Gastroenterology Mouth ulcers: Minor Aphthous Ulcers (MAU) Round Grey-white Painful Small(less than 1cm) Shallow with

w with red rim Pain subsides after 3 to 4 days Occur singly or in crops of 5 ulcers 7-14 days to heal Recurs after 1 to 4 months Major Aphthous Ulcers Large (greater than 1cm) Numerous ulcers (10 or more) Ulcers coalesce Heal slowly Trauma Ulcers with irregular border Herpetiform Ulcers Large crops (up to 100) Occur in posterior part of mouth Heal in a month Herpes Simplex Small/discrete ulcers Numerous Signs os systemic infection Oral thrush Creamy-white soft elevated patches Medicine induces ulcers Include cytotoxic agents, Nicorandil, Alendronate, NSAIDs, Beta blockers. Ulcers seen at start of therapy or when dose is increased Carcinoma Referral trigger points Start as Painless spots/lumps/ulcers Become painful/change colour/bleed Children under 10 Erythema multiform Ulcers greater than 1cm Caused by infection or drug therapy Ulcers in crops 5 or more Sudden widespread ulceration in oral cavity More than 2 weeks Annular symmetric erythematous skin lesions Painless Conjunctivitis and eye pain Eye involvement Behcets syndrome Recurrent painful major aphthous ulcers Slow to heal Ulcers in genital areal Eye involvement (iridocyclitis)

OTC medication for ulcers Antibacterial agents (eg. Chlorhexidine) Products containing anaesthetic or analgesics Choline salicylate Protectants

Gingivitis Swelling/reddening of gums that easily bleed with slight trauma Plaque and halitosis might be present Gingivitis specific questions Inflammation of gums & excess build-up of plaque
Tooth brushing technique - too much force gums can bleed or over cleaning Bleeding gums- unexplained or with slight trauma like brushing

Periodontitis Similar to gingivitis Spontaneous bleeding Taste disturbance Halitosis Difficulty eating Loose teeth

Medicine induced gum bleeding Warfarin , Heparin , & NSAIDs cause gum bleeding Cyclosporine , nifedipine & phenytoin cause gum hypertrophy

Spontaneous bleeding Agranulocytosis & leukemia Trigger points

Foul taste due to bleeding gums Loose teeth Spontaneous gum bleeding Signs of systemic illness

OTC medication Chlorhexidine gluconate stains teeth &tongue o corsodyl 0.2% o eludril 0.1% o 10ml 2 times a day Hexetidine mild irritation/ numbness of tongue o Oraldene 15ml 2-3 times a day Hydrogen peroxide mucosal irritation o Peroxyl 10ml rinsed around mouth 4 times a day

Dental flossing Using fluoride reduces dental caries Mouthwash rinsed around mouth for 30sec- 1min

Dyspepsia Non-ulcer dyspepsia indigestion Gastro-oesophageal reflux disease Gastrisis Duodenal ulcers Gastric ulcers Trigger points

Abdominal aching above umbilicus Bloating Flatulence Feeling of fullness Nausea/vomiting Heartburn

Peptic ulceration Mid-epigastric pain described as constant/annoying In gastric ulcers o pain is when stomach is empty o Aggravated by alcohol and caffeine o Weight loss Duodenal ulcers o Pain occurs 2-3 hrs after eating Medicines that cause dyspepsia: o Wakes the person at night Antibiotics eg-macrolides & Medicine induced dyspepsia tetracyclines Aspirin and NSAIDs Anticoagulants Irritable bowel syndrome ACE inhibitors Lower abdominal pain in left lower quadrant Alcohol (in excess) Gastic carcinoma Bisphosphonates Nausea/vomiting Calcium antagonists Oesophageal carcinoma Iron Constricted oesophagus difficulty swallowing Metaformin Atypical angina Metronidazole Retrosternal pain radiates to the neck back or left shoulder Nitrates Dyspepsia-like symptoms after heavy meal Oestrogens Antacids fail to relieve symptoms Potassium supplements SSRIs (Selective Serotonin Reuptake OTC medication Antacids Alginates For GORD H2 antagonists Rantidine & Famotidine Proton pump inhibitors
Inhibitor) Steroids Theophylline

ALARM Anaemia Loss of weight Anorexia Recent onset of progressive symptoms Melaena, dysphagia and haematemesis Severe debilitating pain wakes patient at night Persistant vomiting Pain that radiates

Sibutramine

Diarrhoea
Increased frequency of passage of Soft/watery stool o Acute- less than 7 days o Persistent- more than 14 days o Chronic- more than a month Viral/bacterial o Rapid onset o Nausea /vomiting o Abdominal cramping o Flatulence and tenderness Medicine induced Irritable bowel syndrome o Alternating diarrhoea and constipation Giardiasis o Contracted through drinking contaminated water o Bloating and flatulence with foul smelling diarrhoea o Epigastric pain Fecal impactation o More common in elderly - due to poor mobility Ulcerative colitis and Crohns disease o 20-30 yrs o Diarrhoea and blood in stool Malabsorption syndromes o Lactose intolerance in infants under 1yr Fever/ vomiting/ perianal excoriation o Coeliac disease bimodal incidence first in early infancy second during forth and fifth decades o Steatorrhoea fatty stool bloating/weight loss Colorectal cancer o Presistant diarrhoea o Feeling the bowel has not really been emptied

Trigger points
Change in bowel habit Diarrhoea after traveling More than 2-3 days in infants elderly Signs of dehydration Blood or mucus in stool Suspected fecal impactation Severe abdominal pain steatorrhoea

OTC medication Oral rehydration solution ORS Rice-based ORS Loperamide Bismuth subsalicylate Kaolin & morphine Rotavirus vaccine

Constipation A symptom not a disease Eating habits/lifestyle Medication opoids Irritable bowel syndrome Pregnancydepression Functional disorders Colorectal cancer Hypothyroidism OTC medication o Bulk-forming laxatives Ispaghula husk Methylcellulose Sterculia o Stimulant laxatives Biscodyl Glycerol Senna Sodium picosulfate o Osmotic laxatives Lactose Macrogols Magnesium salts o Stool softeners Liquid paraffin Docusate sodium

Irritable bowel syndrome Abdominal pain in left lower quadrant Relieved by defecation