Mucosal ulceration

Signs and Symptoms Abdominal pain, cramps, diarrhea, fever, vomiting, tenesmus, and blood, pus, or mucus in stools. Infections also cause mucosal ulceration, rectal bleeding, drastic dehydration. Serious less frequent complications include sepsis, seizures, convulsions, rectal prolapse, toxic megacolon, intestinal perforation, renal failure, and hemolytic uremic syndrome. 

Methotrexate, an antimetabolite, is indicated for moderate to severe psoriasis. It is particularly beneficial for psoriatic arthritis. It is also indicated for patients refractory to topical or UV therapy. Methotrexate can be administered orally, subcutaneously, or intramuscularly. The starting dose is 7.5 to 15 mg per week, increased incrementally by 2.5 mg every 2 to 4 weeks until response maximal doses are approximately 25 mg/wk. Adverse effects include nausea, vomiting, mucosal ulceration, stomatitis, malaise, headache, macrocytic anemia, and hepatic and pulmonary toxicity. Nausea and macrocytic anemia can be ameliorated by giving oral folic acid 1 to 5 mg/day. Methotrexate should be avoided in patients with active infections and in those with liver disease. It is contraindicated in pregnancy because it is teratogenic. 

The nose is usually the first site of contact in the respiratory tract for many airborne chemicals of environmental and occupational concern. Examples of human nasal effects include loss of olfactory function (e.g., anosmia and hyposmia), atrophy of the nasal mucosa, mucosal ulcers, perforated nasal septum, or sinonasal cancer related to exposure to certain metal dusts and vapors (Sunderman 2001). 

One application per ulcer treatment is usually sufficient. If the ulcer pain returns shortly after rinsing with water, some part of the ulcer was not covered. Then apply a second application to the ulcer immediately until it remains pain-free after rinsing. It is not recommended that more than 1 treatment session be performed on any individual mucosal ulcer. Do not reapply the product to the same lesion after it is free of pain. 

Concurrent leucovorin Trimetrexate must be used with concurrent leucovorin to avoid potentially serious or life-threatening complications, including bone marrow suppression, oral and Gl mucosal ulceration, and renal and hepatic dysfunction. Leucovorin therapy must extend for 72 hours past the last dose of trimetrexate. Inform patients that failure to take the recommended dose and duration of leucovorin can lead to fatal toxicity. Closely monitor patients for the development of serious hematologic adverse reactions. 

Thalidomide is approved for use in the United States for the treatment of cutaneous manifestations of erythema nodosum leprosum, a potentially life-threatening systemic vasculitis that occurs in some patients with leprosy. Although not approved for other indications, thalidomide has also been shown to be very effective in the management of Behget s disease, HIV-related mucosal ulceration (aphthosis), and select cases of lupus erythematosus. 

It is important to differentiate between gastrointestinal irritation and pseudomembranous cohtis. In its most extreme form, the cohtis results in mucosal ulceration and bleeding and infrequently may necessitate colectomy. On rare occasions it has been fatal. 

Inspect the patient s mouth for signs of mucosal ulceration... 

Trimetrexate given without concurrent leucovorin may result in serious or fatal hematologic, hepatic, and/or renal complications, including bone marrow suppression, oral and GI mucosal ulceration, and renal and hepatic dysfunction. 

Nausea and mucosal ulcers are the most common toxicities. Progressive dose-related hepatotoxicity in the form of enzyme elevation occurs frequently, but cirrhosis is rare (< 1%). Liver toxicity is not related to serum methotrexate concentrations, and liver biopsy follow-up is only recommended every 5 years. A rare hypersensitivity-like lung reaction with acute shortness of breath is documented, as are pseudolymphomatous reactions. The incidence of gastrointestinal and liver function test abnormalities can be reduced by the use of leucovorin 24 hours after each weekly dose or by the use of daily folic acid, although this may decrease the efficacy of the methotrexate. This drug is contraindicated in pregnancy. 

Gastrointestinal signs and symptoms of vitamin B12 deficiency occur in 26% of cases. These include sore tongue, stomatitis, mucosal ulceration, appetite loss, flatulence, and constipation or diarrhea. Appetite loss, excess gas, and diarrhea are probably related to the underlying gastric disorder (i.e., gastric atrophy) in pernicious anemia. Gastrointestinal symptoms may occur in the absence of symptomatic anemia or macrocytosis. 

Nathan KI. Development of mucosal ulcerations with lithium carbonate therapy. Am J Psychiatry 1995 152(6) 956-7. 

