The Gastrointestinal System
Lupus is an autoimmune disease that can affect almost any part of the body, most often the joints, skin, kidneys, heart, lungs, blood, or brain. Lupus can also affect the gastrointestinal (GI) system. The GI system is your body’s pathway for taking in, processing, and disposing of everything you eat and drink. Everything you swallow goes from your mouth to your esophagus in your throat, on through your stomach to your intestines, and then to your colon, ending at your urinary tract or rectum. Muscle contractions control swallowing and bowel movement.
People with lupus may be affected by problems in any area of the GI system, including the surrounding organs such as the liver, the pancreas, the bile ducts, and the gallbladder. Not all of these problems will be directly related to lupus disease activity; some may be traced to side effects of medication you take or other diseases that may be present. Gastroenterologists are the physicians who specialize in the GI system.
Esophageal Disorders in Lupus
The esophagus is the muscle that joins your throat to your stomach. When lupus causes inflammation in the esophagus, stomach acid can move back up into your esophagus. Almost everyone experiences this backward flow of acid, called reflux, from time to time, as either gas or the burning sensation of heartburn. However, reflux that keeps occurring is known as gastroesophageal reflux disease (GERD). The most common causes of GERD are hiatal hernia caused by a weak sphincter (the muscle between your esophagus and your stomach), or by weak muscle contractions in your esophagus. In addition to reflux, esopha-geal problems may also cause you to have difficulty swallowing, a condition called dysphagia.
Digestive problems are common in lupus. The symptoms you may experience include nausea, vomiting, diarrhea, or constipation. Often these symptoms are caused by drugs you take for lupus, such as non-steroidal anti-inflammatory drugs (NSAIDs) and corti-costeroids. Sometimes, though, these symptoms occur because your muscles are not properly moving waste through your intestines. This group of symptoms is known as irritable bowel syndrome (IBS), and may be caused by irregularities in your nervous system.
Ulcerative Colitis and Crohn’s Disease
Ulcerative colitis (which causes ulcers in the lining of the rectum and colon) and Crohn’s disease (which causes inflammation of the digestive system) are two forms of inflammatory bowel disease that affect the colon. Bloody diarrhea and abdominal pain are common symptoms in both, but there are differences that will help your doctor to distinguish between the two. People with lupus sometimes will develop ulcerative colitis, but only rarely will a person have both lupus and Crohn’s disease.
Peritonitis and Ascites
The peritoneum is a thin lining on the inside of your abdomen. Inflammation of this lining can cause a condition called peritonitis. Most cases of peritonitis are due to an infection. However, inflammation caused by lupus can also cause a build-up of fluids in the abdominal cavity called ascites (pronounced uh-SAHY-teez). The symptoms you may experience can include severe abdominal pain, tenderness when your belly is touched, nausea and vomiting, fever, and/or lack of bowel movements. Ascites can also be caused by infection, pancreatitis, liver disease, cancer, or other conditions, so your doctor may want to examine a sample of the fluid to determine its cause and begin the proper treatment.
Inflammation of the pancreas (pancreatitis) can be caused by lupus, but also can be caused by vasculitis (inflammation of the blood vessels) or by certain medications you may be taking for lupus, including corticosteroids, immunosuppressants, and diuretics. Because pancreatic vasculitis is treated with corticosteroids, while steroid-induced pancreatitis is treated by withdrawing the steroid medication, it is very important that your pancreatitis is diagnosed accurately, and that you are treated and closely monitored by a doctor with experience in this area.
Your liver is the largest organ inside your body. It is also one of the most important. The liver has many jobs, including changing food into energy and cleaning alcohol and poisons from the blood. Your liver also makes bile, a yellowish-green liquid that helps with digestion. When lupus causes inflammation in the liver, a condition called hepatic vasculitis can occur. This affects the blood vessels that supply the liver and can cause blood clots in those vessels. The liver may become enlarged due to ascites or congestive heart failure. People with lupus also may develop jaundice, a liver condition that gives a yellowish color to the skin. Jaundice in lupus also can be a sign of anemia or pancreatitis. If your liver enzyme levels are increased, this may be due to NSAIDs or acetaminophen, or may be a sign of lupus activity.
Autoimmune hepatitis is a disease in which the immune system attacks the liver, causing the liver to become inflamed. Autoimmune hepatitis is classified as either type 1 or 2. Type 1 is the most common form in North America. It occurs at any age and is more common among women than men. About half of those with type 1 have other autoimmune disorders, such as type 1 diabetes, proliferative glomerulonephritis, systemic lupus, thyroiditis, Graves' disease, Sjögren's syndrome, autoimmune anemia, or ulcerative colitis. Type 2 autoimmune hepatitis is less common, typically affecting girls ages 2 to 14, although adults can also be affected.
Fatigue is probably the most common symptom of autoimmune hepatitis. Other symptoms include an enlarged liver, jaundice, itching and skin rashes, joint pain, abdominal discomfort, abnormal blood vessels on the skin (spider angiomas), nausea and vomiting, loss of appetite, dark urine, and pale or gray colored stools.
Because severe viral hepatitis or hepatitis caused by a drug -- for example, certain antibiotics -- have the same symptoms as autoimmune hepatitis, tests may be needed for an exact diagnosis. Your doctor also should review and rule out drugs you are taking before diagnosing autoimmune hepatitis. Both types of autoimmune hepatitis are treated with daily doses of a corticosteroid (such as prednisone), but azathioprine (Imuran®) is also used.
If you take NSAIDs as a lupus treatment you are at increased risk for damage to your stomach. This tissue damage could cause bleeding ulcers to develop either in your stomach lining or in your duodenum (where your stomach, bile duct, and pancreatic duct meet your small intestine). Ulcers also can be caused by the Helicobacter pylori bacterium, which may be more common in people with lupus due to their generally higher risk for infection. Medications that help prevent ulcers from developing include Prevacid®, Prilosec®, and Cytotec®, and medications that help to relieve the upset stomach associated with NSAID use include Zantac.
15 Questions with Dr. David Isenberg - Gastrointestinal Issues with Lupus