The document discusses diseases of the upper and lower digestive tract. The upper tract includes the esophagus, stomach, and duodenum. Gastroesophageal reflux disease (GERD) and hiatal hernia are common upper tract diseases described. In the lower tract, duodenal ulcers, inflammatory bowel diseases like ulcerative colitis and Crohn's disease, and their signs, symptoms, and oral health considerations are outlined. Crohn's can involve any GI part and cause complications like strictures, while ulcerative colitis only impacts the colon.

2. Introduction
 The digestive tract is a long muscular tube that moves
food and accumulated secretions from the mouth to
the anus.
 the GI tract includes all structures between
the mouth and the anus.
 The tract itself is divided into upper and lower tracts.
 The upper gastrointestinal tract consists of
the esophagus, stomach, and duodenum.
 The lower gastrointestinal tract includes most of
the small intestine and all of the large intestine.
 The exact demarcation between the upper and lower
tracts is the suspensory ligament of the duodenum
(also known as the Ligament of Treitz)

4. ▼ Diseases of the Upper Digestive Tract
Gastroesophageal Reflux Disease
 is a chronic symptom of mucosal damage caused by
stomach acid coming up from the stomach into
the esophagus.
 Although this can occur normally, it may be attributed
to GERD if it is associated with symptoms.
 GERD is usually caused by changes in the
barrier between the stomach and the esophagus
including abnormal relaxation of the
lower esophageal sphincter, which normally
holds the top of the stomach closed.

5.  In healthy patients, the "Angle of His’’—the angle at which the
esophagus enters the stomach—creates a valve that prevents
duodenal bile, enzymes, and stomach acid from traveling back
into the esophagus where they can cause burning and
inflammation of sensitive esophageal tissue.
 Factors that can contribute to GERD:
 Hiatal hernia .
 Obesity .
 Zollinger-Ellison syndrome, which can be present with increased
gastric acidity due to gastrin production.
 Hypercalcemia, which can increase gastrin production, leading
to increased acidity.
 Obstructive sleep apnea
 Gallstones, which can impede the flow of bile into
the duodenum, which can affect the ability to neutralize gastric
acid.

6. Signs and symptoms
 Heartburn is the cardinal symptom of GERD and is
defined as a sensation of burning or heat that spreads upward
from the epigastrium to the neck.
 Chest pain is another important symptom that is related to
disorders of the esophagus.
 Dysphagia is also a common presenting complaint that
may serve to prompt the dentist to refer the patient to the
patient’s physician.
 Regurgitation is the expulsion of material from the
pharynx, or esophagus.

7. Other symptoms include
 Pain with swallowing/sore throat (odynophagia)
 Increased salivation (also known as water brash)
 Nausea
 Coughing

8. Oral Health Consideration
 Patients who experience GERD complain of dysgeusia
(foul taste), dental sensitivity related to hot or cold stimuli,
dental erosion, and/or pulpitis. Dental thermal sensitivity is
generally due to erosion of enamel by gastric acid. if the
erosion is severe, irreversible pulpal (nerve) damage may
result that requires root canal therapy.
 Dental management should provide topical fluoride
applications using custom-made occlusive tray delivery in
order to ensure optimal dental mineralization and reduction
of thermal sensitivity.
 The dentist can restore tooth structure destroyed by gastric
acid in order to provide comfort and esthetics and to
minimize further hard tissue damage.

9.  Medical therapy can affect the dental management of
patients with GERD in a number of ways. Patients taking
cimetidine (Tagament) or other H2 receptor antagonists may
experience a toxic reaction to lidocaine (or other amide local
anesthetics) if the anesthetic is injected intravascularly.
 Soft tissue changes such as esophageal stricture and fibrosis may
complicate intubation if the patient requires general anesthesia
for an oral maxillofacial procedure.

10.  Erythema and mucosal atrophy
may be present as a result of chronic exposure of
tissues to acid. Mild sodium bicarbonate rinses may
again be useful if mild signs of stomatitis are present.

11. Hiatal Hernia
 The esophagus passes through the diaphragmatic hiatus and into
the stomach just inferior to the diaphragm. The hiatus causes an
anatomic narrowing of the opening into the stomach and thus
helps prevent reflux of stomach contents into the esophagus.
Some patients have a weakened or enlarged hiatus, perhaps due
to hereditary factors. It may also be caused by obesity, exercising
(eg, weight lifting).
 When a weakened or enlarged
hiatus occurs, a portion of the
stomach herniates into the
chest cavity through this
enlarged hole, resulting in
a hiatal hernia.

12. Signs and Symptoms
 chest pain, which may radiate in patterns similar to those of
myocardial infarction pain.
 Infants with hiatal hernia usually regurgitate blood stained
food and may also have difficulty in breathing and swallowing.
 Adult patients may experience chronic acid reflux into the
esophagus.
chronic esophageal inflammation may produce scarring, resulting
in esophageal narrowing. This narrowing causes dysphagia.
 Heartburn is exacerbated when bending forward or lying down.

