Chapter 6 The gastrointestinal system
The gastrointestinal history
Presenting symptoms (Table 6.1)
Abdominal pain
Major symptoms |
Frequency and duration
Try to determine whether the pain is acute or chronic, when it began and how often it occurs.
Aggravating and relieving factors
Pain due to peptic ulceration may or may not be related to meals. Eating may precipitate ischaemic pain in the gut. Antacids or vomiting may relieve peptic ulcer pain or that of gastro-oesophageal reflux. Defaecation or passage of flatus may relieve the pain of colonic disease temporarily. Patients who get some relief by rolling around vigorously are more likely to have a colicky pain, while those who lie perfectly still are more likely to have peritonitis.
Heartburn and acid regurgitation
Heartburn refers to the presence of a burning pain or discomfort in the retrosternal area. Typically, this sensation travels up towards the throat and occurs after meals or is aggravated by bending, stooping or lying supine. Antacids usually relieve the pain, at least transiently. This symptom is due to regurgitation of stomach contents into the oesophagus. Usually these contents are acidic, although occasionally alkaline reflux can induce similar problems. Associated with gastro-oesophageal reflux may be acid regurgitation, in which the patient experiences a sour or bitter-tasting fluid coming up into the mouth. This symptom strongly suggests that reflux is occurring. Some patients complain of a cough that troubles them when they lie down. In patients with gastro
Questions to ask a patient presenting with recurrent vomiting
denotes symptoms for the possible diagnosis of an urgent or dangerous problem.
oesophageal reflux disease, the lower oesophageal sphincter muscle relaxes inappropriately. Reflux symptoms may be aggravated by alcohol, chocolate, caffeine, a fatty meal, theophylline, calcium channel blockers and anticholinergic drugs, as these lower the oesophageal sphincter pressure.
Dysphagia
Dysphagia is difficulty in swallowing. Such difficulty may occur with solids or liquids. The causes of dysphagia are listed in Table 6.2. If a patient complains of difficulty swallowing, it is important to differentiate painful swallowing from actual difficulty.1 Painful swallowing is termed odynophagia and occurs with any severe inflammatory process involving the oesophagus. Causes include infectious oesophagitis (e.g. Candida, herpes simplex), peptic ulceration of the
Mechanical obstruction |
Neuromuscular motility disorders (hints from the history: solids and liquids equally difficult, symptoms intermittent) |
Questions to ask the patient with acid reflux or suspected gastro-oesophageal reflux disease (GORD)
! denotes symptoms for the possible diagnosis of an urgent or dangerous problem.
oesophagus, caustic damage to the oesophagus or oesophageal perforation.
If the patient complains of food sticking in the oesophagus, it is important to consider a number of anatomical causes of oesophageal blockage.1 Ask the patient to point to the site where the solids stick. If there is a mechanical obstruction at the lower end of the oesophagus, most often the patient will localise the dysphagia to the lower retrosternal area. However, obstruction higher in the oesophagus may be felt anywhere in the retrosternal area. If heartburn is also present, for example, this suggests that gastro-oesophageal reflux with or without stricture formation may be the cause of the dysphagia. The actual course of the dysphagia is also a very important part of the history to obtain. If the patient states that the dysphagia is intermittent or is present only with the first few swallows of food, this suggests either a lower oesophageal ring or oesophageal spasm. However, if the patient complains of progressive difficulty swallowing, this suggests a stricture, carcinoma or achalasia. If the patient states that both solids and liquids stick, then a motor disorder of the oesophagus is more likely, such as achalasia or diffuse oesophageal spasm.
Diarrhoea
Questions to ask a patient who reports difficulty swallowing
! denotes symptoms for the possible diagnosis of an urgent or dangerous problem.
to an increased interest in defaecation.
Clinically, diarrhoea can be divided into a number of different groups based on the likely disturbance of physiology.2
Questions to ask the patient presenting with diarrhoea
! denotes symptoms for the possible diagnosis of an urgent or dangerous problem.
disappearance with fasting and by large-volume stools related to the ingestion of food. Osmotic diarrhoea occurs due to excessive solute drag; causes include lactose intolerance (disaccharidase deficiency), magnesium antacids or gastric surgery.
