Erosive Mucosal Lesions Research Articles

OCULAR CICATRICIAL PEMPHYGOID, A DIFFICULT TREATMENT CASE

Background: Mucous membrane pemphigoid (MMP) or cicatricial pemphigoid is an autoimmune disease associated with high morbidity. It presents as erosive mucosal lesions with scarring for which different treatments are used, depending on the degree of involvement. It may cause ocular complications requiring interdisciplinary management together with ophthalmology specialists because patients may need cataract surgery and corneal transplant in the event of perforation, or even a keratoprosthesis as the only option for visual rehabilitation. Case Presentation: Clinical case of the dermatology service of University Hospital La Samaritana in Bogota, Colombia. The patient presented with multiple illnesses and a longstanding history of the disease with no improvement despite multiple approaches to management. In view of disease activity after several treatments and because of the need for surgery, annual rituximab administration was instituted in an attempt at controlling the disease and avoiding reactivations. Conclusion: MMP is a disease associated with high morbidity. Diagnosis is usually delayed because onset of the disease is not evident at first and because of similarity with other diseases, resulting in the use of inadequate treatments in the absence of high quality evidence about potential interventions. In some cases, treatment for life is required in order to prevent progression.

A Case Report: Lamotrigine Induced Steven Johnson Syndrome

A 21 years old male with complaints of erythematous erosive lesions, itchy and burning sensation all over the body for 5 days and multiple erythematous maculopapular lesions on palms and soles, erosive mucosal lesions in oral mucosa, erosive erythematous lesions on the scrotum, discharge from the eye, blurring of vision and redness in both the eyes. The patient was evaluated by three local doctors but not fully diagnosed. The lesions started after taking antidepressant selective serotonin reuptake inhibitor (SSRI’S) which was Lamotrigine, along with this Aripiprazole-Atypical antidepressant and Desfenlafaxine-a serotonin and norepinephrine reuptake inhibitor (SNRI’S) was taken, it was prescribed by a psychologist who thought the patient is depressed, but the patient was inactive due to anemia. The initial dose of Lamotrigine is 25mg per day which can be managed further based on symptoms, but the patient was directly started with 100mg half tablet for 8days along with one 200mg of lamotrigine at night. The patient was not made aware of drug-related information like it’s side effects, improper drug usage and what if dose is missed. After taking patient history and examination the diagnosis was made to be Lamotrigine induced Steven Johnson syndrome (SJS). The patient was not depressed and he was not active as he was anemic. After correct diagnosis, the management was done with a corticosteroid, antihistamines, Pantoprazole, and antibiotic along with mouthwash and eye drops. The recovery period was of 40 days.

Diagnosis value of staining endoscopy for malignant and benign erosive mucosal lesions

Objective To analyze the diagnosis effect of staining endoscopy for malignant and benign erosive mucosal lesions.Methods We chose 142 cases in digestion Department of internal medicine of our hospital who were diagnosed as gastrointestinal erosive mucosal lesions according to clinical pathology,all patients had abdominal dull pain,indigestion and other typical symptoms,they were randomly divided into the use of staining endoscopy patients in observation group and normal endoscopic examination of the patients in the control group with 71 cases in each.Patients in the control group used conventional endoscopic examination, in the focus and mucosal 4-6 block submission the observation group in the conventional endoscopic detection of suspicious lesions,using physiological saline to gastric mucosa cleaning,spraying gun through the hole into the biopsy of stomach,with 0.2％ indigo carmine 25 ml in suspicious lesions,mucosal 4-6 block.Results Among the observation group and the control group patients,there were no statistical difference (P＞ 0.05) in general information such as sex,age,course of disease,the patients in the observation group of endoscopic examination in the diagnosis was correct in 95.8％,significantly higher than that of control group (84.5％,P ＜ 0.05).Conclusion Staining endoscopy can significantly improve the erosive mucosal lesions in patients with clinical diagnosis rate,for the development of rational treatment and to provide the basis for the best treatment time. Key words: Staining endoscopy; Erosive mucosal lesions; Diagnosis

Small‐bowel capsule endoscopy in patients with gastrointestinal food allergy

Food allergy may present with a plethora of gastrointestinal and extraintestinal symptoms such as abdominal pain, diarrhea, cardiocirculatory symptoms, cutaneous reactions, or rhinitis. Macropathological lesions like lymphofollicular hyperplasia and erosive or ulcerative lesions have seldom been described in gastroscopy and colonoscopy previously. Fifteen patients presenting with unspecific abdominal symptoms in which food allergy was detected in due course were included. During the examination process, those patients showed various indications for small-bowel capsule endoscopy, such as weight loss and anemia. Fourteen (93.3%) of the 15 small-bowel capsule endoscopies could be assessed, showing nonerosive lesions such as erythema, swelling, and lymphoid hyperplasia in 8 patients (57.1%) and erosive lesions such as aphthoid lesions, erosions, and petechiae in 4 patients (28.6%) with food allergy. In 15 patients with confirmed food allergy and after exclusion of other diseases, 12 (85.7%) showed various unspecific nonerosive or erosive mucosal lesions within the small bowel, resulting, however, partially in grave consequences such as anemia. Lymphoid hyperplasia was the most prominent finding in 7 patients (50%), albeit infectious disease had been excluded. Anemia improved within 1 year after adequate antiallergic treatment.