13. Types of Hiatal hernia
 Hiatal hernias are classified into three major types :
1) sliding type is the most common. Characterized by an
upward herniation of the cardia and GE junction.
2) Fixed hernia characterized by an upward herniation of
the gastric fundus. Cardia and GE jn are in normal place

14. 3) The complicated type is the most serious and least
common form of hiatal hernia.This form includes a
variety of herniation patterns of the stomach, including
those in which the entire stomach moves into the chest.

15. Oral Health Considerations
 If a hiatal hernia is treated with medications that cause
xerostomia(dry mouth), the dose or drug type may need to
be altered by the patient’s physician. Various treatment
modalities for dry mouth, such as artificial saliva, alcohol-free
mouthwashes, or increased fluid intake, may need to be
prescribed.
 If reflux into the oral cavity is present, oral manifestations
that are the same as those of GERD may be present.

16. ▼ Diseases of the Lower Digestive Tract
 Disorders of the Intestines
1. Duodenal Ulcer Disease
A duodenal ulcer represents a break through the mucosa into
the submucosa or deeper. The base of the ulcer is necrotic
tissue consisting of pus and fibrin. When the ulcer
erodes into an adjacent blood vessel, there is
hemorrhage. If erosion continues through
the serous outer layer of the duodenum,
adjacent organs or perforation into the
peritoneal cavity occurs. When conditions
are favorable, the ulcer heals, with
granulation tissue and new epithelium. If the ulcer is present
for prolonged periods, it becomes associated with scar tissue
and possible deformity.

17. Etiologic factor
 The most common primary cause is H. pylori infection.
 aspirin, ibuprofen, and other NSAIDs.
 Less commonly, factors such as stress, parathyroid disease,
malignant carcinoid, and chronic lung disease have been
associated with duodenal ulcers.
The ulceration is usually located in
the first part of the duodenum
because the acidic chyme ordinarily
becomes alkaline after pancreatic
secretions enter the intestines in the second part of the
duodenum.

18. Signs and Symptoms
 Epigastric pain: perceived as a burning sensation, usually occurs when the
stomach is empty or when not enough of a meal remains in the stomach. In
contrast to the symptoms of Duodenal ulcers, the pain of Gastric ulcer is
aggravated by food.
 bloating and abdominal fullness.
 Hematemesis : When an ulcer perforates and hemorrhages, the patient often
vomits gross blood.
 The blood loss can lead to iron
deficiency anemia.
 duodenal perforation, which leads
to acute peritonitis.
 Melena.

19. Dental management
 If a patient presents with symptoms of epigastric pain, as
described previously, the dentist should refer this person to
the primary care physician for diagnostic workup.
 Dentist should avoid administering drugs that exacerbate ulceration
and cause gastrointestinal distress such as aspirin and other NSAIDs.
Instead, acetaminophen products should be recommended.
 antacids contain calcium, magnesium, and aluminum salts that bind
antibiotics, such as erythromycin and tetracycline, dentists should
remember that administering one of these drugs within 1 hour of
antacid therapy may decrease the absorption of the antibiotic as much
as 75 to 85 % .
 erythromycin and tetracycline should be taken 1 hour before or 2 hours
after ingestion of antacids.
 Exogenous steroid administration is likely to exacerbate the ulcer
because of the increased production of acid caused by the steroid and
should be avoided.

20.  Its good to prescribe penicillin V instead of penicillin G
(because of the destruction of penicillin G by gastric acid)
 Hyposalivation and dry mouth (xerostomia) are common
complaints in patients taking anticholinergic drugs.
Patients who wear either complete or partial dentures are
particularly troubled by oral dryness. Denture adhesives
and artificial saliva may aid in the retention of their dental
prostheses.
 Cimetidine and rantidine, drugs commonly prescribed for
duodenal ulcer patients, have occasionally been associated
with thrombocytopenia and may compete with antibiotics
or antifungal medications.

21. Inflammatory Bowel Diseases
 Inflammatory bowel disease (IBD) is a general classification of
inflammatory processes that affect the large and small intestines.
Ulcerative colitis and Crohn’s disease together make up IBD.
 Inflammatory bowel diseases fall into the class of autoimmune
diseases, in which the body's own immune system attacks
elements of the digestive system.

22. Ulcerative Colitis
The inflammation in ulcerative colitis may affect all or part of
the large intestine. Macroscopically, the mucosa may have a
granular appearance if the disease is mild. When fulminant,
the disease may include stripping of the mucosa, with areas of
sloughing, ulceration, and bleeding .Ulcerative colitisi restricted
to the colon and the rectum. Microscopically, ulcerative colitis
is restricted to the mucosa (epithelial lining of the gut), while
Crohn's disease affects the full thickness of the bowel wall.

