Mucosal Tags Research Articles

Management of orofacial granulomatosis: A case report

The term orofacial granulomatosis (OFG) was introduced by Wiesenfeld in the year 1985. OFG describes a disease with frequent or persistent edema in the orofacial region. It may be idiopathic or may present as a localized form or generalized form as in Crohn’s disease, tuberculosis, and sarcoidosis. The clinical features include facial or lip swellings, angular cheilitis, oral ulcerations, vertical fissures of lips, gingival enlargement, mucosal tags, and sometimes lymph node enlargement. The diagnosis of OFG is quite challenging and it should be excluded from other granulomatous conditions. The usual treatment for this condition includes corticosteroids, monoclonal antibodies, and tumor necrosis factor-α inhibitors. It has been suggested that intralesional triamcinolone injections are a safe and effective therapeutic strategy in controlling the permanent disfiguring swelling of OFG. Hereby, we present a case of a 34-year-old female patient who reported with swollen upper lips and gingival enlargement.

Oral manifestations in Crohn's disease - Two patient cases from the clinic

Crohn’s disease (CD) is an inflammatory disease of the gastrointestinal system. It is suspected to be caused by a combination of genetic and environmental factors and changes in the patient’s intestinal microbiome. As opposed to colitis ulcerosa, which usually only affects the large intestine, CD may affect various parts of the gastrointestinal tract. Many patients show oral lesions related to CD, which sometimes can precede the first gastrointestinal symptoms. Specific oral lesions include granulomatous cheilitis, cobblestone-like mucosal tags and linear ulcerations. Non-specific lesions occur in the form of angular cheilitis and opportunistic candidiasis, aphthous ulcerations, reduced salivation, dental caries and many more. We present two cases of patients suffering from Crohn’s disease with different oral manifestations and discuss the dentist’s role in early detection of specific oral lesions and the importance of the follow-up care of affected patients.

Evaluating false-positive detection in a computer-aided detection system for colonoscopy.

Computer-aided detection (CADe) systems can efficiently detect polyps during colonoscopy. However, false-positive (FP) activation is a major limitation of CADe. We aimed to compare the rate and causes of FP using CADe before and after an update designed to reduce FP. We analyzed CADe-assisted colonoscopy videos recorded between July 2022 and October 2022. The number and causes of FPs and excessive time spent by the endoscopist on FP (ET) were compared pre- and post-update using 1:1 propensity score matching. During the study period, 191 colonoscopy videos (94 and 97 in the pre- and post-update groups, respectively) were recorded. Propensity score matching resulted in 146 videos (73 in each group). The mean number of FPs and median ET per colonoscopy were significantly lower in the post-update group than those in the pre-update group (4.2±3.7 vs 18.1±11.1; P<0.001 and 0 vs 16s; P<0.001, respectively). Mucosal tags, bubbles, and folds had the strongest association with decreased FP post-update (pre-update vs post-update: 4.3±3.6 vs 0.4±0.8, 0.32±0.70 vs 0.04±0.20, and 8.6±6.7 vs 1.6±1.7, respectively). There was no significant decrease in the true positive rate (post-update vs pre-update: 95.0% vs 99.2%; P=0.09) or the adenoma detection rate (post-update vs pre-update: 52.1% vs 49.3%; P=0.87). The updated CADe can reduce FP without impairing polyp detection. A reduction in FP may help relieve the burden on endoscopists.

Dermatologic Manifestations of Systemic Diseases in Childhood

Dermatologic Manifestations of Systemic Diseases in Childhood

Orofacial Granulomatosis Treated with Systemic Steroid: A Case Report

Orofacial granulomatosis refers to conditions restricted to oral region mainly characterized by chronic swelling of orofacial tissues with histological evidence of non-caseating granuloma. It may be idiopathic where there is absence of identifiable granulomatous disease or may present as a component of localized or generalized Crohn’s disease, tuberculosis and sarcoidosis. The clinical features are facial or lip swelling, angular cheilitis, oral ulcerations, vertical fissures of lips, gingival enlargement, mucosal tags and sometimes lymph node enlargement. A middle-aged female presented to our outpatient department with diffuse chronic swelling of lips which after treatment with systemic steroid showed visible improvement during follow up.