A Rare Endoscopic Finding: Pseudomelanosis Duodeni

Purpose: Pseudomelanosis Duodeni (PD) has been rarely reported in English literature. We present a patient who was found to have this condition incidentally while having upper gastrointestinal endoscopy and present picture with a literature review. A 68-year-old female patient presented to an outpatient gastroenterology clinic with right upper quadrant abdominal of one month duration. Her past medical history was significant for Chronic Kidney Insufficiency, hypertension and Diabetes Mellitus. The medications included hydralazine, furosemide, aspirin, metoprolol and amlodipine. She underwent endoscopy which revealed diffuse pigmentation in the duodenum with dark speckles on the villi (photo 1-4). Biopsy report diagnosed PD. PD was formerly described in the literature as Melanosis Duodeni. It was determined that the pathology was not related to melanocytes or distribution of melanin. The color pattern was instead found to be due to pigment laden lysosomes in macrophages of the lamina propria of duodenal villi. The lysosomes have been reported to contain aluminum, silicon, sulfur, calcium, magnesium, aluminum, iron sulfide and iron oxide in heterogeneous masses. In earlier case reports, authors regarded the pigment in duodenal melanosis as melanin for its positive reaction with Masson-Fontana stain. Later, with electromicroscopy and electron probe energy dispersive X-ray analysis studies, it was found that the pigment is essentially ferrous sulfide. Rex and Jersild proposed that iron in combination with variable amount of sulfur were engulfed by macrophages after iron was released into the mucosa. Shedding blood can add iron moiety while sulfur can be derived from food or certain medications like Hydrochlorothiazide. The clinical association between PD and systemic hypertension may point toward some hidden factors in favor of forming iron sulfide. These factors remain unknown and could be attributed to some extent to antihypertensive treatment. Clinical correlation with PD is unclear. According to literature, it is more common in females in their sixth and seventh decades of life. The youngest reported case involved an 18-month-old child. It is associated with chronic renal insufficiency, hypertension, erosive mucosal lesions, Diabetes Mellitus, upper GI bleeding, congestive heart failure and anemia. There is also a relationship with hydralazine, propranolol, and thiazide diuretics. PD is a benign condition with no associated symptoms. Endoscopic finding reversion has been achieved in some cases by removal of the offending factors such as a medication or treating the existing condition such as an erosive mucosal lesion. The diagnostic and prognostic significance of PD awaits further studies.

Oral Lichenoid Lesions Associated With Dental Amalgam Restorations: A 60-Year-Old Woman With a 7-Year History of Painful, Erosive Mucosal Lesions

CASE PRESENTATION but had never been formally tested for this problem.She A 60-year-old white woman was first seen in the Oral Medicine Clinical Service with a chief complaint of persistent oral lesions. The patient had been experiencing recurrent mouth sores for at least 7 years, but had decided that these were ‘‘canker sores.’’ Because they were only mildly troubling, she had not sought care for them, and had instead used over-thecounter remedies. She had been recently examined in the School of Dentistry’s ‘‘new patient’’ assessment clinic, and during that visit had been made aware that her oral lesions warranted follow-up. She was referred to the Oral Medicine Clinical Service to evaluate these lesions.

Heartburn in primary care: problems below the surface

Heartburn is a common physiological event often associated with an underlying occurrence of gastroesophageal reflux disease (GERD). Studies show that GERD is a highly prevalent and chronic condition that significantly impacts on the patient's quality of life (QoL) and, in the long term, increases the risk for developing esophageal adenocarcinoma, more commonly referred to as Barrett's esophagus. Data indicate that symptom severity is a poor predictor of either the presence of erosive mucosal lesions or the development of complications. Given that lifestyle modifications are often insufficient for long-term treatment of GERD, drugs that inhibit gastric acid production--such as the proton pump inhibitors (PPIs)--are now the most effective strategy. Although generally well tolerated, the potential of PPIs for interactions with other drugs needs to be considered. This review discusses the symptoms and risk factors associated with GERD, possible links to Helicobacter pylori infection, and effective treatment strategies within a primary care setting.

