12/8/2010

Journey thru the GI tract—practical pearls The Teeth for the healthcare professional • and heart disease • , subclinical vasculitis and coronary plaque development

• State with the least teeth is the state with the most heart disease Barb Bancroft, RN, MSN, PNP Chicago, IL www.barbbancroft.com

Oral and coronary artery Floss disease • 4 bacteria are implicated—Tannerella forsythia, • “Floss only the teeth you want to keep…” Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, Treponema denticola. • Enter the bloodstream via small ulcers that develop in the gum tissue of patients with periodontal disease • MINUTIAE: On average, each person uses 54 • Contribute to plaque formation via ; induce feet of dental floss every month or about 1.5 platelet aggregation and clot formation feet of floss per day which equals 548 feet of • Depending on the bacterial concentration, the increased risk of heart attack in persons with one or another of these dental floss per year. bacteria ranges from 200-300 percent, compared to people with no evidence of the bacteria

Drugs used for and and tooth loss osteoporosis—the • Osteoporosis of the and on • Alendronate (Fosamax), risendronate dental X-rays—loss of trabecular (Actonel), ibandronate (Boniva) for PMF • Women who do NOT take estrogen have fewer • Pamidronate (Aredia), zolendronic Acid natural teeth (Zometa) for —doses are 4-12 x higher than doses to prevent osteoporosis—inhibit osteoclastic production of calcium and • The bisphosphonates and osteonecrosis of the therefore treat the hypercalcemia of malignancy (multiple myeloma , breast cancer metastases to bone, etc.)

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Osteonecrosis of jawbone (2/3 are bone mandible) • Less than 1 / 100,000 patient years in people • 95% of cases are taking IV Aredia or Zometa to who take Fosamax for osteoporosis stop in certain (breast and multiple myeloma) • More common with IV bisphosphonates such • Incidence—1.3-7% as pamidronate (Aredia) and zolendronic acid • Discuss risks of dental complications and (Zometa) perform dental procedures BEFORE starting these drugs • Hard to treat—stopping therapy does little good because these drugs are metabolized slowly and stay in bone for many years (especially alendronate/Fosamax)

The teeth-- Forensics and meth mouth

• 22 y.o. meth user; snorted and/or injected meth x 2 • Changes in teeth w/ meth mouth—cannot years • Denied use of any other drugs recognize dental prints • Drank 2-3 liters of carbonated drinks each day • Problem when meth labs blow up and the because of a dry mouth; rampant dental caries human remains are incinerated at the scene because of acidic environment • How addicting is ? Dopamine and • (British Journal of Medicine 2006;333:156)

Speaking of…forensic odontology Forensic odontology--January 15, 1978

• “Listen my children and you shall hear…” • Two girls attacked at the Chi Omega sorority house in Tallahassee FL; both girls were strangled and beaten, and one was raped. No fingerprints were left at the • Dental records—the first forensic dentist in crime scene, but the killer did leave one identifying mark—he bit one of the girls twice on the left the U.S. was none other than the famous Paul buttock. Revere who was known for his identification • The impression was clean enough to make a match of fallen Revolutionary soldiers via dental with the dental impression—his bite mark bore an records uneven alignment and several chips giving the forensic odontologist two good impressions to work with

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1st case in FL history to convict a killer via dental forensics—Ted Bundy Bites… • As a general rule in the world of biology, If it bites, it’s female…the exception to this rule— sexual predators such as Bundy and Dahmer

Bites and child abuse 3 characteristics/components of bite marks

• When seen on a living child, have a high index 1) the bite mark is an ovoid area with teeth of suspicion indentations; shape and size are significant • May signal escalating danger 2) the suck mark—caused by pulling of the skin • Sign that the child will most likely be further into the mouth, creating a negative pressure— abused and fatally injured in the future if the resembles a contusion in the middle of the abuse is not stopped bite 3) the thrust mark—caused by the tongue as it pushes against the skin

Child abuse Bite marks

• Bite marks on the tongue of a child with no • From another child? Adult? Animal? A teeth diameter of greater than 3 cm between • Suspicious? cuspids is human • Bite mark from the abuser shows a curve in • Human bites—crescent; usually 2 opposing the direction opposite the child’s dental arch semicircles which may be incomplete; individual teeth marks may be visible or the dental arch may be represented by a continuous line • DOGS vs. CAT bites