Constipation
It is important to determine what patients mean if they say they are constipated.3 Constipation is a common symptom and can refer to the passage of infrequent stools (fewer than three times per week), hard stools or stools that are difficult to evacuate. This symptom may occur acutely or may be a chronic problem. In many patients, chronic constipation arises because of habitual neglect of the impulse to defecate, leading to the accumulation of large, dry faecal masses. With constant rectal distension from faeces, the patient may grow less aware of rectal fullness, leading to chronic constipation. Constipation may arise from ingestion of drugs (e.g. codeine, antidepressants and aluminium or calcium antacids), and with various metabolic or endocrine diseases (e.g. hypothyroidism, hypercalcaemia, diabetes mellitus, phaeochromocytoma, porphyria, hypokalaemia) and neurological disorders (e.g. aganglionosis, Hirschsprung’sb disease, autonomic neuropathy, spinal cord injury, multiple sclerosis). Constipation can also arise after partial colonic obstruction from carcinoma; it is, therefore, very important to determine whether there has been a recent change in bowel habit, as this may indicate development of a malignancy. Patients with very severe constipation in the absence of structural disease may be found on a transit study to have slow colonic transit; such slow-transit constipation is most common in young women.
Constipation is common in the later stages of pregnancy.
A chronic but erratic disturbance in defaecation (typically alternating constipation and diarrhoea) associated with abdominal pain, in the absence of any structural or biochemical abnormality, is very common; such patients are classified as having the irritable bowel syndrome.4 Patients who report abdominal pain plus two or more of the following symptoms—abdominal pain relieved by defaecation, looser or more frequent stools with the onset of abdominal pain, passage of mucus per rectum, a feeling of incomplete emptying of the rectum following defaecation and visible abdominal distension—are more likely to have the irritable bowel syndrome than organic disease.
Bleeding
Patients may present with the problem of haematemesis (vomiting blood), melaena (passage of jet-black stools) or haematochezia (passage of bright-red blood per rectum). Sometimes patients may present because routine testing for occult blood in the stools is positive (page 183). It is important to ensure that if vomiting of blood is reported, this is not the result of bleeding from a tooth socket or the nose, or coughing up of blood.
Haematemesis indicates that the site of the bleeding is proximal to or at the duodenum. Ask about symptoms of peptic ulceration; haematemesis is commonly due to bleeding chronic peptic ulceration, particularly from a duodenal ulcer. Acute peptic ulcers often bleed without abdominal pain. A Mallory-Weiss tear usually occurs with repeated vomiting; typically the patient reports first the vomiting of clear gastric contents and then the vomiting of blood. Less-common causes of upper gastrointestinal bleeding are presented in Table 6.3.
Upper gastrointestinal tract |
Less common 10. Vascular anomalies—angiodysplasia, arteriovenous malformations, blue rubber bleb naevus syndrome, hereditary haemorrhagic telangiectasia, CRST syndrome |
Lower gastrointestinal tract |
Less common |
CRST = calcinosis, Raynaud’s phenomenon, sclerodactyly and telangiectasia.
* George Kenneth Mallory (b. 1900), professor of pathology, Boston, and Soma Weiss (1898–1942), professor of medicine, Boston City Hospital described this syndrome in 1929.
† Georges Dieulafoy (1839–1911), Paris physician.
‡ Edvard Ehlers (1863–1937), German dermatologist, described the syndrome in 1901, and Henri Alexandre Danlos (1844–1912), French dermatologist, described the syndrome in 1908.
§ Pierre Ménétrier (1859–1935), French physician.
# Johann Friedrich Meckel the younger (1781–1833), Professor of Surgery and Anatomy at Halle. His father and grandfather were also professors of anatomy.
Questions to ask a patient presenting with constipation
! denotes symptoms for the possible diagnosis of an urgent or dangerous problem.
Questions to ask the patient who presents with vomiting blood (haematemesis)
! denotes symptoms for the possible diagnosis of an urgent or dangerous problem. !
from the upper gastrointestinal tract, although right-sided colonic and small bowel lesions can occasionally be responsible. Massive rectal bleeding can occur from the distal colon or rectum, or from a major bleeding site higher in the gastrointestinal tract. With substantial lower gastrointestinal tract bleeding, it is important to consider the presence of angiodysplasia or diverticular disease (where bleeding more often occurs from the right rather than the left colon, even though diverticula are more common in the left colon). Less-common causes of lower gastrointestinal bleeding are presented in Table 6.3.
