Gastrointestinal manifestations of systemic lupus erythematosus

Dr Raj Srirajaskanthan, Specialist Registrar in Gastroenterology and Dr Terry Wong MA MD FRCP, Consultant Gastroenterologist, Guys and St. Thomas’ Hospital, London

First published in the Summer 2009 News and Views magazine, published by Lupus UK

INTRODUCTION

Systemic lupus erythematosus (SLE) is an illness that can affect numerous systems within the body. Gastrointestinal (GI) manifestations are fairly common with this condition and in some cases can be the initial symptoms with which patients present.When looking at the way SLE affects the GI tract, one can consider both conditions caused by the disease and also conditions related to the medications used to treat SLE. In this article we describe the common GI conditions which are linked to SLE starting at the mouth, the top part of the GI tract and finishing in the large bowel, see Figure 1.

MOUTH/ ORAL CAVITY

Ulceration in the mouth is a common feature of SLE, occurring in between 6-50% of patients. Oral ulceration is actually one of the 11 criteria used by the American college of Rheumatology to classify SLE. Often the ulcers are superficial, painless and commonly found in the hard palate. These ulcers can usually be treated with mouthwashes or steroid gels applied over the effected areas.

Ulcers in the mouth can also be due to infection especially in patients on treatments that reduce their immune system. In these immuno-compromised patients viruses that cause ulceration, for example cold sores, are not uncommon findings.

Dry mouth is a recognised manifestation of SLE and it has been reported in up to 8% of patients with SLE. Dry mouth in conjunction with dry eyes is sometimes called secondary Sjogren’s syndrome.

OESOPHAGEAL DISEASE

Heartburn is a very common symptom in patients with SLE occurring in up to half of all patients. Heartburn appears to be caused by acid from the stomach travelling (refluxing) into the oesophagus. By studying the contraction and motion of the oesophagus (gullet) using specialised manometry (pressure monitoring) equipment, it has been demonstrated that sometimes there are abnormalities in the contraction of the oesophagus. In most cases this abnormality is due to weaker than normal contractions or poorly synchronised contractions. This results in development of symptoms such as heartburn.

Occasionally the acid that refluxes into the oesophagus from the stomach can cause irritation to the lining of the oesophagus a condition termed oesophagitis.To manage symptoms of heartburn or oesophagitis a number of medical therapies are available, some are over the counter medications like Gaviscon or ranitidine. Other drugs like proton-pump inhibitors require a prescription; these tablets all can control the symptoms. Difficulty swallowing (dysphagia) is a less common feature of SLE, thought to occur in less than 10% of cases. This condition again is thought to be due to problems with co-ordination of the swallowing muscles or weakened muscles.

STOMACH

Inflammation of the stomach lining is called gastritis, this can occur in patients with SLE, however, is most commonly due to medications that patients are taking. Specifically steroids and anti-inflammatory drugs can irritate the stomach lining leading to inflammation and in some cases ulceration of the stomach. This inflammation can often cause symptoms such as pain in the stomach after eating or general pain in the abdomen. To confirm the presence of this inflammation patients can be investigated with a specialised camera test called oesphagogastroduodenoscopy (OGD). This enables one to look directly at the lining of the stomach and see if there is inflammation or ulceration.This test can also be used to look for oesophagitis. Treatment for patients with gastritis or gastric ulcers comprises of removing the drugs that may be causing the problem and also giving proton pump inhibitors which reduce the acid secretion of the stomach, such as Omeprazole. Gastric antral vascular ectasia (GAVE) is an uncommon condition which is occasionally seen in patients with SLE. The underlying cause is unclear, however, it is due to abnormal collection of blood vessels in the lower part of the stomach (antrum). These vessels can occasionally bleed and can cause a low blood count (anaemia). Treatment of these vessels involves cauterization using heat.

SMALL BOWEL

SLE can cause inflammation of blood vessels (vasculitis) in almost any part of the body.The gut receives a vast percentage of the body’s overall blood supply and the small bowel is supplied by hundreds of small vessels.The small bowel is over four metres long in most people.

If SLE causes inflammation of the blood vessels supplying the small bowel a condition called intestinal vasculitis can occur. The other term for this condition is mesenteric vasculitis. Unfortunately, this condition is usually painful and patients present with a history of cramping or perisistent abdominal pain. To diagnose this condition specialized CT scans which look at the blood vessels supplying the gut can be performed. Other tests include swallowing a small pill that has a camera inside to take photos of the small bowel.The treatment for this condition involves the use of immunosupressants and occasionally surgery.

MALABSORPTION

Nutrients from the food that we eat are mainly absorbed in the small and large bowel. In SLE some patients can develop malabsorption, whereby not all proteins and fats are absorbed from the gut. This can lead to fluid collecting around the ankles and in the abdomen. Investigations are initially done to exclude other conditions that may have similar findings for example coeliac disease. Treatment with nutritional supplementation is sufficient to control these symptoms.

In worse cases patients may develop a condition whereby they are losing large volumes of protein from the gut; this condition is termed a protein losing enteropathy. However, this is not a common condition and the cause for this remains unclear. Treatment for this condition involves use of steroids and other disease modifying medications.

CONCLUSION

SLE is a disease that affects multiple systems.There are a number of conditions that can occur within the GI tract in SLE. The majority of these affect the upper GI tract, mainly the mouth, oesophagus and stomach. These can be controlled with medications and do not require invasive procedures or surgery. Within the small bowel intestinal vasculitis is a serious but fortunately uncommon condition which is usually successfully managed with medical therapy.

Our thanks to Dr Srirajaskanthan and Dr Wong for so kindly supplying this article, as a result of a number requests from our members.

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