Gastrointestinal Aspects of Sjögren’s Syndrome- A Review

Introduction

Sjogren’s syndrome is an autoimmune disorder that is caused by the infiltration of lymphocytes, mainly in the salivary and lacrimal glands. Though it shows numerous manifestations in the gastrointestinal system, it is still not recognized and understood properly. These manifestations also show a complex relationship between the gut health and immune response. Clinical observations show varied gastric symptoms in these patients, ranging from difficult and painful swallowing to bowel disorders and reflux disease. These are not only challenging to treat, but they are also diagnostic challenges. With this, there is an increased need for awareness among clinicians and a multi-departmental approach to managing these cases. This article intends to explain the relationship of gastrointestinal involvement in Sjogren’s syndrome, briefing on its clinical presentation, causative factors and mechanisms, and various management strategies to approach the disease.

What Is Sjogren's Syndrome?

It is an autoimmune disorder that is mainly shown as inflamed exocrine glands. The salivary and lacrimal glands are affected in particular. Symptoms such as dry eyes and mouth are common. Because of dry eyes, the patient may complain of redness, sensitivity to light, and itching sensation in the eye. A dry mouth can make it difficult for the patient to swallow, speak, taste, etc. It also makes the mouth more prone to dental caries. This syndrome can also affect other organs like joints, muscles, skin, and systemic illnesses. In severe cases, multiple organs like the liver, kidneys, lungs, and nervous system are all affected.

Other symptoms include:

• Tiredness.

• Pain in joints.

• Dry skin and rashes.

• Numbness and tingling.

• Organ involvement: Lungs, kidneys, liver, and nervous system can lead to severe complications.

What Are the Gastrointestinal Clinical Manifestations?

Gastrointestinal involvement can manifest in different ways in patients with Sjogren's syndrome. Common symptoms include:

• Difficulty Swallowing (Dysphagia): This could result from decreased saliva in the mouth. Because of this, the patient may feel that foods are not palatable, as they stick to the throat, and may feel like coughing. Ultimately, this leads to avoiding foods, leading to loss of appetite and weight loss.

• Pain While Swallowing (Odonophagia): An inflamed or ulcerated esophageal lining can cause this pain. Consuming hot or acidic foods can exacerbate the pain.

• Acid Reflux: Patients may experience severe acidity, heartburn, and the return of stomach contents into the food pipe. Chronically, this can lead to gastroesophageal reflux disease.

• Pain in the Abdomen: Pain is common as there must be inflammation underlying visceral neuropathy.

• Diarrhea or Constipation: When bowel habits are changed, ideal movement is lost, leading to diarrhea (loose stools) or constipation (strained passing of stools).

• Nutritional Deficiencies: Due to pain and inflammation, individuals cannot eat adequate nutritious food, leading to deficiencies. Also, malabsorption in the gut system leads to inadequate calorie content.

• Visceral Neuropathy: Patients may feel full early on while eating, bloating, and gastroparesis delayed in gastric emptying might be seen.

The factors involved in Sjogren's are multiple, consisting of local and systemic immune responses. Autoimmune reactions in the gastrointestinal tract alters gut microbiota and impairs gastric secretion production. All this leads to epithelial damage and dysmotility. Autoantibodies such as anti-Ro and anti-La antibodies have a major role in developing all symptoms.

What Are the Management Strategies?

Diagnosing Sjogrens from gastrointestinal symptoms is very challenging as the factors vary considerably and are generally not very specific to the syndrome. There are no particular biomarkers available that can help in diagnosing. Routine endoscopy and imaging findings are usually normal in these patients. Management typically entails a multidisciplinary approach involving a combination of techniques. Management of gastrointestinal symptoms majorly involves relieving the patients' symptoms by prescribing appropriate medication, helping them prevent further complications, and simultaneously addressing their underlying autoimmune disorder.

1. Pharmacological Therapy involves :

   1. Proton Pump Inhibitors: Pantoprazole and Omeprazole are some of these agents. They are prescribed to reduce the acid content in the stomach and relieve patients of discomfort.

   2. Prokinetic Agents: Metoclopramide and Domperidone are important medications prescribed to increase motility and relieve gastroparesis and constipation.

   3. Immunosuppressive Therapies: This is used in severe cases with significant inflammation.

      1. Corticosteroids: Prednisone helps suppress the reaction and give a lot of relief.

      2. Immunomodulators: Azathioprine and Methotrexate are some agents used to avoid remission of immune response and stop remission.

      3. Biologic Agents: Rituximab helps target specific immune systems and reduce disease activity.

1. Dietary Modifications: A low-fiber diet helps reduce pain. Patients are advised to avoid foods considered difficult to digest, such as acidic and spicy foods. This helps relieve symptoms of gastric reflux.

2. Artificial tears and drops facilitate lubrication in the eye and prevent complications such as corneal damage and sight impairment.

3. Saliva substitutes help relieve dry mouth symptoms and significantly decrease caries risk.

4. Humidifiers in the house.

5. Lifestyle Changes: Avoiding smoke and dry air at home and making changes that favor healthy living can help overall health.

What Are the Future Perspectives?

Advanced understanding and research in Sjogren's syndrome have led to new ways to find links between gastrointestinal and other glandular symptoms. This also helps improve the available therapy modes. Various gastrointestinal treatment approaches, like altering the gut microbiota using probiotics, etc, have been tried to relieve the overall symptoms. Personalized medicine approaches have been incorporated to increase the therapeutic efficacy of these syndrome-associated gastrointestinal disorders. Ongoing research has investigated targeted biological agents and therapies to modify the affected autoantibodies. Scientists, researchers, and clinicians must collaborate to raise awareness and improve the outcomes in managing this syndrome.

Conclusion

Gastrointestinal involvement is a very common presentation in Sjogren's syndrome. Though significant, it is underrecognized and often neglected. Healthcare providers must be on the lookout for GI symptoms in patients who frequently have dry eyes and mouth. A multi-department approach involving rheumatologists, gastroenterologists, and other specialists is necessary to manage these patients best. Continued research in this field seems promising for developing new treatment modalities modifying the body's immune response. A collaborative effort from immune, neural, and microbial factors might be necessary to create personalized therapies and improve the lives of the affected individuals.