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Dogs tear vs. cats puncture Dog bites

• Cats cause puncture wounds with those little • 2-5 million Americans bitten by dogs every fangs year • Dogs rip a major portion of skin off • Arms and legs in young adults; face in children • • Pasteurella and necrotizing fasciitis (the flesh- More than 50% occur in kids under age 12 eating disease) • Most nonrabid bites are provoked • • Antibiotics for cat bites Dog bites comprise 80-90% of all animal bites requiring medical care • TETANUS shots for all bites!

Myth: A dog’s mouth is cleaner than a human mouth… The immunocompromised patient • Fact: Despite being able to lick body parts that • Candida albicans (inhaled steroids in no human has the capability of licking, Fido’s asthmatics) mouth is often touted as scientifically more • Diabetics with hyperglycemia sterile. Truth be told, oral bacteria are so • Fungal infections and TNF-α antagonists species-specific that one cannot be considered (infliximab/Remicade; adalimumab/Humira; “cleaner” than the other, just different. certolizumab/Cemzia etanercept/Enbrel)* (LiveScience.com) • Kaposi’s sarcoma • HPV • HIV (TB)

The diabetic mouth Dental care and diabetes

• In addition to uncontrolled blood sugars and • 1 to 2 periodontal treatments per year an increased risk of yeast infections such as decreased diabetes costs by 11-12% candida, diabetics also have neuropathy that • Univ of Michigan School of Public Health can result in hyposalivation • Science Daily, January 8, 2009

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Herpes labialis – HSV-1 Active herpes and dental procedures…

• Virus-1 and 2, VZV • Patients with active herpes lesions should avoid elective • Ophthalmic, maxillary or mandibular root of the trigeminal dental treatment; it’s easy to spread the virus in the dental nerve setting • Tend to not “jump” roots • Recent studies have shown taking antiviral medicine before • Can be in more than one root certain dental procedures can help decrease recurrent HSV outbreaks. • The first time children are infected, they may have a fever, a • sore mouth, and red and inflamed . has been reported as triggering event. • • Adults who are infected for the first time may exhibit a sore In surgical procedures involving the trigeminal nerve root, throat or tonsillitis and occasionally some sores in the mouth. HSV reactivation occurs in up to 50 % of the patients (Haydeir LE)

Recurrent (RHL)—16-38% of the population The “herpes family”… • HSV-1—herpes labialis/genitalia, Bell’s palsy (VII)—mucous • Patients with a previous history of RHL seem to be at membranes higher risk. It is not clear whether RHL is linked to the • HSV-2—herpes genitalia/labialis—mucous membranes procedure itself, to the anesthetic procedure or both. • VZV—varicella-zoster-virus--airborne • Prophylactic antiviral treatment in RHL patients who • CMV—cytomegalovirus—shed throught epithelial cells are undergoing extractions. Increased awareness of • EBV (Epstein-Barr virus)—MONO--the “kissing” disease—how this potentially severe post-extraction long does EBV live in ? Posterior cervical nodes complication—some patients have been hospitalized • HHV-6—roseola, ?MS for IV acyclovir therapy • HHV-7 • KSHV (HHV-8)—Kaposi’s sarcoma herpes virus (STD)

The antiherpetics—the “cy{i}clovirs” Treating

• Acyclovir (Zovirax) • Acyclovir (Zovirax)(4000/d) • • Famciclovir (Famvir) Famciclovir (Famvir)(750/d) • Valacyclovir (Valtrex)(3000/d) • Valacyclovir (Valtrex) Tx must be started within 48-72 hours after the first • Ganciclovir (Cytovene)– CMV retinitis in HIV signs of a rash appear. patients; CMV pneumonitis in transplant • +Prednisone patients PREVENTION--Zostavax

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What is the hardest thing to Say “ah”…what are we looking for? swallow?… • Soft and uvula • Relationship of the pharyngeal musculature • Clear fluids such as water with CN IX (Glossopharyngeal) and X (Vagus) • Stroke patients • Ya’ can’t size it, ya’ can’t shape it… • Swallowing (brainstem {bulbar} vs. hemispheric stroke)(25-50%)(swallowing center is in the brainstem • Post polio syndrome—bulbar muscle dysfunction—25-30 years after

