Lupus and Gastro Issues

posted in Diet And Lupus on May 7, 2024 by

Gavin Abson

Updated June 17, 2024

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Lupus and its treatments can affect the gastrointestinal (GI) tract, from the mouth to the intestines. Understanding the relationship between lupus and gastro issues is crucial for effectively managing symptoms and improving the quality of life for individuals with lupus.

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This blog post article was edited and contributed to by Donald Thomas, MD; author of “The Lupus Encyclopedia.” Parts of this blog post come from “The Lupus Encyclopedia: A Comprehensive Guide for Patients and Health Care Providers, edition 2.“

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The Gastrointestinal System: An Overview

The gastrointestinal system plays a vital role in digestion, absorption of nutrients, and elimination of waste from the body. In lupus, GI involvement can manifest in various ways, ranging from mild symptoms such as nausea, vomiting, abdominal pain, and diarrhea to more severe complications such as digestive tract inflammation.

Excerpt from “The Lupus Encyclopedia: A Comprehensive Guide for Patients and Health Care Providers”: short overview:

The digestive system, also called the gastrointestinal (GI) system, handles what we eat and drink, breaking nutrients down into tiny molecules to be absorbed into the bloodstream. The digestive system starts at the mouth and ends at the anus, where the final waste products are eliminated in the feces. In between are the esophagus, stomach, and intestines. In addition to the gastrointestinal tract, other organs in the digestive system include the liver, gall bladder, and pancreas.

The GI system is the largest organ of the immune system.

The walls of the stomach and intestines are lined with important immune system cells, and the intestinal walls contain many types of immune system white blood cells. The GI tract has more of these white blood cells than the entire rest of the body. It should be no surprise that what we eat and the microorganisms (microbiome, chapter 3) in our GI tract regularly interact with our immune system. These interactions play essential roles in autoimmune disorders, such as SLE (chapters 3 and 38).
SLE affects the GI tract in many ways. The main problem from lupus inflammation in the mouth is oral ulcers, discussed in chapter 8. The salivary glands are part of the digestive system and can be affected by Sjögren’s disease (chapter 14). This chapter discusses the other areas of the digestive system.

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Common Lupus Gastro Issues

Individuals with lupus may experience a range of GI issues, including:

• Abdominal pain and cramping
• Nausea and vomiting
• Diarrhea or constipation
• Loss of appetite
• Acid reflux or heartburn
• Difficulty swallowing

Understanding the Mechanisms

The exact mechanisms underlying GI involvement in lupus are not fully understood. However, researchers believe that immune dysregulation and inflammation play critical roles in developing gastrointestinal symptoms. Inflammation of the GI tract can damage the intestinal lining, causing symptoms such as abdominal pain, diarrhea, and malabsorption of nutrients.

Diagnosing Gastrointestinal Involvement in Lupus

Diagnosing GI involvement in lupus can be challenging, as lupus GI issues may overlap with other gastrointestinal conditions. However, healthcare providers may use a combination of medical history, physical examination, laboratory tests, and imaging studies to evaluate GI symptoms and assess disease activity.

Treatment and Management Strategies

Treatment for lupus-related gastrointestinal issues focuses on controlling inflammation, relieving symptoms, and preventing complications. This may involve medications such as hydroxychloroquine, biologics (like Benlysta and Saphnelo), corticosteroids, immunosuppressants (like methotrexate), and proton pump inhibitors to reduce inflammation and manage symptoms such as acid reflux.

Lifestyle Modifications

In addition to medication, lifestyle changes can help manage gastrointestinal symptoms in lupus. This may include dietary changes, such as avoiding trigger foods that exacerbate symptoms and adopting a balanced diet rich in fiber and nutrients to support digestive health.

Knowledge and Support for Lupus and GI Issues

Understanding the link between lupus and gastro issues is essential for effectively managing symptoms. By staying informed, seeking appropriate medical care, and adopting healthy lifestyle habits, individuals with lupus can better manage gastrointestinal symptoms and enhance their overall well-being.

Excerpts from “The Lupus Encyclopedia: A Comprehensive Guide for Patients and Health Care Providers”

Since lupus and its treatments can affect the GI track in many different ways, two entire chapters (chapters 15 and 28) are devoted to this topic. Below is are excerpts from the book to give you an idea.

Nausea, Vomiting, Abdominal Pain, and Diarrhea in Lupus

Nausea and vomiting (N/V) in SLE patients are most commonly due to medications. They typically begin soon after starting the medication, making it easy to identify. In this case, the medication should be stopped, or the dosage decreased. But N/V can sometimes occur after someone has been on a medication for a while. In that case, several medicines may need to be stopped, then reintroduced one at a time to figure out which one is causing the problem.