Oral manifestations of inflammatory bowel disease: the neglected piece of the puzzle.

Inflammatory bowel disease (IBD) is a chronic relapsing remitting autoimmune disease including Crohn's disease and ulcerative colitis. IBD is associated with various extra-intestinal manifestations including oral manifestation. To date, only limited studies addressing the characteristics of the oral manifestations are available. The aim of the present review is to report the oral manifestations and their characteristics in IBD. A Medline/PubMed and Embase databases search were conducted and all relevant studies were extracted and analyzed. Overall, the oral manifestations in IBD were mostly associated with Crohn's disease rather than Ulcerative colitis where their prevalence ranged from 8 to 50%. Specific lesions for Crohn's disease include mucosal tags, cobblestoning and deep linear ulcerations with vertical fissures, while for ulcerative colitis, pyostomatisis vegetans was more disease specific. Notably, most of the oral manifestations were unrelated to disease activity, however more data are needed to accurately assess this correlation. Oral manifestations among IBD patients are not uncommon as Crohn's disease account for most of them. More data are warranted to precisely characterize their prevalence and association to intestinal activity.

Oral lesions as first clinical manifestations of Crohn's disease in paediatric patients: a report on 8 cases.

Oro-facial granulomatosis is a descriptive term commonly encompassing a variety of conditions that exhibit similar clinical and microscopic features. It is generally used to describe persistent enlargement of the soft tissues of the oral and maxillofacial region. We report on the salient clinical features of 8 cases of Crohn's disease in paediatric patients (age range from 9 to 13 years old), with oral lesions as first clinical manifestations. The clinical presentation of oro-facial granulomatosis is highly variable but usually recurrent facial swelling, mainly in the lips with or without intraoral manifestations, is the single most common clinical sign at onset. The association with systemic conditions such as sarcoidosis and Crohn's disease has been widely reported in literature. In paediatric age, oro-facial granulomatosis may frequently represent an extra-intestinal manifestation of Crohn's disease and oral lesions can be the first sign of an unknown intestinal disease. The diagnosis in paediatric patients is challenging as oro-facial granulomatosis may precede Crohn's disease by several years, frequently remaining the only evident active focus of the disease. The detection of specific oral manifestations often preceded by painless gingival enlargement (diffuse lip and buccal mucosal swelling, oral cobblestoning, buccal sulcus ulceration and mucosal tags) and/or unspecific or ancillary ones (cheilitis, scaly perioral erythematous rashes and frank intraoral abscess formation, labial and tongue fissuring, glossitis and aphthous stomatitis) is mandatory for the early diagnosis of intestinal Crohn's disease.

Improving the Accuracy of Serrated Colon Polyp Designation

ABSTRACT Background: Serrated polyps are the most common polyps of the large bowel. In the past decade, the focus on sessile serrated polyp (SSP) has been increased as it has proved that untreated SSP is associated with substantial increased risk of developing colon cancer. The microscopic diagnosis can be challenging due to overlapping features with hyperplastic polyps, which can cause misdiagnosis and inappropriate follow up of the patients. Methods: The purpose of this study is to assess the effect of educational sessions on appropriate designation of sessile serrated polyps. We re-evaluated hyperplastic polyps for two years and repeated the re-evaluation after few educational sessions. Results: During the first phase, we evaluated 365 hyperplastic polyps and reclassified 60 (16%) of them as SSP. We also found 11 tubular adenomas, 2 traditional sessile serrated adenomas and 8 mucosal tags. After the education, phase 2, we reviewed another 191 hyperplastic polyps and reclassified 16 (8%) of them as SSP. We found 3 tubular adenomas, but no other polyps. Most of the polyps (67%) were 0.5 cm in diameter or larger. Conclusion: Our study shows that the educational intervention was successful in increasing the accurate designation of SSP and improved that significantly.