Back to CN IX and X Causes of nasal speech

• The gag reflex • Cleft palate (folic acid) • CN IX and X close off the nasopharynx • Guillain-Barré Syndrome (GBS)—what is the • Head injured patients (and surgical) lose their gag #1 cause of GBS in U.S. today? reflex and have a high risk of aspiration pneumonia • Lou Gehrig’s (ALS) disease • Open your mouth and pant like a dog • “K, K, K, K, K” • Glossopharyngeal nerve palsy (viral) • uvula midline (if deviated, it points toward the good • ACE inhibitors—”does my voice sound funny side—tug of war) to you?”

Who are the ACE inhibitors? Some notes on tongues…

• Captopril (Capoten) • Hypothyroidism and fluid retention—teeth • Enalapril (Vasotec) indentations • Lisinopril (Prinivil, Zestril) • Perindopril (Aceon) • Down syndrome (high risk of child abuse—be • Moxepril (Univasc) on the lookout) • Benazepril (Lotensin) • Amyloidosis • Quinapril (Accupril) • Sarcoidosis • Trandolapril (Mavik) • Ramipril (Altace) • halitosis

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Tardive dyskinesia and anti-psychotic Halitosis meds • Tongue thrusting • 600 species of bacteria—thrive on remnants • Haloperidol (Haldol), Thorazine of meals, dead squamous cells, and mucus • Higher doses of risperidone (Risperdal) from post-nasal drip • Tardive dyskinesia was described in the late 19th • Survive by snipping off pieces of sugar on century, over 50 years before the discovery of the glycoproteins, leaving the protein fragment first antipsychotic med; approximately 40% of • Other bacteria breakdown the proteins into schizophrenics will develop TD in the absence of amino acids and eventually foul-smelling treatment (Fenton) hydrogen sulfide and methyl mercaptan compounds

Halitosis Halitosis

• Foul-smelling nitrogen containing compounds • Provide a sticky oily substance bacteria can adhere to—Dentyl are also formed with nasty names like skatole pH, marketed by Blistex and indole—both of which smell like the most • Gargle with the tongue sticking out, allowing the mouthwash distal portion of the GI tract – the rectum to reach the back of the tongue • Don’t use mouthwash right after brushing; • Other nitrogenous gases—putrecine (decay) contains a foaming soap, which takes some of mouthwash’s and cadaverine (corpses) effective ingredients out of commission by binding to them • the back of the tongue and the crevices • Use mouthwash before bedtime; eat a good breakfast with between the teeth are the usual dining areas rough foods for bacteria • Clean your tongue; floss every day (Fisher R)

Salivary glands—parotid, sublingual, submandibular Acetylcholine • Saliva as innate defense, taste • Acetylcholine innervates the salivary glands to • sublingual drugs—you need saliva to absorb produce saliva sublingual drugs; NTG under the tongue to • Anti-cholinergic drugs stop the flow of saliva— vasodilate the coronary arteries in patients dry mouth with anginal chest pain • Cannot absorb drugs under the tongue • Calcium channel blockers sublingually for esophageal spasms • Triptans on the tongue for migraine headaches

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A list of anti-cholinergic drugs—the usual suspects and some surprises… More anticholinergic drugs

• Amitryptyline (Elavil) • Paroxetine (Paxil) • Hyoscyamine (Anaspaz, Atropine) • Codeine • Doxepin (Sinequan) • Oxycodone • oxybutynin (Ditropan) • Diphenhydramine (Benadryl) • Meclizine (Antivert) • Fexofenadine (Allegra) • Theophylline • Hydroxyzine (Atarax) • Captopril (Capoten), nifedipine (Procardia) • Prednisolone • trifluoperazine (Stelazine) • dig, dipyridamole (Persantine) • Loratadine (Claritin) • warfarin • dicyclomine (Bentyl) • Furosemide (Lasix) • Cimetidine (Tagamet), ranitidine (Zantac) • isosorbide dinitrate (Isordil)