Jaundice
Usually the relatives notice a yellow discoloration of the sclerae or skin before the patient does. Jaundice is due to the presence of excess bilirubin being deposited in the sclerae and skin. The causes of jaundice are described on page 185. If there is jaundice, ask about the colour of the urine and stools; pale stools and dark urine occur with obstructive or cholestatic jaundice because urobilinogen is unable to reach the intestine. Also ask about abdominal pain; gallstones, for example, can cause biliary pain and jaundice.5
Pruritus
This symptom means itching of the skin, and may be either generalised or localised. Cholestatic liver disease can cause pruritus which tends to be worse over the extremities. Other causes of pruritus are discussed on page 445.
Abdominal bloating and swelling
A feeling of swelling (bloating) may be a result of excess gas or a hypersensitive intestinal tract (as occurs in the irritable bowel syndrome). Persistent swelling can be due to ascitic fluid accumulation; this is discussed on page 175. It may be associated with ankle oedema.
Lethargy
Tiredness and easy fatiguability are common symptoms for patients with acute or chronic liver disease, but the mechanism is not known. This can also occur because of anaemia due to gastrointestinal or chronic inflammatory disease. Lethargy is also very common in the general population and is not a specific symptom.
Treatment
Questions to ask the patient presenting with jaundice
! denotes symptoms for the possible diagnosis of an urgent or dangerous problem. !
hypersensitivity reaction to chlorpromazine or other phenothiazines, sulfonamides, sulfonylureas, phenylbutazone, rifampicin or nitrofurantoin. Anabolic steroids and the contraceptive pill can cause dose-related cholestasis. Fatty liver can occur with alcohol use, tetracycline, valproic acid or amiodarone. Large blood-filled cavities in the liver called peliosis hepatis can occur with anabolic steroid use or the contraceptive pill. Acute liver cell necrosis can occur if an overdose of paracetamol (acetaminophen) is taken.
Social history
The alcohol history is very important, particularly as alcoholics often deny or understate the amount they consume (see Table 1.3, page 7).6 Contact with anybody who has been jaundiced should always be noted. The sexual history should be obtained. A history of any injections (e.g. intravenous drugs, plasma transfusions, dental treatment or tattooing) in a patient who presents with symptoms of liver disease is important, particularly as hepatitis B or C may be transferred in this way.
Family history
A family history of colon cancer, especially of familial polyps, or inflammatory bowel disease is important. Ask about coeliac disease in the family. A positive family history of jaundice, anaemia, splenectomy or cholecystectomy may occur in patients with haemolytic anaemia (due to haemoglobin abnormalities or auto-immune disease) or congenital or familial hyperbilirubinaemia.
The gastrointestinal examination
Examination of the gastrointestinal system includes a complete examination of the abdomen. It is also important to search for the peripheral signs of gastrointestinal and liver disease. Some signs are more useful than others.7
Examination anatomy
An understanding of the structure and function of the gastrointestinal tract and abdominal organs is critical for the diagnosis of gastrointestinal disease (Figure 6.1). The mouth is the gateway to the gastrointestinal tract. It and the anus and rectum are readily accessible to the examiner, and both must be examined carefully in any patient with suspected abdominal disease. The position of the abdominal organs can be quite variable, but there are important surface markings which should be kept in mind during the examination.
Figure 6.1 MRI scans of the abdomen
Courtesy M Thomson, National Capital Diagnostic Imaging, Canberra.
Positioning the patient
For the proper examination of the abdomen it is important that the patient be lying flat with the head resting on a single pillow (Figure 6.2). This relaxes the abdominal muscles and facilitates abdominal palpation. Helping the patient into this position affords the opportunity to make a general inspection.
General appearance
Jaundice
The yellow discoloration of the sclerae (conjunctivae) and the skin that results from hyperbilirubinaemia is best observed in natural daylight (page 185). Whatever the underlying cause, the depth of jaundice can be quite variable.
Skin
The gastrointestinal tract and the skin have a common origin from the embryoblast. A number of diseases can present with both skin and gut involvement (Figures 6.3–6.8, Table 6.4).8
Figure 6.3 (above) Glucagonoma: migratory rash involving the groin
From McDonald FS, ed., Mayo Clinic images in internal medicine, with permission. © Mayo Clinic Scientific Press and CRC Press.
Figure 6.4 (right) Dermatitis herpetiformis
From McDonald FS, ed., Mayo Clinic images in internal medicine, with permission. © Mayo Clinic Scientific Press and CRC Press.
