upper Small Bowel Colonic
Gastrointestinal
Anorectal
Stenson WF, et al. Inflammatory bowel disease. In: Yamada T et al., eds. Textbook of Gastroenterology
Philadelphia, PA: Lippincott Williams & Wilkins;4th Ed. 2003:1699.
Worldwide
Geographical Prevalence of IBD
High
Intermediate
Low
Loftus EV. Gastroenterology. 2004;126:1504.
Epidemiology
of IBD in North America
• Incidence (per 100,000 person-years)
– UC: 2.2 to 14.3 cases
– CD: 3.1 to 14.6 cases
• Prevalence (per 100,000 persons)
– UC: 37 to 246 cases
– CD: 26 to 199 cases
• New diagnoses (per year)
– UC: 7,000 to 46,000 cases
– CD: 10,000 to 47,000 cases
Loftus EV. Gastroenterology. 2004;126:1504.
• Population experiencing IBD – 1,400,000
Demographic Features
of IBD in North America
• Slight male predominance in UC
– Incidence of UC seems to have stabilized
overall but continues to rise in males
• Slight female predominance in CD
– Especially in late adolescence and early
adulthood
– Hormonal factors might play a part
• Mean age at diagnosis 15 – 35
• Late onset 50’s-60’s
Loftus EV. Gastroenterology. 2004;126:1504.
Recurrent Aphthous Ulcers
• 48-80% incidence in
Crohn’s, less in UC
• Parallel or predate
intestinal disease
• Biopsies can often
diagnose Crohn’s
• Treatment – topical,
intralesional, systemic
steroids;
aminosalycilate preps
•
Orofacial granulomatosis
• Chronic swelling of
the lips and lower half
of the face
• Oral lesions
• Hyperplastic gingivitis
Potential Risk Factors
Associated With IBD
Risk Factors With
IBD Association
• Cigarette smoking
– + risk factor for CD
– - risk factor for UC
• Appendectomy
– + risk factor for CD
– - risk factor for UC
Risk Factors With
Questionable IBD
Association
• Perinatal and childhood
factors
• Measles infection or
vaccination
• Mycobacterial infection
• Oral contraceptives
– Weak association with IBD
• Diet
– Increased sugar intake
Loftus EV. Gastroenterology. 2004;126:1504.
Evolution of Crohn's
Disease Behavior Over Time
Cumulative probability %
100
90
80
70
Penetrating
60
50
40
30
Stricturing
Inflammatory
20
10
0
years
1
3
5
7
9
11
13
15
17
19
Established percentage of CD patients remaining free of penetrating complications (upper curve) and free
of stricturing and/or penetrating complication (lower curve) in 2002 patients with Crohn’s disease since
onset (diagnosis) of the disease.
Adapted from Cosnes J, et al. Inflammatory Bowel Dis. 2000;8:244.
The Role of Proinflammatory
Cytokines in Crohn’s Disease
IL- 6
Inflammation and
Tissue Damage
B Cell
Plasma Cell
IL- 12
Antigenpresenting Cell
Activation
of T cells
Inflammatory
Cell Adhesion
Humoral
Immune
Response
TNF
IL- 1
Antigen
IL- 8
GM-CSF
Leukotrienes,
Superoxides,
Nitric Oxide, and
Prostaglandins
Sands BE. Inflammatory Bowel Diseases. 1997; 3:95-113.
Feldman M, et al. Advances in Immunology. 1997; 64:283-350.
Key Actions Attributed to TNF
Mechanism for Antibody
Neutralization of TNF
van Deventer S. Gut. 1997; 40:443-48.
Scallon BJ. Cytokine. 1995; 7:251-59.
Feldman M. et al. Advances in Immunology. 1997;
64:283-350.
Results of Infliximab Use
The use of Infliximab is no longer
restricted to patients who have severe
disease, not responsive to conventional
therapy.
1.
A single infusion can induce remission
in ~60% of patients with active Crohn’s
Disease (Targan et al., 1997).
2.
Three infusions over six weeks led to
closure of fistulae in 50% of patients
(Present et al., 1999).
3.
Before Treatment
Week 2
Repeated infusions maintains remission
in >60% of patients (Hanauer et al.,
2002).
Figure: Closure of an abdominal fistula in a 60year old man with treatment of Infliximab
(5mg/kg). Present et al., 1999.
Week 18
Ringed Esophagus
Esophageal nodules
Whitish exudates
Esophageal Stricture with Food
Impaction
Diagnosis:
Endoscopic Features of EE
Vertical Lines Rings
White Specks
Epidemiology
• Described in 1978; not recognized until
late 1990’s
• 15 fold increase in last 16 years
• Male to female 2:1
(Allergic) Eosinophilic Esophagitis
• 50 – 75% atopic
• Food sensitization common
• Aero-allergens may also play a role
GERD and Dental
Erosions
4/7/2015
38
Dental Erosions and GERD
• Critical pH of enamel – 5.5
• Gastric refluxate - 2.2
• Salivary protective factors vary
– rate of salivary flow
– pH
– viscosity
– protein and mineral content
• Fluoride – unproven to help
• Brushing after GERD without rinsing first
Diagnosis:
Clinical symptoms in EE
Symptom
Median Age of Presentation (years)
Feeding disorders
2
Vomiting/reflux
8
Abdominal pain
12
Dysphagia
13.4 and adults
Food impaction
16 and adults
Noel NEJM;351, 2004
EE vs. GERD
Characteristic
Atopy
Food sensitization
Histology
Peripheral eosinophilia
Esophageal pH
PPI
Steroids
Food allergen
elimination
EE
High
High
>24 eos/hpf
~50%
Normal
Usually not
helpful
Helpful
Sometimes
helpful
GERD
Nml
Nml
0-7 eos/hpf
rare
Abnormal
Helpful
Not helpful
Not helpful