What is the initial approach to a patient presenting with oral ulcers and gastrointestinal (GI) symptoms?

From the Guidelines

The initial approach to a patient presenting with oral ulcers and gastrointestinal symptoms involves a comprehensive history and physical examination, followed by targeted laboratory testing. Begin by documenting the duration, pattern, and characteristics of the oral ulcers, along with specific GI symptoms such as abdominal pain, diarrhea, constipation, or bleeding. Obtain a complete medication history, as drugs like NSAIDs can cause both oral ulcers and GI symptoms. Laboratory tests should include complete blood count, comprehensive metabolic panel, inflammatory markers (ESR, CRP), and celiac disease antibodies 1. Consider testing for nutritional deficiencies such as iron, folate, vitamin B12, and zinc. Depending on the clinical presentation, additional testing may include stool studies for infection or inflammation, and serologic testing for conditions like inflammatory bowel disease, Behçet's disease, or systemic lupus erythematosus 1.

Some key points to consider in the diagnosis and management of oral ulcers and GI symptoms include:

• The potential for underlying conditions such as inflammatory bowel disease, Behçet's disease, or systemic lupus erythematosus 1
• The importance of assessing health-related quality of life and symptom-specific anxieties 1
• The need for a multidisciplinary approach to care, including collaboration with mental health providers and other specialists as needed 1
• The use of topical anesthetics and supportive care for symptomatic management of oral ulcers and GI symptoms [@Example@]

Initial symptomatic management includes topical anesthetics for oral pain (such as viscous lidocaine 2% or benzocaine products), maintaining good oral hygiene, and avoiding spicy or acidic foods. For GI symptoms, provide supportive care with hydration and anti-emetics if needed. This systematic approach helps identify the underlying cause, which could range from infectious diseases to autoimmune conditions, allowing for appropriate targeted therapy once a diagnosis is established.

From the FDA Drug Label

The study population had a mean age of 45 years (8% age 65 years or older), were 52% male, and were primarily Caucasian (64%). Maintenance of remission was assessed using a modified UC-DAI. For this trial, maintenance of remission was based on maintaining endoscopic remission defined as a modified UC-DAI endoscopy subscore of ≤1 An endoscopy subscore of 0 represented normal mucosal appearance with intact vascular pattern and no friability or granulation.

The initial approach to a patient presenting with oral ulcers and gastrointestinal (GI) symptoms is not directly addressed in the provided drug label for mesalamine. However, the label discusses the treatment of ulcerative colitis, which may present with GI symptoms.

• The label does not provide information on the treatment of oral ulcers.
• For GI symptoms related to ulcerative colitis, mesalamine may be considered as a treatment option, but the label does not provide guidance on the initial approach to patients presenting with these symptoms 2.

From the Research

Initial Approach to Oral Ulcers and GI Symptoms

The initial approach to a patient presenting with oral ulcers and gastrointestinal (GI) symptoms involves a thorough evaluation of the patient's history and symptoms.

• A detailed patient history is critical in assessing ulcerative oral lesions and should include a complete medical and medication history 3.
• The presence of systemic symptoms such as fever, arthritis, or other signs of underlying systemic disease should be evaluated 3.
• The patient's history should also include whether an inciting or triggering trauma, condition, or medication can be identified, the length of time the lesion has been present, the frequency of episodes in recurrent cases, the presence or absence of pain, and the growth of the lesion over time 3.

Differential Diagnosis

A differential diagnosis is essential in patients presenting with oral ulcers and GI symptoms.

• Conditions such as Behçet's disease, which can cause oral and genital ulcers, as well as GI symptoms, should be considered 4.
• Other conditions, such as Crohn's disease, can also cause similar symptoms and should be ruled out 4.
• The presence of ulcerated lesions of the oral mucosa can have many underlying etiologic factors, most commonly infection, immune-related, traumatic, or neoplastic 3.

Treatment Approach

The treatment approach for oral ulcers and GI symptoms depends on the underlying cause.

• For patients with Behçet's disease, treatment with prednisolone and 5-aminosalicylic acid may be effective 4.
• For patients with oral ulcers caused by immune checkpoint inhibitors, treatment with proton pump inhibitors or H2 blockers may be used 5.
• A multidisciplinary treatment approach may be necessary for patients with refractory oral ulcers, such as major aphthous ulcer 6.
• Minimal invasive approach and differential diagnosis are considered to be the main solutions for oral ulcers in pediatric patients 7.