Does Body Mass Index associate with the endoscopic severity of gastroesophageal reflux disease?

To evaluate the association between body mass index (BMI) and gastroesophageal reflux disease (GERD) severity in the group ofpatients frequently suffering from moderate/severe gastroesophageal reflux symptoms, one hundred and fifty eight previouslyuntreated patients underwent upper panendoscopy as indicated by typical moderate/severe reflux symptoms, occurring three ormore times per week. Patients’ BMI values were tabulated and compared to the severity of endoscopic findings (according toSavary-Mille r/modified by Siewert). Association between reflux disease activity and BMI was analyzed by Kruskall-Wallis test,while mild and severe group were compared using Mann Whitney test. Analyzing the whole group, including the patients whohad no endoscopically verified erosions (Savary-Miller 0 stage = non erosive reflux disease/NERD) association was found at thelevel of perceivable statistical significance (p=0.0501). However subdividing the examined population into mild (Savary -Miller 0-1 stage) and severe (Savary -Miller 2-4 stage) groups according to the endoscopically verified mucosal lesions of the esophagus,there was a strong significant relationship between severity of GERD and BMI (p=0.0056). In the group of patients with moderateand severe GERD symptoms elevation of BMI can be a risk factor of increased severity of GERD particularly in those whoalready have erosive mucosal lesions at the time of examination.

MUCOSAL PATHOLOGY OF THE UPPER GASTROINTESTINAL TRACT ASSOCIATED WITH INTENSIVE CHEMOTHERAPY IN CHILDREN: Vitamin A Supplements Do Not Prevent Lesions

Intensive chemotherapy (ICT) for a malignant disease in children may be associated with clinically significant mucosal lesions of the upper gastrointestinal tract. This prospective and randomized study was conducted to evaluate more thoroughly the mucosal damage and to find out whether vitamin A therapy might prevent the development of these lesions. Gastroduodenoscopy and noninvasive methods were used to examine a consecutive series of 20 patients (10 females, 10 males, aged 1-15 years) 4 weeks after initiating the therapy regimen. Half of the patients were randomized to take vitamin A supplements for 6 weeks. During a follow-up of 6 weeks, 13 (65%) reported some symptoms of the gastrointestinal (GI) tract, diarrhea and mouth pain being most prominent. Endoscopic abnormalities were found in 13 (65%) subjects: esophagitis in 10, erosive duodenitis in 8, and gastritis in 7. Histologically, 11 subjects had duodenitis, 5 had gastritis, 3 had eosinophilic esophagitis, and 2 had lymphocytic esophagitis. Both endoscopic and histological abnormalities of the duodenum showed a close relationship with long-term (more than 2 weeks) granulocytopenia. The 4 patients with the most extensive endoscopic abnormalities were treated with HCl inhibitors, and re-endoscopy performed 4-8 weeks later showed complete recovery. The sugar permeability values, measured as the lactulose/mannitol ratio were comparable to the values obtained in the controls, and lactose intolerance was found in only 3 (20%) of the 15 children able to perform the breath test. Both the incidence of the reported GI symptoms and the endoscopically or histologically observed GI lesions were similar in the subjects randomized to take vitamin A supplements as in the controls. In this study, two-thirds of children with ICT showed erosive mucosal lesions of the upper gastrointestinal tract, and vitamin A therapy failed to prevent them. Endoscopic examination is recommended if a patient has severe symptoms indicative of mucosal pathology.

Haematemesis and melaena in the elderly.

Erosive mucosal lesions associated with the ingestion of ulcerogenic drugs or alcohol, or bile reflux, were the major causes of bleeding found in a group of aged patients on endoscopy for upper gastro-intestinal bleeding. Nonsteroidal anti-inflammatory drugs were strongly associated with bleeding from any site, and indiscriminate prescribing of these drugs in the elderly is ill-advised. Mortality from bleeding was similar to that reported for younger groups. A history of prior upper gastro-intestinal pathology, with or without bleeding, is not helpful in predicting the source of blood loss and endoscopy is necessary on each admission for accurate diagnosis. Endoscopy is safe despite the adverse effects of blood loss and intercurrent illness in elderly patients.

Pemphigus vulgaris in childhood.

Pemphigus vulgaris rarely occurs in children. We present the youngest reported case. All six cases of childhood pemphigus vulgaris proven by biopsy began with lesions confined to the oral mucosa. In each case diagnosis was delayed until the more typical cutaneous lesions began to appear. Either mucosal or cutaneous biopsy specimens are diagnostic, and early biopsy of erosive mucosal lesions is indicated. Vigorous therapy with systemic steroids is important in the prevention of fatality.