Why Should Gastroenterologists Look into Patientsʼ Mouth?

Abstract

Purpose: We herein report five cases of patients referred to upper endoscopy, that were diagnosed with several oral lesions, most of them related to patients gastrointestinal disease, revealed throughout careful routine mouth observation. Patient 1 was a 70-year-old man, with alcoholic cirrhosis, smoker, referred to upper endoscopy for variceal ligation. Mouth observation revealed suspicious tongue ulceration and histology confirmed oral squamous cell carcinoma. This type of carcinoma should always be suspected when a mouth ulceration, namely in the tongue or lips is seen particularly in smokers and alcoholics, the major risk factors. Patient 2 was a 33-year-old woman, with chronic diarrhea and weight loss. Mouth observation showed aphthous ulcers. Upper endoscopy revealed duodenal atrophy and histology confirmed celiac disease. Aphthous ulcers may provide a clue to the presence of celiac disease as 26% of adults with celiac disease have recurrent oral ulcers. Patient 3 was a 60-year-old woman, with Crohn's disease on infliximab therapy. She complained of burning pain in the mouth with significant limitation of food intake and speech. She had white lesions with a reticular appearance, without erythema, in the oral mucosa and soft palate, compatible with oral lichen planus (OLP) that was confirmed by histological examination. To our knowledge, there are only two reported cases of OLP due to biologic therapy in Crohn's disease. Patient 4 was a 42-year-old man, with a liver transplant, on high doses of steroids due to acute hepatocellular rejection that was referred to upper endoscopy due to severe odynophagia. He had multiple painful ulcers in his mouth with yellow exudate (Figure 1). Histology showed herpes simplex and cytomegalovirus co-infection. Multiple viral infections are very rare even in the context of immunosuppression. Patient 5 was a 39-year-old woman, with HIV and was referred to upper endoscopy due to odynophagia. She had multiple painful ulcers in her mouth and in the distal esophagus. Histology confirmed herpes simplex infection and patient responded to acyclovir. This case series shows that patients' mouths, mainly in patients with common gastrointestinal conditions like cirrhosis, celiac disease or inflammatory bowel disease, may have lesions that are important to recognize and diagnose, especially because it may prompt additional therapeutic measures that improve quality of life.Figure: [1332]