2084 An Atypical Case of Oral Crohn’s Disease

INTRODUCTION: Oral manifestations of Crohn’s disease are wide-ranging from fissuring and linear ulcerations to cobblestone plaques, mucosal tags, and buccal edema. The commonality between them is the presence of subepithelial non-caseating granulomas on biopsy not explained by another etiology. There is general agreement that oral manifestations are underdiagnosed and that there may be a wider spectrum of disease than previously realized. We present a case of oral Crohn’s that differs in presentation from others previously described in the literature. CASE DESCRIPTION/METHODS: 25-year-old woman who was diagnosed with Crohn’s ileocolitis on colonoscopy in 2011. After initial treatment failure with mesalamine, she was on Infliximab for 3-4 years but stopped as she preferred to avoid infusions. She started Humira in January 2017 after a Crohn’s flare but did not improve despite the addition of 6-MP. She stopped both Adalimumab and 6-MP in September 2017 after developing facial and lip swelling concerning for an allergic reaction. Complement and C1 esterase inhibitor levels were within normal limits, ruling out hereditary angioedema. Her abdominal symptoms worsened off treatment; colonoscopy revealed moderately active left-sided colitis. While her facial swelling improved, her lip swelling did not. On exam she initially had cobblestoning, a tongue fissure, and swelling of the lower lip. She was evaluated by oral and maxillofacial surgery (OMFS) in May 2018 and at that time had a firm, mobile 1.5 × 1 cm exophytic lesion with surface ulcerations of the right buccal mucosa and right lower lip swelling. The buccal lesion was thought to be either a traumatic fibroma or oral Crohn’s disease. It was excised a month later and pathology revealed granulomatous inflammation with no organisms on gram stain or AFB stain, consistent with oral Crohn’s disease. She subsequently started Ustekinumab and attained clinical and endoscopic remission. An oral prednisone taper for her lip swelling had no effect. She then had 2 triamcinolone injections by OMFS with improvement in the lip appearance. DISCUSSION: In this case a woman with intestinal Crohn’s disease developed an exophytic lesion of the buccal mucosa diagnosed as oral Crohn’s disease on biopsy. This atypical presentation of an underdiagnosed aspect of Crohn’s disease points to a wider spectrum of the disease than previously acknowledged. It also highlights the importance of an interdisciplinary approach with dentistry to better recognize and treat oral symptoms.

Prevalence of Oral Lesions and Correlation with Intestinal Symptoms of Inflammatory Bowel Disease: A Systematic Review.

Background: Extra-intestinal manifestations of inflammatory bowel disease (IBD) are widely studied. Oral manifestations are manifold, miscellaneous, and hardly detected by general practitioners and gastroenterologists. Objectives: The main purpose of this systematic review is to find all the possible correlations between inflammatory bowel disease and the oral cavity in order to underline the importance of multidisciplinary cooperation with dental care providers, and to secure better treatments for patients. Materials and methods: Articles were searched up to June 2019 through Ebsco’s, Google Scholar, and PubMed databases. The search terms included IBD, oral manifestations of inflammatory bowel disease, oral manifestations of Crohn’s disease or Ulcerative colitis, an extra-intestinal manifestation of IBD, oral Crohn’s disease, and paediatric inflammatory bowel disease. Discussion: The prevalence of the oral manifestation of IBD ranges from 0.7% to 37% in adults and from about 7% to 23% in children. They can be divided into specific manifestations (cobblestoning mucosa, mucosal tags, cheilitis granulomatosa, pyostomatitis vegetans) and nonspecific manifestations (halitosis, dysphagia, aphthous ulcerations, deep oral fissuring, cheilitis angularis, taste changes, lichen planus). Moreover, the link between IBD and the higher prevalence of dental caries and periodontitis have also been studied. Conclusions: The presence of oral manifestations that precede or follow intestinal symptoms of IBD, must be taken into serious consideration from both gastroenterologists and dentists in order to allow for early diagnosis and improve patients’ quality of life.

Clinicopathologic Features of Colorectal Polyps in Shahid Beheshti University of Medical Sciences (SBMU).

