Pediatric GI Update 2006

January 30, 2018 | Author: Anonymous | Category: Science, Health Science, Immunology
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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

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