Figure 6.5 Peutz-Jeghers syndrome, with discrete brown-black lesions of the lips
Figure (a) from Jones DV et al, in Feldman M et al, Sleisenger & Fordtran’s gastrointestinal disease, 6th edn, Chapter 112. Philadelphia: WB Saunders, 1998, with permission. Figure (b) from McDonald FS, ed., Mayo Clinic images in internal medicine, with permission. © Mayo Clinic Scientific Press and CRC Press.
Figure 6.6 Acanthosis nigricans: (a) axilla; (b) chest wall
From McDonald FS, ed., Mayo Clinic images in internal medicine, with permission. © Mayo Clinic Scientific Press and CRC Press.
Figure 6.7 (right) Hereditary haemorrhagic telangiectasia involving the lips
From McDonald FS, ed., Mayo Clinic images in internal medicine, with permission. © Mayo Clinic Scientific Press and CRC Press.
Pigmentation
Generalised skin pigmentation can result from chronic liver disease, especially in haemochromatosis (due to haemosiderin-stimulating melanocytes, to produce melanin). Malabsorption may result in Addisonian-type pigmentation (‘sunkissed’ pigmentation) of the nipples, palmar creases, pressure areas and mouth (page 311).
Peutz-Jeghersc syndrome
Freckle-like spots (discrete, brown-black lesions) around the mouth and on the buccal mucosa (Figure 6.5) and on the fingers and toes, are associated with hamartomas of the small bowel (50%) and colon (30%), which can present with bleeding or intussusception. In this autosomal dominant condition the incidence of gastrointestinal adenocarcinoma is increased.
Acanthosis nigricans
These are brown-to-black velvety elevations of the epidermis due to confluent papillomas and are usually found in the axillae and nape of the neck (Figure 6.6). Acanthosis nigricans is associated rarely with gastrointestinal carcinoma (particularly stomach) and lymphoma, as well as with acromegaly, diabetes mellitus and other endocrinopathies.
Hereditary haemorrhagic telangiectasia (Rendu-Osler-Weber syndromed)
Multiple small telangiectasia occur in this disease. They are often present on the lips and tongue (Figure 6.7), but may be found anywhere on the skin. When they are present in the gastrointestinal tract they can cause chronic blood loss or even, occasionally, torrential bleeding. An associated arteriovenous malformation in the liver may be present. This is an autosomal dominant condition and is uncommon.
Porphyria cutanea tarda
Fragile vesicles appear on exposed areas of the skin and heal with scarring (Figure 6.8). The urine is dark in this chronic disorder of porphyrin metabolism associated with alcoholism, liver disease and hepatitis C.
Mental state
Assess orientation (page 380). The syndrome of hepatic encephalopathy, due to decompensated advanced cirrhosis (chronic liver failure) or fulminant hepatitis (acute liver failure), is an organic neurological disturbance. The features depend on the aetiology and the precipitating factors (page 188). Patients eventually become stuporous and then comatose. The combination of hepatocellular damage and portosystemic shunting due to disturbed hepatic structure (both extrahepatic and intrahepatic) causes this syndrome. It is probably related to the liver’s failure to remove toxic metabolites from the portal blood. These toxic metabolites may include ammonia, mercaptans, short-chain fatty acids and amines.
The hands
Nails
Leuconychia
When chronic liver or other disease results in hypoalbuminaemia, the nail beds opacify (the abnormality is of the nail bed and not of the nail), often leaving only a rim of pink nail bed at the top of the nail (Terry’s nails;eFigure 6.9). The thumb and index nails are most often involved. The exact mechanism is uncertain. It may be that the explanation is compression of capillary flow by extracellular fluid.
Figure 6.9 Leuconychia—Terry’s nails
From McDonald FS, ed., Mayo Clinic images in internal medicine, with permission. © Mayo Clinic Scientific Press and CRC Press.
The arms
Inspect the upper limbs for bruising. Large bruises (ecchymoses) may be due to clotting abnormalities. Hepatocellular damage can interfere with protein synthesis and therefore the production of all the clotting factors (except factor VIII, which is made elsewhere in the reticuloendothelial system). Obstructive jaundice results in a shortage of bile acids in the intestine, and therefore may reduce absorption of vitamin K (a fat-soluble vitamin), which is essential for the production of clotting factors II (prothrombin), VII, IX and X.
Look for muscle wasting, which is often a late manifestation of malnutrition in alcoholic patients. Alcohol can also cause a proximal myopathy (page 391).
