Silent ulcer with hemorrhage: A case report Carl J. Smith, DDS, ALW,~Reginald F. Munden, DMD, ik~$D,~Jane O’Keefe, MT, AMT,’ and Richard J. Albenesius, DMD,d Charleston, S.C. MEDICAL
UNIVERSITY
OF SOUTH CAROLINA
A case of acute silent ulcer disease discovered after a routine dental clinical laboratory reported. (ORALSURGORALMEDORALPATHOL 1992;73:389-90)
CASEREPORT
A 74-year-old black woman was seenat the dental clinic for a routine dental screening examination. Her medical history was positive for arthritis, gastric ulcer, high blood pressure, and a penicillin allergy. Her current medications were acetaminophen, Ipropranolol, and ranitidine. She denied hospitalization or seriousillness in the past 5 years. Her only subjective complaint was a tired feeling. Routine screening laboratory data revealed hemoglobin of 8.7 gm/dl (normal 12 to 16 gm/dl) and hematocrit of 27.7 ml/d1 (normal 37 to 47 ml/dil). Findings of the oral examination were unremarkalble. The patient was immediately referred to her physician. She was admitted to the hospital and received a transfusion of 2 units of packed red cells, began famotidine treatment, 20 mg intravenously e,very 12 hours, and was maintained with nothing by mouth. Upper gastrointestinal endoscopy revealed an erosive gastritis and a gastric ulcer as the cause of the hemorrhage. The patient continued taking the medication and was dlischargedafter 3 days, after an uncomplicated recovery. The hemoglobin level had risen to 12 gm/dl and hematocrit t.o 30 ml/d1 at the time of discharge. The blood values 3 mionths after her hospital stay remained stable at the discharge 1e:vel. DISCUSSION
Peptic ulcer dise:ase is a disorder occurring in approximately 10% of the population and is a common cause of morbidity. The frequency of the disease is reported to be decreasing except in the elderly.‘> 2 Despite this, the true incidence of peptic ulcers may aAssociate Professor and Director of Oral Medicine, College of Dental Medicine. bResident in Radiology, College of Medicine. CDivision of Oral Medicine, College of Dental Medicine. dInstructor, Division of Oral Medicine, College of Dental Medicine. 7/17/32522
screening
is
be greater than reported because of the lack of symptoms in many cases. The cardinal manifestation of peptic ulcer disease is epigastric pain, which improves after consumption of food or antacids. The pain typically occurs several hours after eating. There may also be an absence of pain in a patient with an active ulceration as in the present case. Silent ulcers can be defined as peptic ulceration of the stomach or duodenum that causes no symptoms.3 Silent ulcers seem to be more prevalent in elderly persons and in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs). Although the pathogenic mechanisms leading to peptic ulcer disease are not well understood, peptic ulcers begin with a breakdown in the interaction of mucosal defense mechanisms and of acid pepsin secretion.4 Complications of peptic ulcers can include pain, perforation of the stomach or duodenal wall, hemorrhage caused by erosion of the ulcer into a vessel, or obstruction resulting from scarring. Peptic ulcers are a common cause of morbidity in the elderly patient population. If medical treatment does not resolve the ulcer and complications, then surgical excision is recommended. The importance of early detection is crucial; otherwise the disease may not be diagnosed until hemorrhage or death occurs. Approximately one third of patients with an acute upper gastrointestinal hemorrhage are bleeding from a hitherto silent, unrecognized peptic ulcer.3 A strong association exists between chronic gastritis and active peptic ulcer disease.2NSAIDs are a known cause of gastritis and are associated with peptic ulcer complications.4 There is evidence that many peptic ulcer deaths are related to NSAIDS.~ The use of NSAIDs has increased rapidly for the relief of pain associated with arthritis, muscu389
390
Smith et ai.
Table
1. Factors in the recognition of silent ulcer
QRALSURGORAL~EDORALPATHOL March 1992
I Signs Symptoms and history
Systemic
Skin and mucous membrane Pallor, smooth or beefy tongue, cheilosis, jaundice, purpura Pallor
loskeletal, and dental problems. In a modern dental practice an increasing number of geriatric patients are being treated. Therefore it is prudent that the dentist is aware of silent peptic ulcer diseaseas a possible cause of death in the elderly recognizes the role of NSAIDs in this process. The patient in this report was fortunate to have had her dental examination at an institution where routine blood work is a part of the screening process. Although screening laboratories are uncommon outside an academic clinic, the dentist should recognize those signs and symptoms of anemia visible during an oral examination. They include a smooth beefy tongue, fatigue, a history of gastric ulcer, and NSAID use (Table I). It is also essential that an accurate medical history be obtained from the patient and that close attention be paid to all the patient’s answers. Any suspicion of anemia should alert the dentist to the possibility of the discovery of a potentially life-
Tachycardia,
adenopathy
Malaise, syncope, fatigue, exercise intolerance; malnutrition, alcoholism, chronic disease; previous history
threatening silent ulcer. This is a valuable service that the dentist can provide. REFERENCES 1. Elasholl JD, Grossman MI. Trends in hospital admissions and death rates for peptic ulcer in the United States from 1970 to 1978. Gastroenterology 1980;78:280-5. 2. ISurata JH, Corbyoy ED. Current peptic ulcer time trends: an epidemiological prohle. J Clin Gastroenterol 1988; IO: 259-68. 3. Pounder R. Silent peptic ulceration: deadly silence or golden silence? Gastroenterology 1989;96:626-31. 4. Andreoli TE et al. Cecil essentials of medicine. Philadelphia: WB Saunders, 1986:295. 5. Freston MS, Freston JW. Peptic ulcers in the elderly: unique features and management. Geriatrics 1990;45:39-42. Reprint requests: Carl J. Smith, DDS, MS Division of Oral Medicine College of Dental Medicine Medical University of South Carolina 17 1 Ashley Ave. Charleston, SC 29425-2609