Aim:This study was designed to report epidemiologic findings of polyps in Iranian patients, and predict histology of polyp regarding to demographic and colonoscopic findings. Background:Classification of colorectal polyps had been revised in the past two decades and there is a need for polyp categorization in the Iranian Health System. Patients and methods: In this retrospective study, the medical records of patients with colonoscopic diagnosis of polyp in pathology departments of SBMU affiliated teaching hospitals were reviewed. Patient’s slides evaluated and demographics findings were assessed. The anatomical location, macroscopic appearance including size and histological assessment of all polyps were recorded. Results:From total number of 1106 polyps (detected in 862 patients), adenomatous polyps (638 [57.7%]) were the most prevalent findings, followed by colon mucosal tag (184[16.6%]), hyperplastic and serrated polyps (122[11%]), inflammatory polyps (110[9.9%]), hamartomatous (21[1.9%]), and malignant lesions (13[1.2%]). Multivariate logistic regression showed age (each one year increasing age; odds ratio [OR] = 1.026, 95%confidence interval [CI] = 1.016–1.036, p < 0.0001), location of polyp (right colon; OR = 1.905, 95%CI = 1.366–2.656, p < 0.0001), and polyp size of 5-10 mm (OR = 1.662, 95%CI = 1.214–2.276, p = 0.002), and polyp size of >10 mm (OR = 2.778, 95%CI = 1.750–4.411, p< 0.0001) were independently associated with neoplastic polyps. Also, polyp size of >10 mm (OR= 2.613, 95%CI= 1.083-6.307, p=0.033), tubulovillous pattern of polyp (OR= 3.508, 95%CI= 1.666-7.387, p=0.001) and villous pattern of polyp (OR= 10.444, 95%CI= 4.211-25.905, p<0.0001) were associated with high grade dysplasia in neoplastic polyps. Conclusion:Increased age, location of polyp (right colon), increased size of polyp and villous component of polyp could classify patients in high risk groups.

Congenital laryngeal paralysis in Alaskan Huskies: 25 cases (2009-2014).

OBJECTIVE To characterize congenital laryngeal paralysis (CLP) in Alaskan Huskies. DESIGN Prospective case series. ANIMALS 25 Alaskan Huskies with CLP. PROCEDURES Data were collected for each dog regarding signalment; history; results of physical, orthopedic, neurologic, and laryngeal examinations; esophagraphic findings; treatments; histologic findings; and outcomes. RESULTS Severely affected dogs were profoundly dyspneic at birth or collapsed after brief exercise; less affected dogs reportedly tired easily or overheated with minimal exercise. Mean age at initial onset of clinical signs was 6.4 months. Blue eyes, white facial markings, and oral mucosal tags or tissue bands were noted in 23 (92%), 19 (76%), and 13 (52%) dogs. Neurologic examination revealed signs of mononeuropathy of the recurrent laryngeal nerve but not of polyneuropathy. Histologic examination revealed neurogenic atrophy of the cricoarytenoideus dorsalis muscle but no polyneuropathy. Eight (32%) dogs underwent unilateral cricoarytenoid lateralization, resulting in substantial clinical improvement, including ability to compete in sled dog races. Without surgery, 4 (16%) dogs died of asphyxiation, 10 (40%) had spontaneous improvement of clinical signs (but insufficient improvement to race), and 3 (12%) remained affected. Results of pedigree analysis suggested an autosomal recessive mode of CLP inheritance, with variable penetrance. CONCLUSIONS AND CLINICAL RELEVANCE CLP in the evaluated Alaskan Huskies involved mononeuropathy of the recurrent laryngeal nerves, without polyneuropathy. Most affected dogs had blue eyes, white facial markings, and oral mucosal tags or tissue bands. Given the apparent genetic component to CLP in this breed, we recommend that dogs with these features be prevented from breeding.

Les manifestations orales de la maladie de Crohn

Crohn’s disease (CD) is a chronic inflammatory bowel disease whose oral features remain underrated at clinical examination. The aim of the study was to report forerunner orofacial presentations leading to diagnosis of CD among nine patients of mean age 23 between 2008 and 2015. Linear ulcerative buccal lesions, cobblestoning, mucosal tags and perioral erythema are highly evocative and might precede intestinal signs for several years. Oral biopsies revealed highly suggestive lesions of CD for 45% of patients before any intestinal symptom or digestive investigation. Mean time to diagnosis was 14 months. Immunomodulatory therapy (azathioprine, infliximab, adalimumab) was introduced alone or in association for 89% of patients. Early diagnosis could lead to specific therapy, often necessary to reduce severity of lesions and improve quality of life.