23. Signs and Symptoms
 The hallmark of ulcerative colitis is rectal bleeding and diarrhea,
sometimes nocturnal diarrhea (Typically, the diarrhea is severe,
possibly five to eight bowel movements in 24 hours).
 pain that is in both abdominal quadrants and that is crampy in
nature and exacerbated prior to bowel movement.
 Erythema nodosum, characterized by red swollen nodules that are
usually on the thighs and legs, may be present.
 .

24.  Joint symptoms occur in up to 20% of patients with the
disease, usually affecting the ankles, knees, and wrists.
 Anemia is commonly associated with ulcerative colitis. It is
most likely caused by blood loss and is typically a microcytic
hypochromic anemia of iron deficiency.
 Eye changes such as uveitis, corneal ulcers, and retinitis may cause
pain and photophobia.

25. Oral Health Considerations
 The oral changes that occur in ulcerative colitis cases are nonspecific and
uncommon.
 Aphthous stomatitis the appearance of these lesion may be coincidental.
 Pyoderma gangrenosum.
 Pyostomatitis vegetans, a purulent inflammation of the mouth.
 hairy leukoplakia

26.  Oral manifestations of anemia may be noted in patients
with ulcerative colitis, especially in undiagnosed or poorly
controlled disease. The oral manifestations include pallor,
angular cheilitis and glossitis.

27. Dental management
 Chronic use of glucocorticosteroids can also result in adrenal suppression
Patients undergoing surgery may require supplemental glucocorticosteroids
before and after the procedure because their own adrenal response to stress is
blunted.
 Prior to dental procedures, blood studies that include hemoglobin,hematocrit,
and a red blood cell count should be undertaken to rule out the presence of
anemia.
 Patients on azathioprine might be expected to have changes in white and red
blood cell counts also Suppression of the liver can be expected so consultation
with the patient’s physician will help the dentist determine the patient’s liver
function.
 Patients who have extensive bowel surgery may suffer from malabsorption
of vitamin K, vitamin B12, and folic acid. Before any surgical procedures are
completed, these patients should be evaluated for both macrocytic and
microcytic anemia and bleeding disorders from insufficient levels of
vitamin K (fibrin clot formation).

28. Crohn’s Disease
 Crohn’s disease is an inflammatory disease of the small or
large intestine. The inflammation involves all the layers of
the gut (tansmural) and affect any part of the gastrointestinal
tract from mouth to anus. Most commonly involves the terminal
ileum.
 characterized by segmental
Distribution of intestinal ulcers
(skip lesions) interrupted by
normal-appearing mucosa.

29. Recent epidemiologic evidence suggests that there are two
forms of Crohn’s disease :
 a nonperforating form that tends to recur slowly .
 perforating or aggressive form that evolves more rapidly.
Patients with the aggressive perforating type are more prone
to develop fistulae and abscesses, whereas the more indolent
nonperforating type tends to lead to stenotic obstruction.

30. Complications
Intestinal
complications
Stricture
Fistula
Perforation
Abscess
Neoplasm
Systemic
complications
Athritis
Ankylosing
spondylitis
Uveitis
Oxalate stones
Erythema nodosum
Pyoderma
gangrenosum

32.  Systemic complication

33. Another manifestation
 recurrent or persistent diarrhea (often without blood)
 abdominal cramps
 anorexia
 Weight loss
 Unexplained fever
 malaise

34. Oral Health Considerations
 Most oral manifestations of Crohn’s disease occur in patients with
active intestinal disease, and their presence frequently correlates
with disease activity.
 Recurrent aphthous ulcers are the most common oral
manifestation of Crohn’s disease.
 pyostomatitis vegetans, cobblestone mucosal architecture, and
minor salivary gland duct pathology represent granulomatous
changes that constitutethe hallmark of Crohn’s disease

35.  Less often, Crohn’s disease patients develop diffuse swelling
of the lips and face, inflammatory hyperplasias of the oral
mucosa.
 increased incidence of bacterial and fungal infections and
dental caries are multifactorial but appear to be related to the
patient’s altered immune status or diet.

36.  Dental management of patients with IBD should include
frequent preventive and routine dental care to monitor oral
health and to prevent the destruction of hard and soft tissue.
 Depending on the results of the consultation with the
patient’s physician, the following laboratory studies may be
indicated before surgical procedures are performed: (1)
complete blood count; (2) hematocrit level; (3) hemoglobin
level; (4) platelet count; (5) coagulation studies (prothrombin
time/INR, and partial thromboplastin time); (6) liver
function test; and (7) blood glucose level.

37.  if the lesions are symptomatic Palliative sodium bicarbonate
mouthrinses (one-half teaspoon of baking soda in 8 ounces
of water) may be used.
 Moderate-potency topical steroid preparations, such as
0.05% fluocinonide, desoximetasone, and triamcinolone, can
be topically applied to the lesions, four times daily.
 Ointments and creams are useful when the lesions are
localized and direct topical application is possible.
 In cases when lesions are disseminated or oropharyngeal in
distribution, dexamethasone elixir 0.5 mg/5 mL can be used
as a rinse or gargle for 1 minute, four times daily.