Aphthous ulcers: The Daily PANCE Blueprint
A 24-year-old woman presents to your clinic with recurrent oral ulcers. She reports that these ulcers have been occurring monthly for the past 6 months. They are painful, round, and have a white base with a surrounding red halo. She also reports intermittent abdominal pain, diarrhea, and a 5-pound weight loss over the past few months. She has a family history of inflammatory bowel disease. On physical exam, you note several small ulcers on her buccal mucosa and tongue. Her abdomen is soft with mild tenderness in the right lower quadrant. Which of the following is the most appropriate next step in the management of this patient?
A. Prescribe a topical corticosteroid
B. Prescribe a course of oral antibiotics
C. Refer the patient for colonoscopy
D. Perform a biopsy of an oral ulcer
E. Reassure the patient that these are likely benign aphthous ulcers and recommend symptomatic treatment
Answer and topic summary
The answer is C. Refer the patient for colonoscopy
This patient’s presentation of recurrent oral ulcers in conjunction with gastrointestinal symptoms (abdominal pain, diarrhea, weight loss) and a family history of inflammatory bowel disease raises suspicion for Crohn’s disease. Oral manifestations, including aphthous-like ulcers, are common in Crohn’s disease. A colonoscopy is indicated to evaluate for intestinal inflammation and to obtain biopsies to confirm the diagnosis of Crohn’s disease. Early diagnosis and treatment of Crohn’s disease are essential to prevent complications and improve long-term outcomes.
Incorrect answer explanations:
- Prescribe a topical corticosteroid: While topical corticosteroids can provide symptomatic relief for oral ulcers, they do not address the underlying cause in this case. Further investigation is needed given the suspicion for Crohn’s disease.
- Prescribe a course of oral antibiotics: Antibiotics are not indicated for the treatment of aphthous ulcers or Crohn’s disease, unless there is a specific bacterial infection identified.
- Perform a biopsy of an oral ulcer: While a biopsy of an oral ulcer might show inflammatory changes, it would not be diagnostic of Crohn’s disease. Colonoscopy with biopsies of the intestinal mucosa is necessary to establish the diagnosis. An oral biopsy may be helpful if the diagnosis is in doubt after colonoscopy or if other oral pathologies are being considered in the differential.
- Reassure the patient that these are likely benign aphthous ulcers and recommend symptomatic treatment: This approach would be inappropriate given the patient’s gastrointestinal symptoms and family history, which raise concern for Crohn’s disease. Delaying the diagnosis could lead to worsening disease and complications.
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Smarty PANCE Content Blueprint Review:
Covered under ⇒ PANCE Blueprint EENT ⇒ Oropharyngeal disorders ⇒ Infectious/inflammatory disorders ⇒ Aphthous ulcers
