Gastrointestinal Tract Problems

Gastrointestinal Tract Problems

 

 

Mouth ulcers

Mouth ulcers are extremely common, affecting as many as one in five
of the population and they are a recurrent problem in some people.
They are classified as aphthous (minor or major) or herpetiform
ulcers. Most cases (more than three quarters) are minor aphthous
ulcers, which are self-limiting. Ulcers may be due to a variety of causes
including infection, trauma and drug allergy. However, occasionally
mouth ulcers appear as a symptom of serious disease such as carcinoma.
The pharmacist should be aware of the signs and characteristics

that indicate more serious conditions.

Patients may describe a history of recurrent ulceration, which began in
childhood and has continued ever since. Minor aphthous ulcers are
more common in women and occur most often between the ages of 10 and 40

Nature of the ulcers

Minor aphthous ulcers usually occur in crops of one to five. The
lesions may be up to 5mm in diameter and appear as a white or
yellowish centre with an inflamed red outer edge. Common sites are
the tongue margin and inside the lips and cheeks. The ulcers tend to last from 5 to 14 days

Other types of recurrent mouth ulcer include major aphthous and
herpetiform. Major aphthous ulcers are uncommon, severe variants of
the minor ones. The ulcers, which may be as large as 30mm in
diameter, can occur in crops of up to ten. Sites involved are the lips,
cheeks, tongue, pharynx and palate. They are more common in sufferers
of ulcerative colitis.
Herpetiform ulcers are more numerous, smaller and, in addition to
the sites involved with aphthous ulcers, may affect the floor of the
mouth and the gums. Table 1 summarises the features of the three
main types of aphthous ulcers.
Systemic conditions such as Behc¸et’s syndrome and erythema
multiforme may produce mouth ulcers, but other symptoms would
generally be present

Duration

Minor aphthous ulcers usually heal in less than 1 week; major
aphthous ulcers take longer (10–30 days). Where herpetiform ulcers
occur, fresh crops of ulcers tend to appear before the original crop
has healed, which may lead patients to think that the ulceration is
continuous.

Oral cancer

Any mouth ulcer that has persisted for longer than 3 weeks
requires immediate referral to the dentist or doctor because an ulcer

of such long duration may indicate serious pathology such as

carcinoma. Most oral cancers are squamous cell carcinomas, of which
one in three affects the lip and one in four affects the tongue. The
development of a cancer may be preceded by a premalignant lesion,
including erythroplasia (red) and leucoplakia (white), or a speckled
leucoplakia. Squamous cell carcinoma may present as a single ulcer
with a raised and indurated (firm or hardened) border. Common
locations include the lateral border of the tongue, lips, floor of the
mouth and gingiva. The key point to raise suspicion would be a lesion
that had lasted for several weeks or longer. Oral cancer is more common in smokers than non-smokers

Medication

The pharmacist should establish the identity of any current medication,
since mouth ulcers may be produced as a side-effect of drug
therapy. Drugs that have been reported to cause the problem include

aspirin

and other NSAIDs, cytotoxic drugs and sulfasalazine (sulphasalazine).
Radiotherapy may also induce mouth ulcers. It is worth
asking about herbal medicines because feverfew (used for migraine)
can cause mouth ulcers.
It would also be useful to ask the patient about any treatments tried
either previously or on this occasion and the degree of relief obtained.
The pharmacist can then recommend an alternative product where
appropriate.

If there is no improvement after 1 week, the patient should see the doctor

Symptomatic treatment of minor aphthous ulcers can be recommended
by the pharmacist, and can relieve pain and reduce healing
time. Active ingredients include antiseptics, corticosteroids and local
anaesthetics. There is evidence from clinical trials to support use of
topical corticosteroids and

chlorhexidine mouthwash. Gels and
liquids may be more accurately applied using a cotton bud or cotton
wool, providing the ulcer is readily accessible. Mouthwashes can be
useful where ulcers are difficult to reach.

Chlorhexidine gluconate mouthwash

There is some evidence that

chlorhexidine mouthwash reduces duration
and severity of ulceration. The rationale for the use of antibacterial
agents in the treatment of mouth ulcers is that secondary
bacterial infection frequently occurs. Such infection can increase discomfort
and delay healing. Chlorhexidine helps to prevent secondary
bacterial infection but it does not prevent recurrence. It has a bitter
taste and is available in peppermint as well as standard flavour.
Regular use can stain teeth brown – an effect that is not usually
permanent. Advising the patient to brush the teeth before using the
mouthwash can reduce staining. The mouth should then be well rinsed
with water as chlorhexidine can be inactivated by some toothpaste
ingredients. The mouthwash should be used twice a day, rinsing 10 ml
in the mouth for 1 minute.

Topical corticosteroids

Hydrocortisone

and triamcinolone act locally on the ulcer to reduce
inflammation and pain, and to shorten healing time. The former is
available as pellets, the latter in a protective paste. To exert its effect, a
pellet must be held in close proximity to the ulcer until dissolved. This
can be difficult when the ulcer is in an inaccessible spot. One pellet is
used four times a day. The pharmacist should explain that the pellets
should not be sucked, but dissolved in contact with the ulcer. These
treatments are best used as early as possible. Before an ulcer appears,
the affected area feels sensitive and tingling – the prodromal phase –
and treatment should start then. They should be applied 3–4 times
daily. They have no effect on recurrence but should be restarted at the

first signs of a new outbreak.

Local analgesics

Benzydamine mouthwash

or spray and choline salicylate dental gel

are short-acting but can be useful in very painful major ulcers. The
mouthwash is used by rinsing 15 ml in the mouth three times a day.
Numbness, tingling and stinging can occur with

benzydamine.
Diluting the mouthwash with the same amount of water before use
can reduce stinging. The mouthwash is not licensed for use in children
under 12. Benzydamine spray is used as four sprays onto the affected
area three times a day. Although aspirin is no longer recommended for
children under 16 years because of possible links with Reye’s syndrome,

choline salicylate dental gel

produces low levels of salicylate
and can therefore be used in children.

Carbenoxolone

Available as gel and mouthwash,

carbenoxolone was shown in one
small study to relieve pain and reduce healing time.

Local anaesthetics (e.g. lidocaine (lignocaine), benzocaine)

Local anaesthetic gels are often requested by patients. Although they
are effective in producing temporary pain relief, maintenance of gels
and liquids in contact with the ulcer surface is difficult. Reapplication
of the preparation may be done when necessary. Tablets and pastilles
can be kept in contact with the ulcer by the tongue and can be of value
when just one or two ulcers are present. Any preparation containing a
local anaesthetic becomes difficult to use when the lesions are located
in inaccessible parts of the mouth.
Both

lidocaine and benzocaine have been reported to produce sensitisation,
but cross-sensitivity seems to be rare, probably because the
two agents are from different chemical groupings. Thus, if a patient
has experienced a reaction to one agent in the past, the alternative