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GP2 Ch7 Digestive and neurological disease (Overview (Digestive disease (–…
GP2 Ch7 Digestive and neurological disease
Digestive disease
Pyostomatitis vegetates
Rare and unusual disorder of the oral cavity
erythema and edema of the mucosa
numerous small, superficial yellow pustules (ulcerative colitis)
UC > CD
Overview
Digestive disease
– Inflammatory Bowel disease 炎症性腸病
Ulcerative colitis 潰瘍性結腸炎
Crohn's disease
– Pyostomatitis vegetans一種炎症性口炎
– Gastroesophageal reflux胃食管反流
– Peutz-Jegher’s syndrome
– Gardner’s syndrome
– Celiac disease腹腔疾病
– Chronic hepatitis 慢性肝炎
Neurological disease
– Epilepsy癲癇病
– Parkinson’s disease
– Alzheimer’s disease
– Multiple sclerosis多發性硬化症
– Bell’s palsy
– Guillain-Barre syndrome
– Myasthenia gravis重症肌無力
Digestive disease
Chronic hepatitis慢性肝炎
Bleeding tendency
Oral pigmentation has been described
Jaundice
Digestive disease
Celiac disease
Concept
Inflammatory disorder of the small bowel ocurring in genetically susceptible individuals.
Results from intolerance不耐受 to wheat小麥 gluten and similar proteins found in rye黑麥, barley 大麥and to a lesser extent, oats
Symtoms
• Malabsorption 吸收不良綜合症
• Gluten intolerance麩質不耐受
• Diarrhea
• Failure to thrive 未能茁壯成長/ delayed growth
• Tiredness, weight loss
Unclear, but inmunological responses to gluten play a key role
Oral and dental manisfestaion
delayed eruption
Recurrent aphthous ulcers復發性口瘡性潰瘍
Enamel defects
Management
Correct existing deficiencies of
folate calcium葉酸鈣
vitamin D
iron
Commence a life-long gluten free diet開始終身無麩質飲食
Digestive disease
Familia Adenomatous polyposis
Intestinal polyposis
– Very high risk of malignant transformation into colonic adenocarcinoma結腸腺癌
– Autosomal dominant
– 1% of all colorectal cancers結直腸癌
– Hundreds to thousands of adenomatous colonic polyps腺瘤性結腸息肉 develop (10-15 years cancer)
– Symptoms such as rectal bleeding- 直腸出血
Extra-intestinal features of FAP
– Congenital hypertrphy肥大 of the retinal pigment epithelium
– Epidermoid cysts*表皮樣囊腫
– Bening osteoma (skull and angle of mandible)*
– Desmoid tumours 硬纖維瘤
– Other malignancies
Dental abnormalities*
Gardner ́s syndrome
skull and mandible osteomas
dental abnormalities
fibromas on
shoulders
arms
scalp
back
Oral manesfestaion
– Multiple enostosis骨質疏鬆 of the jaws
– Supernumerary多餘 and/or unerupted teeth
– Increased risk of odontomas
– Osteomas of the jaws and paranasal sinuses
– Epidermoid cysts表皮樣囊腫 of the skin of the head and neck
Digestive disease
Peutz- Jegher's Syndromes
clinical feature
Hamartomatous polyposis
autosomal dominant
Risk of cancer
mostly of the small intestine
Perioral口周 and/or oral pigmentation
Non related to the sun
lesions
painless
brown pigmented patches
flat
Diagnosis feature
requires 2 of 3
Small bowell polyposis
Mucocutaneous pigmentation
Family history suggesting autosomal dominant inheritance
Digestive disease
Gastroesophageal reflux
Concepts
• Affects aproximately 30% of the general population
• Oesophageal mucosa食道粘膜 is exposed to gastroduodenal contents for prolonged periods of time
• Oesophagitis食管炎
• Abnormalities of the lower oesophageal sphincter食管下括約肌異常 ( reduced tonicity張力降低 )
Hiatus hernia疝氣
Pressure gradient between the abdominal and thoracic cavities is lost
Delayed oessophageal clearance
Gastric contents
