Introduction

Systemic lupus erythematosus (SLE), more commonly known as lupus, is an autoimmune disease characterised by chronic inflammation which can affect multiple organs and tissues. While lupus is usually associated with symptoms such as joint pain, skin rashes and fatigue, it can also have significant effects on the gastrointestinal system. Understanding these GI symptoms is crucial for the management of lupus, as they can significantly impact a patient's quality of life and may sometimes indicate serious complications.¹

Lupus is an autoimmune condition where the immune system attacks the body's own tissues. This leads to widespread inflammation and tissue damage in the affected organs. The exact cause of lupus is unknown, but it is believed to result from a combination of genetic, environmental, and hormonal factors. The disease is more common in people assigned female at birth (AFAB), especially those of childbearing age, and can vary in terms of severity and presentation.¹

Symptoms of GI lupus 

Common symptoms of lupus include:

• Fatigue
• Joint pain and swelling - Arthritis-like symptoms are common in lupus patients
• Skin rashes - characteristic butterfly-shaped rash across the cheeks and nose
• Photosensitivity - increased sensitivity to sunlight
• Fever
• Kidney issues - inflammation of the kidneys can occur
• Neurological symptoms - such as headaches, confusion, and memory problems

GI symptoms can be caused by lupus itself or as side effects of medications used to treat the condition. They can affect any part of the digestive system, from the mouth to the rectum.

Below is a list of symptoms associated with GI lupus corresponding with which part of the GI system they are felt.^1,2 

Oral cavity

• Mouth ulcers - Approximately 25-50% of lupus patients experience mouth ulcers. These sores are usually painless and can appear on the lips, inside the cheeks, or on the roof of the mouth. They can be a direct manifestation of the disease or related to immunosuppressive treatments

Oesophagus

• Dysphagia - difficulty swallowing is a common symptom in lupus patients. This can occur due to the muscles of the oesophagus not working properly
• Esophagitis - inflammation of the oesophagus which can cause heartburn and chest pain, which is a direct result of immune-mediated damage or secondary infections

Stomach

• Gastroparesis - this involves delayed stomach emptying which can lead to symptoms of nausea, vomiting and bloating. This can occur due to nerve damage of the stomach muscles
• Peptic ulcers - sores on the lining of the stomach/ duodenum. The risk of having this symptom is increased with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) which are often prescribed for pain and inflammation associated with lupus

Intestines

• Lupus enteritis - inflammation of the small intestine, which causes symptoms such as abdominal pain, nausea, vomiting and diarrhoea. This can sometimes mimic other conditions like inflammatory bowel disease which makes the diagnosis of lupus more challenging
• Mesenteric vasculitis - inflammation affecting the blood vessels which supply the intestines. This leads to reduced blood flow, causing severe abdominal pain and bloody diarrhoea
• Protein - losing enteropathy - where proteins leak into the intestine causing low levels in the blood. This causes symptoms such as swelling mainly in the legs, diarrhoea and abdominal pain

Liver and pancreas

• Autoimmune hepatitis - the immune system attacks liver cells which leads to inflammation and damage of the liver. This causes symptoms like fatigue and jaundice
• Pancreatitis - inflammation of the pancreas which can occur as a direct result of lupus, or as a side effect from corticosteroid treatment. This produces symptoms like abdominal pain, nausea and vomiting

Colon

• Colitis - inflammation of the colon as a result of lupus or a secondary infection in immunosuppressed individuals. This can lead to symptoms of abdominal pain, diarrhoea and rectal bleeding
• Irritable bowel syndrome (IBS) - some lupus patients report symptoms of IBS, including abdominal cramps, bloating and changes in bowel movements. IBS is not directly caused by lupus, but the chronic stress and immune dysregulation involved with the condition may contribute to these symptoms

How lupus is diagnosed

Due to the complex nature of lupus, there is not one test that can confirm a diagnosis of the condition, but a series of tests will be used to determine what is causing your symptoms and rule out other possible conditions. This is known as a differential diagnosis. 

There are a range of tests which can be used, including:

• Blood tests - check how well your immune system is functioning, they also check for infections or other underlying issues such as low blood cell counts or anaemia
• Urinalysis - tests for signs of infection/ other health conditions
• Antinuclear antibody test - looks for antibodies, people with lupus have an overactive immune system so will have certain antibodies in their blood
• Biopsy - of the skin or kidney tissue will show damage if you have lupus 

Treating lupus

Lupus treatments aim to manage what physical manifestations of the condition you have. Most people suffering from lupus need a combination of medications to help prevent flare-ups and lessen the severity of their symptoms.¹

Some treatments include:

• NSAIDs - these are over-the-counter medications which help reduce inflammation and relieve any pain you may be feeling
• Corticosteroids - reduce inflammation, they can be taken orally or can be injected into one of your joints 
• Immunosuppressants - stop your immune system from being overactive, they help prevent tissue damage and inflammation 

You may require additional medications or treatments to address specific lupus symptoms or other related health conditions. For instance, if lupus leads to anaemia, high blood pressure (hypertension), or osteoporosis, you might need treatments tailored to those issues.

Prevention

You can’t prevent lupus as the cause of the condition is unknown.

There are certain things you can do to prevent flare-ups of lupus which include:¹

• Staying active - moving and using your joints gently can help relieve pain and stiffness. Things you can do to stay active include walking, swimming or yoga
• Avoiding sun exposure - lupus symptoms can be triggered by spending too much time in the sun so you should try to avoid going out in the sun between 10am and 4pm when the sun is at its hottest. You should also use a sunscreen that is at least SPF 50 and wear sun-protective clothing

Outlook 

Lupus is a chronic condition, meaning you will need to manage its symptoms for your entire life. It can be unpredictable, with its effects changing over time. Regular visits to your doctor are necessary to monitor any changes in your symptoms.

You will likely work with a team of healthcare professionals to manage your condition. Your doctor can refer you to specialists to address specific issues or symptoms. You will probably need to see a rheumatologist, a specialist in autoimmune diseases. The specialists you visit will depend on your symptoms and how they impact your body.¹

Currently, there is no cure for lupus. Your doctor may prescribe you a combination of treatments to manage your symptoms and aim to achieve remission. 

Summary

Gastrointestinal manifestations of lupus are diverse and can significantly impact a patient's quality of life. Recognising and addressing these symptoms early is important for effectively managing the condition. With a combination of medications, lifestyle changes and regular monitoring, many lupus patients can achieve a better quality of life despite the challenges caused by this complex disease. Ongoing research continues to improve our understanding of lupus and its various manifestations, paving the way for more targeted and effective treatments in the future.