Die oralen Auswirkungen von Morbus Crohn

Crohn’s disease (CD) is a chronic inflammatory bowel disease whose oral features remain underrated at clinical examination. The aim of the study was to report forerunner orofacial presentations leading to diagnosis of CD among nine patients of mean age 23 between 2008 and 2015. Linear ulcerative buccal lesions, cobblestoning, mucosal tags and perioral erythema are highly evocative and might precede intestinal signs for several years. Oral biopsies revealed highly suggestive lesions of CD for 45% of patients before any intestinal symptom or digestive investigation. Mean time to diagnosis was 14 months. Immunomodulatory therapy (azathioprine, infliximab, adalimumab) was introduced alone or in association for 89% of patients. Early diagnosis could lead to specific therapy, often necessary to reduce severity of lesions and improve quality of life.

Oral manifestations of gastrointestinal disorders.

BackgroundA considerable number of gastrointestinal disorders (GIDs) of varied nature (inflammatory, infectious, genetic and other etiology) may produce alterations in the hard and soft oral tissues. Among these are Crohn’s disease, ulcerative colitis, celiac and gastroesophageal reflux disease.Material and MethodsArticle search was done using the National library of medicine (PubMed) database using different search terms and analyzed according to their importance.ResultsA large variety of GIDs can give rise to oral lesions, including: RAS like ulceration, mucosal tags, cobblestoning, mucogingivitis, labial and facial swelling, pyostomatitis vegetans, disgeusia and dental abnormalities, among others. Although in most cases the gastrointestinal signs and symptoms highlight in the clinical picture, a considerable percentage of these patients are affected by oral manifestations before the onset of gastrointestinal symptoms. This lesions can cause significant functional and aesthetics damages as well deteriorate the patient quality of life.ConclusionsAlthough the frequency of oral manifestations is variable across GIDs and in most cases is non-specific, these alterations may precede the underlying disease and therefore can facilitate an opportune diagnosis. Key words:Gastrointestinal disorders, oral lesions, oral mucosal disorders.

Oral pathology in inflammatory bowel disease

The incidence of inflammatory bowel diseases (IBD) - Crohn's disease (CD) and ulcerative colitis (UC) - has been increasing on a global scale, and progressively, more gastroenterologists will be included in the diagnosis and treatment of IBD. Although IBD primarily affects the intestinal tract, extraintestinal manifestations of the disease are often apparent, including in the oral cavity, especially in CD. Specific oral manifestations in patients with CD are as follows: indurate mucosal tags, cobblestoning and mucogingivitis, deep linear ulcerations and lip swelling with vertical fissures. The most common non-specific manifestations, such as aphthous stomatitis and angular cheilitis, occur in both diseases, while pyostomatitis vegetans is more pronounced in patients with UC. Non-specific lesions in the oral cavity can also be the result of malnutrition and drugs. Malnutrition, followed by anemia and mineral and vitamin deficiency, affects the oral cavity and teeth. Furthermore, all of the drug classes that are applied to the treatment of inflammatory bowel diseases can lead to alterations in the oral cavity due to the direct toxic effects of the drugs on oral tissues, as well as indirect immunosuppressive effects with a risk of developing opportunistic infections or bone marrow suppression. There is a higher occurrence of malignant diseases in patients with IBD, which is related to the disease itself and to the IBD-related therapy with a possible oral pathology. Treatment of oral lesions includes treatment of the alterations in the oral cavity according to the etiology together with treatment of the primary intestinal disease, which requires adequate knowledge and a strong cooperation between gastroenterologists and specialists in oral medicine.