Xerostomia Sjögren’s syndrome

• is primary cause of gum disease and • Xerostomia and xerophthalmia (dry eyes) tooth loss in 3 out of every 10 adults; decreased • Takes an average of 6.5 years to diagnose SS; oral pH and significant increase risk of plaque and 90% are women, usually between 20 and 40; dental caries • Autoimmune disease that overlaps with • is one of the most common oral symptoms of lupus, rheumatoid arthritis, infections seen in association with xerostomia MCTD; • 20% of elderly w/ xerostomia; primary cause is drugs • Salivary flow studies, tear production studies • Sarcoidosis, amyloidosis, and Sjögren’s syndrome

Symptoms of Sjögren’s syndrome Saliva replacement

Vary from person to person but may include: • Sjogren’s, head and neck radiation for malignancy, drugs • a dry, gritty or burning sensation in the eyes • Artificial saliva? • dry mouth, a sore or cracked tongue, dry or burning throat; • stimulate acetylcholine (but only if the salivary glands have drinking water to swallow food the potential to function— 5mg QID; cevimeline (Evoxac) • dry or peeling • Saliva substitutes—Entertainer’s Secret (spray), Glandosane • difficulty talking, chewing or swallowing , digestive problems; (spray), Moi-stir (spray and swab sticks)…and more… a change in taste or smell, dry nose • increased dental decay • American Dental Association. The public: Oral health topics: • joint pain Dry mouth. [www document] (September 12, 2000). • vaginal and skin dryness Available from URL: www.ada.org/public/topics/drymouth.html. • fatigue

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Excessive saliva in patients with Speaking of saliva… Parkinson’s disease • Patients with Parkinson’s disease have • How much saliva do you make a day? unopposed acetylcholine (due to dopamine deficiency) resulting in excess saliva about 1½ liters of saliva per day production • How many times do you swallow in • PD is also a cause of oropharyngeal dysphagia an hour? (70/200/10)—per hour/meal/sleep • Swallowing is something we take for granted…

Salivary glands—parotid gland and the Gums and mucous membranes • Why would you see the mumps in the year • One of first signs of iron deficiency anemia is 2010? pallor, manifested in the gums and mucous • Failure to vaccinate due to unwarranted fear membranes of vaccines • Other oral signs include and angular • Is this dangerous for little boys? YES, the mumps virus LOVES the testicles… • Hair loss • Mumps orchitis • Pica for ice • Causes of iron deficiency anemia

Iron deficiency anemia Peritonsillar abscesses…

• Dietary deficiency—kids need iron to grow vertically • Say ahhhhh… not horizontally* • Can you say “ouch”? • Too much cow’s milk (causes loss of blood in GI • Can you say “I have a sore throat, and I can’t swallow…” tract); tea or coffee (tannins) inhibit iron absorption • Tripod position and • Celiac disease in kids (ask mom’s about growth) • Group A beta hemolytic strep—new strains • Peritonsillar abscesses • Need iron to grow a baby…pregnancy • Oral prednisone for the pain • All other causes? GI bleeding and other bleeds

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If untreated…increased risk of:

• Endocarditis, myocarditis—rheumatic heart disease • Mitral valve • Aortic valve • #1 cause of valve replacements under the age of 60 is RHD damage to valves

J Am Dent Assoc, Vol 138, No 6, 739-760.© 2007

Can you “catch” any bugs having oral Human papilloma virus sex? Ohhhhhh yeah… • Gonorrhea is easy to transmit to the back of • So, you think oral sex is “less risky” than the throat usual method? People who perform oral sex • The good news, syphilis is NOT on more than five partners in their lifetime • The bad news, the oncogenic virus, HPV, have a 250 percent higher risk of developing human papilloma virus is easily transmitted throat cancer. Pharyngeal infections with HPV via any mucous membrane surface(30 increase the risk of throat cancer by 32-fold. different types invade mucous membranes) (N Engl J Med, May 6, 2007) • But oral sex is NOT sex, right BILL??