Scratch marks due to severe itch (pruritus) are often prominent in patients with obstructive or cholestatic jaundice. This is commonly the presenting feature of primary biliary cirrhosish before other signs are apparent. The mechanism of pruritus is thought to be retention of an unknown substance normally excreted in the bile, rather than bile salt deposition in the skin as was earlier thought.
Spider naevii (Figure 6.10) consist of a central arteriole from which radiate numerous small vessels which look like spiders’ legs. They range in size from just visible to half a centimetre in diameter. Their usual distribution is in the area drained by the superior vena cava, so they are found on the arms, neck and chest wall. They can occasionally bleed profusely. Pressure applied with a pointed object to the central arteriole causes blanching of the whole lesion. Rapid refilling from the centre to the legs occurs on release of the pressure.
The differential diagnosis of spider naevi includes Campbell de Morganjspots, venous stars and hereditary haemorrhagic telangiectasia. Campbell de Morgan spots are flat or slightly elevated red circular lesions that occur on the abdomen or the front of the chest. They do not blanch on pressure and are very common. Venous stars are 2- to 3-cm lesions that can occur on the dorsum of the feet, legs, back and the lower chest. They are due to elevated venous pressure and are found overlying the main tributary to a large vein. They are not obliterated by pressure. The blood flow is from the periphery to the centre of the lesion, which is the opposite of the flow in the spider naevus. Lesions of hereditary haemorrhagic telangiectasia (page 228) occasionally resemble spider naevi.
Palpate the axillae for lymphadenopathy (page 229). Look in the axillae for acanthosis nigricans.
The face
Eyes
Look first at the sclerae for signs of jaundice (Figure 6.11) or anaemia. Bitot’sk spots are yellow keratinised areas on the sclera (Figure 6.12). They are the result of severe vitamin A deficiency due to malabsorption or malnutrition. Retinal damage and blindness may occur as a later development. Kayser-Fleischer ringsl (Figure 6.13) are brownish green rings occurring at the periphery of the cornea, affecting the upper pole more than the lower. They are due to deposits of excess copper in Descemet’s membranem of the cornea. Slit-lamp examination is often necessary to show them. They are typically found in Wilson’s disease,n a copper storage disease that causes cirrhosis and neurological disturbances. The Kayser-Fleischer rings are usually present by the time neurological signs have appeared. Patients with other cholestatic liver diseases, however, can also have these rings. Iritis may be seen in inflammatory bowel disease (page 191).
Figure 6.12 Bitot spot: focal area of conjunctival xerosis with a foamy appearance
From Mir MA, Atlas of Clinical Diagnosis, 2nd edn. Edinburgh: Saunders, 2003, with permission.
Figure 6.13 Kayser-Fleischer rings
From McDonald FS, ed., Mayo Clinic images in internal medicine, with permission. © Mayo Clinic Scientific Press and CRC Press.
Xanthelasma are yellowish plaques in the subcutaneous tissues in the periorbital region and are due to deposits of lipids (see Figure 4.19, page 57). They may indicate protracted elevation of the serum cholesterol. In patients with cholestasis, an abnormal lipoprotein (lipoprotein X) is found in the plasma and is associated with elevation of the serum cholesterol. Xanthelasma are common in patients with primary biliary cirrhosis.
Periorbital purpura following proctosigmoidoscopy (‘black eye syndrome’) is a characteristic sign of amyloidosis (perhaps related to factor X deficiency) but is exceedingly rare (Figure 6.14).
Salivary glands
Next inspect and palpate the cheeks over the parotid area for parotid enlargement (Table 6.5). Ask the patient to clench the teeth so that the masseter muscle is palpable; the normal parotid gland is impalpable but the enlarged gland is best felt behind the masseter muscle and in front of the ear. Parotidomegaly that is bilateral is associated with alcoholism rather than liver disease per se. It is due to fatty infiltration, perhaps secondary to alcohol toxicity with or without malnutrition. A tender, warm, swollen parotid suggests the diagnosis of parotiditis following an acute illness or surgery. A mixed parotid tumour (a pleomorphic adenoma) is the commonest cause of a lump. Parotid carcinoma may cause a facial nerve palsy (page 343). Feel in the mouth for a parotid calculus, which may be present at the parotid duct orifice (opposite the upper second molar). Mumps also causes acute parotid enlargement which is usually bilateral.