Oral manifestations of Crohn’s disease: A case report

Crohn’s disease is a chronic inflammatory bowel disease still with unknown etiology. In 0.5-20% of patients, extra intestinal lesions in the oral cavity can be presented in forms of orofacial granulomatosis, cobblestone and corrugated oral mucosa, mucosal tags, deep linear ulcerations with hyperplastic folds, pyostomatits vegetans, aphthous ulcers, angular cheilitis, labial/facial edema and gingival erythema/edema. We describe a case of a 28-year-old male who was presented with oral lesions of Crohn’s disease and treatment procedure. The patient was candidate for biologic treatment so dental procedures and preparation of the patient for treatment are described. Good communication and cooperation between the patient’s doctor and dentist are important for successful treatment.

Evaluation of the Oral Mucosa of Crohn’s Disease

Introduction: we aimed at the evaluation of the oral mucosa in Crohn’s disease patients and matched controls. Due to the proctrated course of Crohn’s disease, its diagnosis may be difficult, and the finding of lesions in the oral mucosa may help to raise the clinical suspicion. Methods: we studied 124 adult patients older than 18 years, of both sexes, 62 outpatients with Crohn’s disease and 62 controls matched by sex and age. We searched for aphthous ulcers, orofacial granulomatosis, mucosal tags, leukoplakia and pyostomatitis vegetans. Both investigators, dentist and physician, were blind respectively to the patient diagnosis, and to findings of the odontologic examination. Results: only six patients among the total sample had oral mucosal lesions, being 5 controls (two with fibrous hyperplasia due to prosthesis trauma , one with labial herpes simplex, one with a hemangioma and one with lichen planus) and one Crohn’s disease with labial herpes simplex. Some patients reported a past history of lesions suggestive of aphtae, being six control patients (9.6 %) and nine Crohn’s (14.5%). No orofacial granulomatosis, mucosal tags, leukoplakia or pyostomatitis vegetans were seen. Discussion: in our population of adult patients with Crohn’s disease and controls, we found that oral mucosal lesions were scarce and similar among controls and cases.

Esophageal tuberculosis presenting with hematemesis

Esophageal tuberculosis is rare, constituting about 0.3% of gastrointestinal tuberculosis. It presents commonly with dysphagia, cough, chest pain in addition to fever and weight loss. Complications may include hemorrhage from the lesion, development of arterioesophageal fistula, esophagocutaneous fistula or tracheoesophageal fistula. There are very few reports of esophageal tuberculosis presenting with hematemesis due to ulceration. We report a patient with hematemesis that was due to the erosion of tuberculous subcarinal lymph nodes into the esophagus. A 15-year-old boy presented with hemetemesis as his only complaint. Esophagogastroduodenoscopy (EGD) revealed an eccentric ulcerative lesion involving 50% of circumference of the esophagus. Biopsy showed caseating epitheloid granulomas with lymphocytic infiltrates suggestive of tuberculosis. Computerised tomography of the thorax revealed thickening of the mid-esophagus with enlarged mediastinal lymph nodes in the subcarinal region compressing the esophagus along with moderate right sided pleural effusion. Patient was treated with anti-tuberculosis therapy (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) for 6 mo. Repeat EGD showed scarring and mucosal tags with complete resolution of the esophageal ulcer.

Characteristics of patients with orofacial granulomatosis

Orofacial granulomatosis has mostly been described in reports of very small numbers of cases. Few large case groups have been described. The aim of this study was to describe the demographics, symptoms, clinical features and laboratory findings in a large cohort of cases. Clinical and laboratory data for 119 cases of orofacial granulomatosis who attended oral medicine clinics in Dublin, Ireland, were examined for demographic characteristics at the time of first presentation. The male/female ratio was approximately 1:1, with a median age (and range) of 28 (5-84) years. Symptoms had been present for a median duration of 12 weeks. A food association was suspected by 30% of patients. The predominant complaint was lip swelling (77%) with only 15% reporting facial swelling, while 8% complained of both. Almost all patients had clinical evidence of lip or facial swelling (95%). Other common extra-oral manifestations were lip fissuring (30%), angular cheilitis (28%) and perioral erythema (28%). Common intra-oral manifestations were cobblestoning of the buccal mucosa (63%), ulcers (36%), granulomatous gingivitis (33%), mucosal tags (29%) and fissured tongue (17%). Over half of the biopsies (56%) performed were reported as typical of orofacial granulomatosis. This is one of the largest cohorts of orofacial granulomatosis patients to have been described in detail.