Alan Thomson, M.D.
Reprinted from Lupus Foundation of America - Lupus News Volume 21, Number 4, Winter 2001
Many otherwise healthy individuals will commonly have symptoms from disorders of the swallowing tube ( esophagus ), stomach, upper intestine ( duodenum ), small intestine and colon, gallbladder, liver and pancreas. These are all parts of the gastrointestinal tract. Symptoms arising from disorders of these organs are very common in people who don't have SLE, so of course these symptoms are also common in lupus sufferers. We need to recognise that just because we suffer from intestinal symptoms and we have lupus, does not necessarily mean that we are developing a complication of the lupus itself. Let's consider examples.
Heartburn
Much of the population suffers from heartburn. This is described as a burning discomfort behind the breastbone, and radiating from the pit of the stomach towards the neck, sometimes towards the neck, sometimes associated with regurgitation of food of fluid into the throat, and being a sufficient nuisance to impair the quality of life.
People with heartburn will often change their lifestyle by eating small, non-fatty meals slowly, not lying down for at least two hours after they eat, staying away from irritation floods such as coffee, orange juice or spicy foods and taking the occasional tablet of antacid such as TUMS, Rolaids, or H2-receptor antagonists such as Zantac. These lifestyle changes and over-the-counter medications can help if your symptoms are occasional.
If your symptoms are frequent and severe, or if there are any alarming symptoms such as pain on swallowing, difficulty swallowing, or vomiting up blood, then you should promptly see your physician so that the condition can be investigated. There are stronger medications which block acid secretion called proton pump inhibitors, or PPIS, such as Prilosec, Nexium, Losec, Pantaloc, Prevacid and Aciphex ( delayed-release tablets with rabeprazole as the active ingredient ). These medications, usually taken once a day in the morning, markedly reduce the acid and effectively relieve symptoms.
Reflux
The lower end of the swallowing tube ( the esophagus ) is an area of high pressure that relaxes when you swallow, allowing food to enter the stomach. Once in the stomach, acid is secreted to help digest your food. If the pressure in the valve between the esophagus and the stomach is reduced, or if this relaxes at the wrong time, then acid may move from the stomach into the esophagus and cause symptoms of heartburn or regurgitation. This is known as gastroesophageal reflux disease, or GERD.
Hernia
Sometimes the esophagus is slightly shortened in this condition, so that a small portion of the stomach is pushed up above the diaphragm. This is known as a hiatus hernia. Just because there is a hiatus hernia does not necessarily mean that you have symptoms of heartburn, and many people with heartburn have no hiatus hernia.
Ulcers
Some patients with SLE take arthritis-treating medications such as none-steroidal anti-inflammatory drugs ( NSAIDs ) or glucocorticosteroids ( commonly known as "steroids" ). These may aggravate the lining of the stomach and cause inflammation or tiny ulcer-like lesions called erosions. In time these may enlarge and become ulcers.
Some people with duodenal ulcers or gastric ulcers from a bug, called Helicobacter pylori. We don's know how we get this infection, but it is very common in people over the age of 50. It can cause ulcer disease in some folks and cancer in others, but thankfully most people with this infection are asymptomatic and don't even know they have it.
Medication side effects
If you have lupus and you are taking medications that may irritate the stomach, it is important to be aware that a change in your medication may be needed, or it may be possible for your doctor to prescribe medications which can protect the stomach and duodenum from damaging effect of drugs such as aspirin ( ASA ) and NSAIDs.
We talked already about the PPIs, proton pump inhibitors, to reduce the acid in the stomach. These can protect to stomach against the side effects of ADA/NSAIDs. Misoprostol, a chemical known as a prostaglandin, can be taken by mouth in tablet form, and is also very effective in preventing development of gastritis or erosions or ulcers.
Some people who need ASA/SAIDs may do just fine with TylenolTM, which does not irritate the stomach, or with one of the new COX-2 inhibitors which has a better safety profile in terms of damaging the stomach. A new study of the efficacy and safety of celecoxib, one of the COX-2 inhibitors, will be done in lupus patients under the direction of Michelle Petri, M.D., and Daniel J. Wallace, M.D.
Checking for problems
If you develop stomach pain and you are not taking medications which can irritate the stomach, your physician can arrange for you to have a breath test, known as a urea breath test, which will tell whether there is a H. pylori infection in the stomach.
Alternatively, your doctor may arrange for you to have an examination of the stomach, known as an endoscopy ( EGD, or esophagogastroduodendoscopy ). This is a simple, safe, outpatient procedure which is performed the day after you have fasted from midnight onwards. You come to the outpatients area of the hospital and are given sedation so that you sleep through the test. The physician gently passes the endoscopic tube through the mouth to the stomach and either examines the stomach by looking through a fiberoptic, viewing piece at one end of the instrument, or looks at the lining of your stomach shown on a large colour television screen. It there are any erosions or ulcers, these can be biopsied. If necessary, and biopsies ( tissue samples ) can also be taken to see if you have and H. pylori infection.
Other causes of inflammation
Some patients with lupus suffer from abdominal bloating, cramping abdominal pain, or a change in their bowel movements. Rarely these may be due to inflammation in the small blood vessels associated with lupus ( vasculitis ), but more commonly these symptoms are due to spasm in the bowel ( this is called the Irritable Bowel Syndrome ); inflammation in the bowel ( from either Crohn's disease or ulcerative colitis ); intolerance to the gluten in the diet ( Celiac disease ); or due to a food intolerance such as milk. When you have these symptoms your physician will probably want to examine you and perhaps do some x-rays.
A blood test can be done to determine whether you have Celiac disease. You may need an x-ray of the small bowel or large bowel, or you may need an endoscopic procedure of the large bowel, call a colonoscopy or a sigmoidoscopy. These are very much like the endoscopy we just talked about, only you don't swallow the tube-instead it is passed through the anus and into the rectum along the bowel, after you have taken enemas the day before to clear the intestine.
Fluid build-up
Some people with lupus will develop swelling of their abdomen, due to an accumulation of fluid known as ascites. There are a lot of causes of ascites including vasculitis ( which can cause small and large intestinal symptoms ) pancreatitis ( a chronic kidney condition known as nephrotic syndrome ), or serositis ( inflammation of the lining tissue of the inside of the belly ).
Also, if a person has heart disease, the pressure in the blood vessels may build up and the fluid may leak into the abdomen. If you are known to have ascites you will want to see your physician because infection ( known as spontaneous bacterial peritonitis ) occasionally may develop.
Liver involvement
Some people with lupus will develop changes in their liver blood tests. These are called liver function tests, although that's not really a good term - liver blood tests are more correctly called transaminases, alkaline phosphatase, bilirubin etc. If your liver tests are abnormal, your doctor will determine whether you've been exposed to hepatitis, and will carefully check your medications to ensure that none of these are irritating the liver. Occasionally a biopsy of the liver is needed to ensure that there is no inflammation or damage from treatable conditions.
Conclusion
So you see, if you have gastrointestinal symptoms and you suffer from lupus, there may be a rare condition causing your symptoms, but is much more likely that you have simple problem which can be readily diagnosed and treated.
Disclaimer :
The Lupus Group of WA (Inc) does not recommend or endorse any products, drugs, treatments, procedures, medical or health professional in this article. We suggest you discuss this information with your doctor or specialist.