Brazier WJ, Dhariwal DK, Patton DW, Bishop K. Ecstasy related periodontitis and mucosal ulceration—a case report. Br Dent J 2003 194 197-9. 

Johlin, F.C., Labrecque, D.R., Neil, G.A. Omeprazole heals mucosal ulcers associated with endoscopic injection sclerotherapy. Dig. Dis. Sci. 1992 37 1373-1376... 

Local reactions to subcutaneous infusion of apomorphine in the nose and throat include swelling of the nose and lips, stomatitis, and buccal mucosal ulceration. 

A 13-year-old girl was given 10% hydrogen peroxide as an enema for constipation. She developed severe rectal bleeding, and colonoscopy showed mucosal ulceration up to the splenic flexure. Histology confirmed ulceration due to traumatic bums. She improved gradually on conservative treatment, and 2 months later a repeat colonoscopy was normal. 

A 61-year-old woman inadvertently took a high dose of methotrexate (10 mg/day) for psoriasis, and developed mucosal ulcers after 3 months. One month later, methotrexate (20 mg/week) was restarted, but she developed... 

Mitomycin when administered intravesicaUy causes cystitis of variable severity, which can lead to mucosal ulceration in the worst cases. However, there has also been a report of bladder fibrosis and loss of frmction in a 74-year-old man who had received 20 mg/week for 8 weeks (14). 

Postmortem examinations of patients treated with paclitaxel have shown mucosal ulceration of the esophagus, stomach, small intestine, and colon (40). Changes associated with epithelial necrosis and mitotic arrest were most prominent in patients who had recently been treated with paclitaxel. These findings suggest that paclitaxel causes transient mitotic arrest associated with cell... 

Rainsford KD. Gastric mucosal ulceration induced in pigs by tablets but not suspensions or solutions of aspirin. / Pharm Pharmacol 1978 30 129-131. 

Eisenberg E +, Oral Surg Oral Med Oral Pathol 5 1,409 Mucosal ulceration... 

Rectal mucosal ulceration (2002) Cruz-Correa M +, Gastroenterology 122(3), 641 Stomatitis (< 1%)... 

Regardless of the site, bowel wall injury is extensive and the intestinal lumen is often narrowed. The mesentery first becomes thickened and edematous and then fibrotic. Ulcers tend to be deep and elongated and extend along the longimdinal axis of the bowel, at least into the submucosa. The cobblestone appearance of the bowel wall results from deep mucosal ulceration intermingled with nodular submucosal thickening. 

Anorexia, hiccups, and a metallic taste in the mouth are common as kidney disease becomes more severe. Nausea, vomiting, diarrhea, or abdominal distention may also occur. Gastric and colonic mucosal ulcerations and telangiectasias with resultant gastrointestinal bleeding are common. Ascites may develop secondary to fluid overload or peritoneal serositis. 

Methotrexate 7.5-15 mg per week, increased incrementally by 2.5 mg every 2 to 4 weeks until response maximal doses are approximately 25 mg/wk Anemia, leukopenia, thrombocytopenia, hepatotoxicity, gastrointestinal upset, nausea, vomiting, mucosal ulceration, stomatitis, malaise, headaches, pulmonary toxicity... 

Methotrexate is associated with nausea and vomiting as well as mucosal ulceration, stomatitis, malaise, headaches, macrocytic anemia, and pulmonary toxicity. Nausea and macrocytic anemia can be ameliorated by administering oral folic acid in doses of 1 to 5 mg/day. 

Y. enterocolitica invade the intestinal epithelium and penetrate the intestinal mucosa. An inoculum of 10 organisms may be required for infection. Most strains produce an enterotoxin, but the role of toxin production in causing diarrhea is not well established. However, this infection causes mucosal ulcerations in the terminal ileum, necrotic lesions in Peyer s patches, and enlargement of mesenteric lymph nodes. 

A 32-year-old female is being treated with methotrexate for a recently diagnosed choriocarcinoma of the ovary, and presents with complaints of oral mucosal ulcers. The patient recalls being advised not to take folate-containing vitamins during therapy. An uncomplicated surgical exploration was performed 5 weeks ago with removal of the affected ovary. The patient has been taking methotrexate for 2 weeks and has never had any of the above symptoms before. On examination, patient was afebrile and appeared ill. Several mucosal ulcers were seen in her mouth. The patient also had some upper abdominal tenderness. Her platelet count is decreased at 60,000/mm (normal 150,000 to 450,000/mm3). 

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