The HPV vaccine The HPV vaccine

• Gardasil to prevent cervical cancer (HPV 16, • Vaccinate girls between 9 and 26; has also 18) and genital (HPV-6 and11)—cervical been approved for boys, same age.. cancer is the number 2 cause of death in • Is it 100% effective? HPV naïve, yes; already + women worldwide (273,000 women died HPV with above types? Not effective… worldwide, 6500 in U.S. in 2002) • Why should I have my daughter get the HPV • By the way—roughly three quarters of U.S. vaccine? She tells me… adults have had at least one HPV infection

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Can Gardasil prevent other cancers caused by HPV? Sublingual Jaundice • Approved to prevent cancer of the cervix • The “yellow jaundice” of hepatitis • • Other cancers caused by HPV-16, 18 Where do you turn “yellow” first with hepatitis? • of the rectum (MSM • The sclera of the eyeball? + heterosexuals) • Nope… • Squamous cell carcinoma of the vagina • SUBLINGUAL • Of course not all patients with hepatitis become jaundiced

So who’s sitting in your waiting room with a high risk of hepatitis? High risk groups—hepatitis A • Hepatitis A, B, C (which was called non-A, non-B • Hepatitis A—fecal oral transmission, before it was characterized in 1989) • Sporadic outbreaks in U.S. from food sources (think • Hepatitis D (delta) accompanies B in some cases Chi-Chi’s Restaurants salad bars in Pittsburgh, PA • Hepatitis E is rare (2004)and the contaminated scallions from Mexico • They skipped the F letter • Daycare—sharing of bodily fluids • And, there’s a hepatitis G • Kids are vaccinated these days with 2 vaccines • However, for the sake of this lecture, A, B, and C are • Adults traveling to far away places with strange- priorities sounding names—need to vaccinate before traveling

Hepatitis A—high risk groups Hepatitis B

• “Employees of this restaurant must wash their • Hepatitis B—risk factors hands after using the washroom…” • Vertical transmission from Mom to child • Sexually transmitted • IV drug use—sharing needles • Blood transfusions

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Hepatitis C virus--1989 Hepatitis C high risk factors

IDENTIFY HIGH RISK GROUPS—primary factors • HCW after a needle stick injury or mucosal exposure • IV drug user (even 1 time experimental drug use) to HCV-positive blood • Persons with conditions associated with high • Current sexual partners of HCV-infected persons prevalence of HCV—HIV (HCV is more aggressive in (prevalence is low, but a negative test provides the context of HIV co-infection) reassurance) • Blood transfusions prior to July1992 —or organ • Persons with unexplained ALT elevations, transplant recipients documented to be elevated for at least 6 months • (the 3 most common diagnoses for mildly elevated Persons who have ever received hemodialysis ALT levels are chronic hepatitis C, alcoholic liver • Hemophiliacs who received clotting factor disease, and nonalcoholic fatty liver disease) concentrates prior to 1987 • Children born to HCV-infected moms (screen at age 1 or older)

Hepatitis C virus—secondary risk factors—the need for screening is uncertain The popularity of tattoos today…

• Sexual transmission with multiple partners—what does • Out there… multiple mean? • Intranasal use • Everywhere… • Tattoos (prison applied?) • Showin’ them off • Piercings • Receipt of injection in a developing world • Endoscopy clinics in Nevada (reuse of needles and syringes); other outbreaks in U.S. due to reuse of medical devices without proper sterilization) • (Parkinson E. What now? Responding to relapse in Hepatitis C. Advance for NPs 2007 (December);49-51)

Let’s go back to the tonsils for a moment, Tongue piercing shall we? • Tongue—4 weeks to heal • Waldeyer’s ring—adenoids and tonsils • chipped and fractured teeth, separation of the (lymphatic tissue) front two teeth, gum trauma, infection, • Kids with big inflammed tonsils and adenoids hemorrhage and even brain abscess. have sleep problems including sleep apnea • Lips—2 to 3 months to heal • Growth hormone is produced at night—sleep deprivation and growth • Sleep apnea? Behavior disorders? ADHD?