N/V occur in around 8% of SLE patients during lupus flares. It could be related to inflammation around the abdominal organs (peritonitis), inflammation of any GI tract organs, or even vasculitis (blood vessel inflammation). When due to SLE, it usually resolves after immunosuppressant treatment.

N/V can also be due to other problems such as stomach ulcers, gastritis, and duodenitis (chapter 28). Around 10% of SLE patients will have N/V during SLE flares due to lupus-induced peritonitis, pancreatitis, cholecystitis, or enteritis. These conditions respond to immunosuppressants. Still, figuring out the cause of abdominal pain can be quite complicated, requiring many tests and the involvement of other specialists, such as gastroenterologists.

Diarrhea is most commonly due to medications or infection. Difficulty absorbing nutrients from food (malabsorption) can also cause diarrhea (as in celiac disease, discussed below). Protein-losing enteropathy is a rare lupus problem and is discussed above.

Pancreas

The pancreas is an organ that lies in the upper abdomen just in front of the spine. It is vital for producing hormones (such as insulin, which lowers blood glucose, or sugar, levels) and secreting them into the blood. The pancreas also makes important food digestion enzymes. It secretes these substances directly into the small intestine. Pancreas inflammation is called pancreatitis and occurs in up to 4% of SLE patients, more commonly in children. SLE patients who are at increased risk of developing pancreatitis include those with high triglyceride levels (a type of fat measured on cholesterol blood tests, chapter 21), pleurisy (chapter 10), psychosis (chapter 13), Sjögren’s disease (chapter 14), and positive SSA (Ro) antibodies.

Pancreatitis symptoms include nausea, vomiting, and abdominal pain in the upper mid-abdomen, which often radiates (spreads) to the back. Blood tests show elevated amylase and lipase levels (enzymes produced by the pancreas). Pancreatitis typically causes amylase and lipase levels to be over three times higher than the upper limits of normal. Cases of subclinical pancreatitis, in which SLE patients have remarkably elevated amylase and lipase levels yet not have any pancreatitis symptoms, are rare. “Subclinical” is a medical term meaning that a condition is occurring, but it is not causing any actual symptoms.

Other Causes of Pancreatitis

Although SLE can cause pancreatitis, there are other potential causes. These include gallbladder stones, alcohol, trauma, high triglyceride levels, high calcium levels, and genetic disorders. SLE drugs, such as azathioprine, steroids, diuretics, and NSAIDs can also cause pancreatitis. Therefore, pancreatitis in someone with lupus and taking steroids or azathioprine presents difficult treatment decisions for doctors.

Treatment often requires hospitalization. The person is not allowed to eat or drink anything to enable the pancreas to rest. Intravenous (IV) fluids are given. A tube is sometimes inserted through the nose down into the stomach so that stomach contents can continuously be suctioned out, allowing the pancreas to rest.

Lupus pancreatitis is usually due to vasculitis (blood vessel inflammation) of the pancreas blood vessels. Therefore, immunosuppressants are generally needed once other causes have been excluded. Plasmapheresis (plasma exchange) and IVIG have been used for severe cases. If a patient has antiphospholipid antibodies, blood clots in the pancreas could be the cause, and blood thinners may be needed.

Pancreatitis is a potentially severe problem with an elevated risk of dying. Severe pancreatitis occurs in children who have SLE (compared to adults). While 60% of lupus pancreatitis patients died in the past, better treatments have decreased this to around 16% (range of 3% to 20%, depending on the study).

KEY POINTS TO REMEMBER

1. Pancreatitis is rare in SLE.
2. Pancreatitis causes nausea, vomiting, or abdominal pain, often radiating to the back.
3. Pancreatitis requires hospitalization, IV fluids, not eating or drinking, and draining the stomach with a nasogastric tube to rest the pancreas.
4. Some SLE drugs (especially azathioprine and steroids) can cause pancreatitis and may need to be stopped.
5. Common causes of pancreatitis are alcohol and gallbladder stones.
6. SLE pancreatitis is treated with immunosuppressants; blood thinners may be needed if antiphospholipid antibodies are present.
7. SLE pancreatitis can have a high mortality rate, especially in children.
8. Mildly elevated amylase and lipase levels are common in SLE and usually do not indicate a significant pancreas problem.

For more in-depth information on Lupus and Gastro Issues:

Read more in The Lupus Encyclopedia, edition 2

Look up your symptoms, conditions, and medications in the Index of The Lupus Encyclopedia

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