Increased intra-abdominal pressure
Dietary and environmental pressure飲食和環境壓力
Clinical feature
– Heartburn胃灼熱
– Regurgitation 反流
– “waterbrash”: salivation due to reflex salivary gland stimulation as acid enters the gullet由於酸進入食道，反射唾液腺刺激引起的流涎
– Patient is often overweight
Complication
Oesophagitis食管炎
mild redness--> severe, bleeding ulceration with stricture formation
Barrett ́s oesophagus
Pre-malignant condition
normal squamous lining of the lower oesphagus is replaced by columnar mucosa柱狀粘膜 (metaplasia)
Anaemia
Occult blood loss from long standing oesophagitis
Gastric volvulus胃腸扭轉
Bening oesophageal stricture
Enamel erosion
Halitosis口臭
Pharyngitis
sore throat
Disphony
Digestive disease
Inflammatory Bowel disease
concept
Ulcerative colitis and Crohn ́s disease-->chronic inflammatory bowel diseases (pursue a protected relapsing and remitting course )
Both environmental and genetic component
because these genetically susceptible individuals mount an abnormal inflammatory response to environmental triggers
In both, intestinal wall is infiltrated with acute and chronic inflammation cells
Many similarity
Ulcerative colitis
mainly involves the colon
does not have extra intestinal manifestation 沒有額外的腸道表現
patient do not required surgery
Rectum and spreads proximal to involve the entire
colon
Bowel can become shortened -->postinflammatory “pseudopolyps” develop
These are normal or hypertrophic residual mucosa within areas of atrophy
Inflammatory process limited to mucosa
Clinical feature
rectal bleeding with passage of mucus
diarrhoea
First attack the most severe - Relapses and remissions
Crohn ́s disease
involve any part of the gastrointestinal tract
increase the incidence in the western world
more “hygienic” environment
domestic refrigeration國內製冷
widespread use of antibiotics
affect the topmost layers
increase the risk of colon cancer
Affect site(most common)
colon alonem terminal ileum alone
ileum and jejunumz
terminal ileum and right side of colon
The entire wall of the bowell is oedematous and thickened
deep ulcers
look of linear fissures
the mucosa between them is described and “cobblestone”
Patchy distribution and the inflammatory process is interrupted by islands of normal mucosa
Chronic inflammatory infiltrate throughout all layers
Clinical feature
abdominal pain
diarrhea 腹瀉
weight loss
glossitis
angular stomatitis
Specific lesion (containing granulomas)
Cobblestoning
Mucogingivitis粘膜牙齦炎
Indurated 頑固 tag-like lesions
Labial swelling
Non specific
Aphtous stomatitis口瘡性口炎
Angular cheilitis
Neurological disease
Alzheimer's disease
Concept
Genetic factors
Brain is macroscopically atrophic宏觀上是萎縮的, particularly the cerebral cortex大腦皮層 and hippocampus海馬
Histologically senile plaques and neurofibrillary tangles in the cerebral cortex大腦皮質中的組織學老年斑和神經原纖維纏結
Most common cause of dementia癡呆症
Clinical features
Impairment of the ability to remember new information
Gradual impairment of memory記憶逐漸受損
Later apraxia(大腦損傷引起的運動障礙), visuospatial impairment and aphasia視覺空間障礙和失語症
Oral manifestations
Inability to self care
• Poor oral hygiene
• Dental caries
• Gingival bleeding
• Drooling
• Increased prevalence of dental plaque牙菌斑
Neurological disease
Epilepsy癲癇
Concrpt
signs and/or symptoms due to abnormal, excessive 過度or synchronous同步 neuronal activity in the brain.