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GERD (gastroesophageal reflux disease) Other causes of GERD

• ACID is the bad guy • Obesity/pregnancy (48-79% w/ daily sx) • The lower esophageal sphincter pressure is maintained by DA/ACH • With GERD--decreased pressure in the lower esophageal sphincter due to drugs, nicotine, alcohol, fatty foods, increased pressure in stomach (late evening meal) • So, how about a pizza, cold beer and a cigarette before bedtime? • What drugs? Bronchodilators, NTG, Viagra and other ED drugs

What are non-drug ways to reduce GERD? Pharmacology of GERD

• Dietary changes? • H2 blockers—over-the-counter • A meta-analysis in the Archives of Internal Medicine • Tagamet (cimetidine)**, Zantac (ranitidine), revealed support for 2 measures: Pepcid (famotidine) • Weight loss and head-of-bed elevation • PPIs (Proton Pump Inhibitors)—the “prazoles” • Avoiding tobacco, alcohol, high-fat foods, and carbonated beverages was NOT shown to alleviate • Omeprazole (Prilosec), lansoprazole symptoms of GERD—even tho’ there is substantial (Prevacid), pantoprazole (Protonix), evidence that consumption of these substances has rabeprazole (Aciphex), and “the purple pill”— an adverse impact on GERD esomeprazole (Nexium)** • Everyone has different “GERD” triggers

The “prazoles”—Proton Pump Inhibitors The “prazoles” • Work within 4-7 days to reduce all acid in the stomach; take 30’-60’ before the first meal of the day or before • MOA—Inhibition of the proton pump at the lumenal the dinner meal (especially if nocturnal GERD is a surface of the stomach…especially after a meal problem) • Blocking acid production also decreases the release of PPIs work here H+, Intrinsic Factor-B12 intrinsic factor which is necessary for binding B12 Lumenal surface • Do you need B12? YES. • Do you need acid to digest food? NO • Parietal cell Do you need acid to zap food-borne pathogens? YES • Do you need acid to absorb calcium? YES (use calcium Basilar surface citrate for low acid conditions—elderly and PPI use)

H2 receptors H2 H2 blockers work here—especially at night

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B12 is essential for maintaining the health of Has your patient been on the “prazoles” the nervous system and RBCs for longer than 5 years? • Check B12 levels in your patients… • Hematologic—lack of B12 resulsts in • The parietal cell that pumps acid also pumps out intrinsic factor (IF) megaloblastic anemia (big, immature RBCs)— • Intrinsic Factor is necessary for the absorption of B12 from MCV is greater than 120 fl; also known as a food macrocytic anemia • If you stop pumping the acid into the stomach, you also stop pumping intrinsic factor for B12 absorption • Neurologic—Cognitive dysfunction; Spinal • Combine that with a decreased absorption of B12 over the cord dysfunction; peripheral neuropathy age of 50 and you may have a B12 deficiency; • May also be caused by an autoimmune disease with • The number 1 nutritional cause of dementia is antibodies against IF (pernicious anemia)+ other autoimmune B12 deficiency—is it reversible? Yes. diseases • How can you supplement with B12?

Why are we so adamant about treating GERD? B12 supplementation To prevent Barrett’s esophagus • Pill • Complication of acid reflux (GERD) • Sublingual • Metaplasia of the lower third of the • Nasal esophagus • Injection • What is metaplasia? The substitution of one adult cell for another adult cell • Need 6 mcg per day; take 1000 mcg by • Usually a protective mechanism mouth/sublingual/nasal daily (1% via passive diffusion in stomach if you take B12 by mouth) • Gastric epithelial cells have replaced • 1000 mcg/month via injection squamous epithelial cells of the esophagus • Do not take over 3,000 mcg per day…the one dreaded side effect is:

What do we know about Barrett’s What do we know about Barrett’s esophagus? esophagus? • Patients with at least weekly symptoms of • Does ultra-aggressive anti-secretory therapy GERD—3-15% are found to have Barrett’s have anti-proliferative effects on intestinal • Caucasian males greater than 55; 10:1 ratio metaplasia? Recent studies say yes…higher males to females than conventional PPI doses • Increasingly high risk of of • BID dosing if QD doesn’t relieve symptoms of the esophagus (10% in 1960; 50% in 2005)— GERD • 30x greater risk of adenocarcinoma w/ • Add H2 blocker at HS—double the OTC dose Barrett’s (Zantac 150 po at bedtime)

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Major causes of cirrhosis of the liver today Portal hypertension are… • Portal pressure must exceed 12 mmHg to • Hepatitis C result in variceal development • Hepatitis B • Usually greater than 20 mmHg to bleed • Alcohol (fatty liver) • Diabetes (fatty liver) • Obesity (fatty liver) • NASH (Non-alcoholic steato-hepatitis) • NAFLD (Non-alcoholic fatty liver disease)

