Intended for healthcare professionals

Rapid response to:

Clinical Review

Crohn’s disease

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6670 (Published 19 November 2014) Cite this as: BMJ 2014;349:g6670

Rapid Response:

We read with interest the clinical review on the presentation and management of Crohn’s disease by Kalla et al.1 As a disease that has various manifestations both intestinal and extrabdominal, it is important to be aware of the many ways the patient may present. We certainly agree that Crohn’s is a systemic disease process.

Studies have shown that around 60% of patients with Crohn’s disease present with oral manifestations including cheilitis, oral ulceration, fissuring and glossitis and this may be the first sign of the disease in 5-10% of cases. 2

As clinicians specifically working with patients presenting with oral and maxillofacial symptoms and signs, we would like to expand a little on the extra abdominal manifestations seen in this region. The authors in this paper note the presentation of oral ulceration, which is indeed seen in patients with Crohn’s disease. They can often present as a deep, linear ulceration in contrast to that of more common oral aphthous ulcers, which are usually oval, shallow, and of shorter duration.

Oral ulceration is seen commonly within our clinical practice. Given that our differential diagnosis is usually by exclusion should we be considering investigating all of these patients presenting with oral ulcers (with no obvious known cause) for Crohn’s disease? Given the high sensitivity and specificity of faecal calprotectin 3 as mentioned by the authors, should we consider non-invasive stool test for faecal calprotectin as a screening tool in order to avoid more invasive investigations. This can perhaps be an area of further investigation/ research.

A more suggestive oral presentation of Crohn’s disease is the hyperplasia/ thickening of the buccal mucosa and labial fold with a fissuring type appearance.4 This has been commonly described as having a ‘cobble-stoned’ appearance and may be one of the first presentations in the younger patient. Further to this there may also be diffuse swellings of the lips and cheeks in patients who present with an orofacial granulomatosis. Although the collective symptoms of orofacial granulomatosis can present as a separate entity we have a high suspicion for Crohn’s in this patient group and routinely question for intestinal symptoms. If bowel disease is already present, the patient may also exhibit symptoms of a swollen tongue or glossitis. This is usually secondary to the deficiency or malabsorption of iron, vitamin B12 or folic acid and should improve if correction can be maintained. 5

Reports from Scotland also confirm a similar trend of increasing incidence and prevalence of Crohn’s disease in adult 6 and paediatric 7 populations.

We would like to thank the authors again for their present discussion on this systemic disease and clearly relevant topic for those involved in the diagnosis and management of these patients.

References:

1. Kalla R, Ventham N T, Satsangi J, Arnott I D R. Crohn’s disease. BMJ 2014; 349:g6670
2. Plauth M, Jenss H, Meyle J. Oral manifestations of Crohn's disease. An analysis of 79 cases. J Clin Gastroenterol Feb 1991; 13(1): 29–37.
3. Van Rheenen PF, Van de Vijver E, Fidler V. Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis. BMJ. 2010; 341: c3369.
4. Zbar AP, Ben-Horin S, Beer-Gabel M, Eliakim R. Oral Crohn's disease: is it a separable disease from orofacial granulomatosis? A review J Crohn’s Colitis. 2012; 6(2): 135-42
5. Soames JV, Southam JC. Oral pathology. 4th edn. Oxford; New York: Oxford University Press, 2005.
6. Steed H, Walsh S, Reynolds N; Crohn's disease incidence in NHS Tayside. Scott Med J. 2010; 55(3): 22-5.
7. Henderson P, Hansen R, Cameron FL et al. Rising incidence of paediatric inflammatory bowel disease in Scotland. Inflamm Bowel Dis 2012; 18(6): 999–1005.

Richard Walton
Core Trainee 2

Shaukat Mahmood
Consultant

Oral and Maxillofacial Surgery
Dumfries and Galloway Royal Infirmary
Dumfries, Scotland.

Competing interests: No competing interests

30 November 2014
Richard Walton
Core Trainee 2 Oral and Maxillofacial Surgery
Shaukat Mahmood. Consultant Surgeon.
Dumfries and Galloway Royal Infirmary
Bankend Road,Dumfries, DG1 4AP.