is the tendency to have unprovoked seizures無端癲癇發作的傾向
normal brain
to remain responsive to the environment without continued unrestrained spontaneous activity.無限制的自發活動
achieve an ongoing balance between excitation and inhibition
GABA inhibitory transmitter
Excitatory amino acids興奮性氨基酸
glutamate谷氨酸
aspartate冬氨酸
seizures
It is likely that many seizures result from an imbalance between this excitation and inhibition激發和抑制之間的不平衡造成的
Types
focal(partial) seizures
Symptoms experienced depend on which cortical area is affected
related to a localised disturbance in the cortex皮質局部紊亂,
Caused by localized cortical activity with retained awareness保留意識
Seizures beginning in one cortical area will cause positive neurological symptoms and signs corresponding to the normal function of that area
Awareness may become impaired受損 if spread occurs to the temporal lobes
generalized seizures
originates in the central mechanisms
controlling cortical activation and spreads rapidly
30% of all epilepsy
Widespread disturbance of structure or function
Types
Tonic-clonic seizures 強直 - 陣攣性癲癇發作
• Initial aura
Patient becomes rigid (tonic) and unconscious, falling heavily if standing
Breathing stops and central cyanosis中樞紫紺 may occur
As cortical discharges reduce in frequency皮質放電頻率的降低, limbs produce jerking抽搐 (clonic) movements for a variable time
• Severely bitten, bleeding tongue (loss of consciousness)
Absence seizures
Myoclonic seizures 肌陣攣性癲癇發作
jerking
brief
movement in arms
Atonic seizures
brief loss of muscle tone肌肉張力短暫喪失
Tonic seizures
generalized increase in tone
associated loss of awareness
Clonic seizures陣攣性癲癇發作
similar to tonic-clonic seizure without tonic phase無強直期
Seizures of uncertain generalized or focal nature
Epileptic spasms癲癇痙攣
marked contractions of the axial musculature軸向肌肉組織明顯收縮
Management
Lifestyle advice
Anticonvulsant therapy
Inmediate care
First aid and common-sense manoeuvres to limit damage or secondary complications
no account should anything be inserted into the patients mouth
Oral manifestations
• Gingival hyperplasia 增生and oral ulceration (phenytoin)
• Dyskinesia of the tongue (carbamazepine)
• Xerostomia 口腔乾燥症(clonazepam)
• Birth defects in neonates of women taking anticonvulstans抗膿桿菌 (deformmities of face, palate,and dental root anomalies)
• Marked teeth abrasion磨損 and coronal fractures冠狀骨折
• Lips, cheeks, skin and face scarring
• Anticonvulsionants抗驚厥藥 may precipitate erythema multiforme多形性紅斑沉澱
Neurological disease
Parkinson's disease
Concept
Depletion消耗 of the pigmented dopaminergic neurons多巴胺能神經元 in the substantia nigra黑質 and the presence of α-synucleicα-突觸核蛋白和 and other protein inclusions in nigral cell黑質細胞 (Lewy bodies)
In most patients the cause remains unknown (mutations in several genes)
Progressive and incurable condition
Having a first-degree relative一級親屬, confers 2-3 times increased of developing disease
Clinical syndrome
associated increased
tone (rigidity)
tremor震顫
loss of postural reflexes姿勢反射喪失
bradikinesia運動遲緩
Clinical features
The loss of dopaminergic neurotransmission is reponsible for many of the clinical features
Non-motor symptoms
• Reduction of smell
Constipation便秘
REM(Rapid Eye Movement) sleep behavioral disturbance
Motor symptoms
Bradykinesia 運動遲緩
Tremor
Rigidity
Speech becomes softer and indistinct模糊
Oral Manifestations
– Loss of facial expression
Hypersalivation
Drooling
– Tremor of the tongue (serpentine tongue)
– Taste appreciation changed
p.s Early identification of affected individuals before symptoms develop essential在症狀發展之前及早識別受影響的個體