The stomach Gastric acid

• “Whoever said the way to a man’s heart is • At maximal secretory rates, the stomach intraluminal concentration of hydrogen ion (acid) is through his stomach flunked geography…” 3 million times greater than that of the blood and --anonymous tissues • Acid reflux and the teeth (bulimia patients)(GERD) • Aspiration of gastric contents into the lungs (aspiration pneumonia) – 50% mortality rate

Mucosal protective barrier of the Peptic ulcer disease stomach The mucosal barrier of the stomach protects the • Usually solitary lesions less than 4 cm in diameter; gastric mucosa from autodigestion and is created duodenum, first portion of stomach—the antrum by: • GE junction, in the setting of GERD 1) mucus secretion via prostaglandin production • 4 million people have peptic ulcers; 350,000 new 2) mucosal blood flow via prostaglandin production cases per year, 100,000 hospitalized, 3000 die 3) bicarbonate secretion to buffer the acid, and the • Male/female for duodenal = 3:1; male/female for 4) epithelial barrier gastric = 1.5 to 2:1 Truly a physiological marvel, or gastric walls would suffer the same fate as a T-bone steak

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The other 30% of gastric ulcers are caused Cause of peptic ulcer disease by NSAIDS • Imbalance between the gastroduodenal • Celecoxib (Celebrex) – 1.4 RR mucosal defense mechanisms and the • Ibuprofen (Motrin, Advil)—2.1 RR damaging forces—gastric acid and the hormone pepsin • Diclofenac ( Cataflam, Voltaren) – 4.0 RR • Hyperacidity is NOT a prerequisite • Meloxicam ( Mobic) – 4.2 RR • • H. pylori is present in 100% of duodenal Indomethacin (Indocin)—5.4 RR ulcers and about 70% of patients with gastric • Naproxen (Aleve) and ketoprofen—5.6 RR ulcers • Piroxicam ( Feldene) – 9.9 RR • Ketorolac (Toradol) – 14.5 RR (González)

The small bowel—duodenum (12 Helicobacter pylori fingerbreadths), jejunum, ileum • Helicobacter pylori—the most common infection worldwide • Elaborates urease and produces ammonia which buffers gastric acid in the immediate vicinity • Gastric ulcers • Chronic inflammation (gastritis) and regeneration of the antrum • The only bacteria known to be “oncogenic” • Is it normal flora? • How do you “catch” it? • How do you treat it? Antibiotics

The duodenum—the organ of nausea Celiac disease

st nd • 5-HT3 (5-hydroxytryptamine)(serotonin) • 1 in 250 in U.S.; greater prevalence in 1 and 2 degree relatives; ?duration of breast feeding; age at receptors which a person ingests gluten; cigarette smoking • Serotonin release causes nausea--Makes ya’ • Autoimmune—HLA-DQ2; HLA-DQ8 sick to your duodenum—chemo, anesthesia, • Ingested gluten crosslinks with tissue morning sickness transglutaminase released in the lamina propria and epithelium of the intestine • 3 5-HT blockers--The “setrons”—ondansetron • Damage to the villi of the small intestine is mediated (Zofran), granisetron (Kytril), dolasetron by the immune system (Anzemet); palonesetron (Aloxi)

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Celiac disease Celiac disease

• Classic symptomatic presentation characterized by • Absorption problems result in anemias—iron diarrhea, abdominal pain, weight loss, flatulence, and nutritional deficiencies deficiency (growth problems in kids); folate • Asymptomatic presentation characterized by gait deficiency; calcium absorption problems ataxia, seizures, peripheral neuropathy, aphthous (osteopenia) , arthritis • Always check for osteopenia and osteoporosis • Geriatric celiac disease—1 in 4 patients diagnosed in your long-term patients with celiac disease! with celiac disease is 60 or older; fatigue, bone pain, pyrexia, arthralgia • May result in tooth loss in long-term patients

