23. Lip swelling

A 27-year-old male presented with an asymptomatic slowly increasing swelling of both lips over two months (Figure 1). The swelling was diffuse, non-tender and more intense in his lower lip and associated with a few small ulcers intra-orally. Extra-orally, there was no detectable peri-oral erythema, other skin lesions, pyrexia or cervical lymphadenopathy. His medical history was clear of allergies, local trauma or infections. He used to smoke 5 to 15 cigarettes per day which he had stopped over the previous two weeks owing to episodes of abdominal pain followed by diarrhoea, nausea and vomiting. None of his close relatives had reported similar problems.

Crohn's disease is the likely cause. This chronic inflammatory bowel disease affects any part of the gastro-intestinal tract causing abdominal pain, diarrhoea and weight loss and may be associated with fever, nausea and vomiting. Of patients with Crohn's disease, 10–30% have oral manifestations. Oral and particularly chronic lip swelling are characteristic and often precede the abdominal problems and are sometimes associated with intra-oral mucosal tags and aphthous-like ulcerations. Our patient has all the major characteristics of this disease, such as the chronic lip swelling, oral ulcerations and the classical abdominal symptomatology.