Accurate Documentation of Aphthous Ulcers

Key Characteristics and Documentation

• Aphthous ulcers should be described using standardized terminology noting their well-demarcated, oval/round appearance with white/yellow pseudomembrane and erythematous halo, documenting their size, number, location, and depth, as recommended by medical guidelines 1
• The American Gastroenterological Association suggests using standardized terminology for consistency in documentation, including photo documentation whenever possible, and validated endoscopic scores like CDEIS or SES-CD for patients with inflammatory bowel disease 2
• The European Crohn’s and Colitis Organisation recommends documenting aphthous ulcers using validated endoscopic scores, and specifying number, size, and presence of passable or non-passable strictures when describing aphthous ulcers in Crohn's disease patients 3

Specialist Referral and Further Evaluation

• The American College of Gastroenterology advises considering specialist referral for ulcers persisting >2 weeks or not responding to 1-2 weeks of treatment, and when ulcers are associated with systemic symptoms suggesting underlying disease 1
• The American Gastroenterological Association recommends considering specialist referral for recurrent, severe, or atypical presentations requiring biopsy or advanced diagnostic testing, with a strength of evidence rated as high 4