Gastroenteritis…

• Umbilicus (belly button)—embryologic origins • CLASSIC acute appendicitis presents initially with colon (Homer and Dr. Colón) with peri-umbilical pain and subsequently • Peri-umbilical pain localizes to the right lower quadrant (RLQ) • Causes of gastroenteritis—food poisoning, viral infections, bacterial infections

Salmonella in raw or undercooked eggs Food-borne illness and gastroenteritis and chicken • Pasteurized eggs for “seizure” salad (Caesar salad), eggnog, and guacamole • Salmonella in chicken • No more sunny-side up, especially for high-risk patients (unless the eggs are pasteurized)

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Campylobacter pylori Cook your chicken

• Undercooked chicken and turkey • 180º whole chicken • Causes 40% of Guillain-Barré syndrome • 170º white meat • 180º dark meat

E. Coli 0157:H7—the “burger” bug Other food-borne agents

• 3rd most deadly toxin in the world • Noroviruses on cruise ships—”shuking” • 10-100 pathogens to make you ill or kill you • Oysters and Vibrio cholera spp. • Very young, very old, very immunocompromised • Acute Renal Failure in Kids—hemolytic uremic • Listeria monocytogenes in hot dogs, bologna, syndrome deli meats, soft cheeses (feta, brie) • Swimming pools, petting zoos • Salmon sushi • Mickey D’s—30 outbreaks per year • Supportive Treatment • Prevent—cook burgers to 160º F

Crohn’s disease Movin’ right along …to the large bowel

• Inflammatory bowel disease anywhere throughout GI tract—?triggered by endogenous bacteria? • • Mycobacterium avian paratuberculosis (MAP) What are the functions of the large bowel? • RX with AB? • Autoimmune response • Inflammation via TNF-alpha • Drugs that block TNF-alpha include infliximab (Remicade), adalimumab (Humira), golimumab (Simponi), etanercept (Enbrel)

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Functions of the large bowel Functions of the large bowel

• Defense against pathogenic bacteria—normal flora • Net absorption of water and salts/net 1) Antibiotic associated diarrhea—C. difficile—What’s secretion of K+; new? A lot…spores and hand washing; new strain— very toxic; which antibiotics? PPIs? Stool transplants • diarrhea and potassium depletion; kayexelate for refractory diarrhea from C. diff to get rid of excess K+ • Production of Vitamin K • Movement and storage of feces/elimination • Opiates and peristalsis—codeine, lomotil, etc. • acetylcholine (nicotine) and peristalsis • prunes and peristalsis

Constipation Constipation

• “If you need time to think, ask older patients • Normal number of bowel movements? to describe their bowel habits…” • 3 per day to 3 per week or fewer than seven bowel movements over a 2-week period with no • --Clifton Meador, M.D. medication usage as a precipitating cause • Causes—drugs (anti-cholinergic agents, opiates including codeine, morphine, meperidine; the “neglect of the call to stool”; laxative abuse over the years; decreased physical activity (?) • Treatment?

Colon cancer Genetics

• Who’s yo’ daddy? • The numbers • When should you start screening family • Gender differences members with a history of early-onset cancer? • Risk factors? • Dad with colon cancer at diagnosed at 42?

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Ulcerative colitis—inflammatory bowel Colon Cancer disease • Risk for colon cancer • Get it in and get it out! • Dysplasia (distortion of the normal orientation • GI transit time…less than 72 hours and architecture of cells)—low-grade • dysplasia vs. high-grade dysplasia and How can you tell? Eat corn tonight… ulcerative colitis • Floaters vs. sinkers

Don’t forget your colonoscopies! Every 10 Fecal occult blood tests (FOBT) or fecal years after 50 immunochemical tests (FIT) annually after 50 PLUS… • Or sigmoidoscopy every 5 years • A change in bowel habits

Rectal exams…are these really necessary for rectal cancer diagnosis? NO, prostate, YES

• Comments from patients during rectal exams: (Dr. • Rectal foreign objects James Ralph) • “How long have you been in politics?” • HPV and rectal warts • “Could you write me a note for my wife, • Herpes saying that my head is not, in fact, up • Other STIs there?” • Rectal cancer—squamous carcinoma of the rectum (HPV)

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Word to the wise… The end.

• Barb Bancroft, RN, MSN, PNP • CPP Associates, Inc. • www.barbbancroft.com

• [email protected]

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