UNIVERSITY
OF SOUTH CAROLINA
A case of acute silent ulcer disease discovered after a routine dental clinical laboratory reported. (ORALSURGORALMEDORALPATHOL 1992;73:389-90)
CASEREPORT
A 74-year-old black woman was seenat the dental clinic for a routine dental screening examination. Her medical history was positive for arthritis, gastric ulcer, high blood pressure, and a penicillin allergy. Her current medications were acetaminophen, Ipropranolol, and ranitidine. She denied hospitalization or seriousillness in the past 5 years. Her only subjective complaint was a tired feeling. Routine screening laboratory data revealed hemoglobin of 8.7 gm/dl (normal 12 to 16 gm/dl) and hematocrit of 27.7 ml/d1 (normal 37 to 47 ml/dil). Findings of the oral examination were unremarkalble. The patient was immediately referred to her physician. She was admitted to the hospital and received a transfusion of 2 units of packed red cells, began famotidine treatment, 20 mg intravenously e,very 12 hours, and was maintained with nothing by mouth. Upper gastrointestinal endoscopy revealed an erosive gastritis and a gastric ulcer as the cause of the hemorrhage. The patient continued taking the medication and was dlischargedafter 3 days, after an uncomplicated recovery. The hemoglobin level had risen to 12 gm/dl and hematocrit t.o 30 ml/d1 at the time of discharge. The blood values 3 mionths after her hospital stay remained stable at the discharge 1e:vel. DISCUSSION
Peptic ulcer dise:ase is a disorder occurring in approximately 10% of the population and is a common cause of morbidity. The frequency of the disease is reported to be decreasing except in the elderly.‘> 2 Despite this, the true incidence of peptic ulcers may aAssociate Professor and Director of Oral Medicine, College of Dental Medicine. bResident in Radiology, College of Medicine. CDivision of Oral Medicine, College of Dental Medicine. dInstructor, Division of Oral Medicine, College of Dental Medicine. 7/17/32522
screening
is
be greater than reported because of the lack of symptoms in many cases. The cardinal manifestation of peptic ulcer disease is epigastric pain, which improves after consumption of food or antacids. The pain typically occurs several hours after eating. There may also be an absence of pain in a patient with an active ulceration as in the present case. Silent ulcers can be defined as peptic ulceration of the stomach or duodenum that causes no symptoms.3 Silent ulcers seem to be more prevalent in elderly persons and in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs). Although the pathogenic mechanisms leading to peptic ulcer disease are not well understood, peptic ulcers begin with a breakdown in the interaction of mucosal defense mechanisms and of acid pepsin secretion.4 Complications of peptic ulcers can include pain, perforation of the stomach or duodenal wall, hemorrhage caused by erosion of the ulcer into a vessel, or obstruction resulting from scarring. Peptic ulcers are a common cause of morbidity in the elderly patient population. If medical treatment does not resolve the ulcer and complications, then surgical excision is recommended. The importance of early detection is crucial; otherwise the disease may not be diagnosed until hemorrhage or death occurs. Approximately one third of patients with an acute upper gastrointestinal hemorrhage are bleeding from a hitherto silent, unrecognized peptic ulcer.3 A strong association exists between chronic gastritis and active peptic ulcer disease.2NSAIDs are a known cause of gastritis and are associated with peptic ulcer complications.4 There is evidence that many peptic ulcer deaths are related to NSAIDS.~ The use of NSAIDs has increased rapidly for the relief of pain associated with arthritis, muscu389
390
Smith et ai.
Table
1. Factors in the recognition of silent ulcer
QRALSURGORAL~EDORALPATHOL March 1992
I Signs Symptoms and history
Systemic
Skin and mucous membrane Pallor, smooth or beefy tongue, cheilosis, jaundice, purpura Pallor
loskeletal, and dental problems. In a modern dental practice an increasing number of geriatric patients are being treated. Therefore it is prudent that the dentist is aware of silent peptic ulcer diseaseas a possible cause of death in the elderly recognizes the role of NSAIDs in this process. The patient in this report was fortunate to have had her dental examination at an institution where routine blood work is a part of the screening process. Although screening laboratories are uncommon outside an academic clinic, the dentist should recognize those signs and symptoms of anemia visible during an oral examination. They include a smooth beefy tongue, fatigue, a history of gastric ulcer, and NSAID use (Table I). It is also essential that an accurate medical history be obtained from the patient and that close attention be paid to all the patient’s answers. Any suspicion of anemia should alert the dentist to the possibility of the discovery of a potentially life-
Tachycardia,
adenopathy
Malaise, syncope, fatigue, exercise intolerance; malnutrition, alcoholism, chronic disease; previous history
threatening silent ulcer. This is a valuable service that the dentist can provide. REFERENCES 1. Elasholl JD, Grossman MI. Trends in hospital admissions and death rates for peptic ulcer in the United States from 1970 to 1978. Gastroenterology 1980;78:280-5. 2. ISurata JH, Corbyoy ED. Current peptic ulcer time trends: an epidemiological prohle. J Clin Gastroenterol 1988; IO: 259-68. 3. Pounder R. Silent peptic ulceration: deadly silence or golden silence? Gastroenterology 1989;96:626-31. 4. Andreoli TE et al. Cecil essentials of medicine. Philadelphia: WB Saunders, 1986:295. 5. Freston MS, Freston JW. Peptic ulcers in the elderly: unique features and management. Geriatrics 1990;45:39-42. Reprint requests: Carl J. Smith, DDS, MS Division of Oral Medicine College of Dental Medicine Medical University of South Carolina 17 1 Ashley Ave. Charleston, SC 29425-2609