Bilateral 3. Mikulicz* syndrome: bilateral painless enlargement of all three salivary glands. This disease is probably an early stage of Sjögren’s syndrome |
Unilateral 2. Tumour infiltration, which usually causes painless unilateral enlargement and may cause facial nerve palsy |
* Johann von Mikulicz-Radecki (1850–1905), professor of surgery, Breslau. He described this condition in 1892.
Submandibular gland enlargement is most often due to a calculus. This may be palpable bimanually (Figure 6.15). The examiner’s gloved index finger is placed on the floor of the mouth beside the tongue, feeling between it and fingers placed behind the body of the mandible. It may also be enlarged in chronic liver disease.
The mouth
The teeth and breath
The very beginning of the gastrointestinal tract is, like the very end of the tract, accessible to inspection without elaborate equipment.9 Look first briefly at the state of the teeth and note whether they are real or false. False teeth will have to be removed for a complete examination of the mouth. Note whether there is gum hypertrophy (Table 6.6) or pigmentation (Table 6.7). Loose-fitting false teeth may be responsible for ulcers and decayed teeth may be responsible for fetor (bad breath).
1 Phenytoin |
2 Pregnancy |
3 Scurvy (vitamin C deficiency: the gums become spongy, red, bleed easily and are swollen and irregular) |
4 Gingivitis, e.g. from smoking, calculus, plaque, Vincent’s* angina (fusobacterial membranous tonsillitis) |
5 Leukaemia (usually monocytic) |
* Jean Hyacinthe Vincent (1862–1950), professor of forensic medicine and French Army bacteriologist, described this in 1898.
1 Heavy metals: lead or bismuth (blue-black line on the gingival margin), iron (haemochromatosis—blue-grey pigmentation of the hard palate) |
2 Drugs: antimalarials, the oral contraceptive pill (brown or black areas of pigmentation anywhere in the mouth) |
3 Addison’s disease (blotches of dark brown pigment anywhere in the mouth) |
4 Peutz-Jeghers syndrome (lips, buccal mucosa or palate) |
5 Malignant melanoma (raised, painless black lesions anywhere in the mouth) |
Other causes of fetor are listed in Table 6.8. These must be distinguished from fetor hepaticus which is a rather sweet smell of the breath. It is an indication of severe hepatocellular disease and may be due to methylmercaptans. These substances are known to be exhaled in the breath and may be derived from methionine when this amino acid is not demethylated by a diseased liver. Severe fetor hepaticus that fills the patient’s room is a bad sign and indicates a precomatose condition in many cases. The presence of fetor hepaticus in a patient with a coma of unknown cause may be a helpful clue to the diagnosis.
1 Faulty oral hygiene |
2 Fetor hepaticus (a sweet smell) |
3 Ketosis (diabetic ketoacidosis results in excretion of ketones in exhaled air, causing a sickly sweet smell) |
4 Uraemia (fish breath: an ammoniacal odour) |
5 Alcohol (distinctive) |
6 Paraldehyde |
7 Putrid (due to anaerobic chest infections with large amounts of sputum) |
8 Cigarettes |
The tongue
Enlargement of the tongue (macroglossia) may occur in congenital conditions such as Down syndrome (page 314) or in endocrine disease, including acromegaly (page 307). Tumour infiltration (e.g. haemangioma or lymphangioma) or infiltration of the tongue with amyloid material in amyloidosis can also be responsible for macroglossia.
Mouth ulcers
This is an important topic because a number of systemic diseases can present with ulcers in the mouth (Table 6.9). Aphthous ulceration is the commonest type seen (Figure 6.16). This begins as a small painful vesicle on the tongue or mucosal surface of the mouth, which may break down to form a painful, shallow ulcer. These ulcers heal without scarring. The cause is completely unknown. They usually do not indicate any serious underlying systemic disease, but may occur in Crohn’so disease or coeliac disease. HIV infection may be associated with a number of mouth lesions (page 457). Angular stomatitis refers to cracks at the corners of the mouth; causes include deficiencies in vitamin B6, vitamin B12, folate and iron.
Common |
Uncommon Infection: viral—herpes zoster, herpes simplex; bacterial—syphilis (primary chancre, secondary snail track ulcers, mucous patches), tuberculosis |
* Halusi Behçet (1889–1948), Turkish dermatologist. He described the disease in 1937.
† Hans Reiter (1881–1969), Berlin bacteriologist, described this in 1916.
Figure 6.16 Aphthous ulceration
From McDonald FS, ed., Mayo Clinic images in internal medicine, with permission. © Mayo Clinic Scientific Press and CRC Press.