GI Symptoms in Sjogren's Syndrome: Is it GERD? Chronic Atrophic Gastritis? Or Something Else?

Here's yet another great question from another awesome reader:

I wanted to ask you about your gastro symptoms specifically, as I've seen you make reference to it. I've never had any problems with GERD or gastritis until these other symptoms intensified (dry mouth and eyes have become much, much worse), along with intense anxiety, fatigue, irritability and just feeling sooo crappy.
Now I have GERD almost constantly, with some brief periods of relief. My rheumatologist said, "Oh, that's nothing to do with your disease. See a gastro." And I'm like... what?? It's my main, most debilitating symptom. All gastro docs seem to know nothing of Sjogren's, don't care to listen, and prescribe protonix. I tried protonix for 2.5 years, they just kept upping the dosage and yet I kept getting worse. I finally just stopped them completely and my symptoms have gotten soooo much better but it's still so uncomfortable, and at times debilitating. I also deal with chronic constipation, which hasn't been a problem until recently as well. (Now that you know my pooping habits, we're friends, right? XD)

First off, yes.

Anyone who feels comfortable sharing their pooping habits with me is immediately one of my closest friends. Absolutely.

So on to your questions about Sjogren's syndrome and it's gastrointestinal effects........

Again, yes.

There is no question that Sjogren's syndrome can and does affect the entire GI tract in multiple ways. For me, personally, I have noticed some issues with gastro esophogeal reflux disease (GERD) and take omiprozole which helps considerably. I have also noticed a slow-down in the motility of my colon, and I have developed some food intolerances since my diagnosis.

However, there's so much more that can be affected. This online book written by Dr. Joop D van de Merwe entitled Sjogren's Syndrome: Information for Patients and Professionals, is a very thorough discussion of all things Sjogren's.  The book is twenty one lengthy chapters and is a very large file if downloaded. The terminology and explanations are geared toward health care providers, but for those with a reasonable understanding of the immune system and anatomy, it is a very informative read and was updated as recently as April 2012.

Of particular interest is Chapter Nine - Gastrointestinal Disorders, found here. Dr. Joop P van de Merwe describes the many, many ways that Sjs can change the GI tract. Here are just a few of his comments:

Difficulty in swallowing
Difficulty in swallowing food can have a variety of causes in Sjögren's syndrome. One obvious cause is dryness of the mouth and throat. In addition, the function of the oesophagus may also be impaired, not only due to dry mucous membranes but also to disorders in the pattern of contractions in the oesophagus. The cause of this may lie in the muscles themselves or in the nerve fibres that "control" the muscles.
Chronic atrophic gastritis
Chronic atrophic gastritis is the medical term for chronic inflammation of the gastric mucosa (lining of the stomach), resulting in a gradual deterioration of the structure and function of the mucosa. This can lead for example to a reduction in the production of gastric acid. This form of inflammation of the gastric mucosa also exists as a separate medical condition, but occurs more commonly in Sjögren's syndrome patients (maybe as many as 50%) than in the remainder of the gastric mucosa. However, this generally concerns a mild form without detrimental consequences.2,6,7
Gastric ulcer
A gastric ulcer, with or without bleeding, in Sjögren's syndrome is mainly the consequence of using older types of NSAIDs. This occurs less frequently with the modern variant of NSAIDs, the selective COX-2 inhibitors (coxibs) or the combined use of NSAIDs with proton-pump inhibitors such as omeprazol. NSAIDs are discussed in chapter 5.
Functional dyspepsia
Functional dyspepsia (FD) is defined as the presence of symptoms thought to originate in the gastroduodenal region, in the absence of organic, systemic, or metabolic disease that is likely to explain the symptoms.31
Typical dyspeptic symptoms are epigastric pain, early satiety, postprandial fullness and epigastric burning. Bloating, belching, nausea, and vomiting may also occur but are less typical.
It is extremely important to realize that dyspeptic symptoms may be due to underlying peptic ulcer disease and gastroesophageal reflux disease (GERD).
Impaired gastric emptying and gastroparesis
Impaired gastric emptying (IGE) and gastroparesis are defined on the basis of the time from the ingestion of a bolus of food until 50% of the bolus has been cleared from the stomach and/or the bolus is beginning to be cleared from the stomach. Gastroparesis is the more severe variant of impaired gastric emptying.


The chapter goes on for considerable length, so head over to read it all.

I wanted to point out one item in this list which I have not discussed before but is interesting and may be important to the reader, which is atrophic gastritis.

Atrophic gastritis is described this way in The new Sjogren's Syndrome Handbook Edited by Daniel J. Wallace, MD, pg. 73:
.....a proportion of patients with Sjogren's have reduced acid secretion by the stomach. This is a result of long-standing inflammation that destroys the cells that produce acid (chronic atrophic gastritis), an immune process similar to the one that destroys the salivary glands. Atrophic gastritis can cause indigestion (dyspepsia) and pain over the upper part of the abdomen. Diagnosis is made by endoscopy.........A biopsy is often taken to confirm the diagnosis.

In other words, among the many potential GI issues in Sjogren's, two are almost opposite in cause: chronic atrophic gastritis, which causes damage to the mucosa of the stomach due to decreased production of normal stomach acids; and GERD (gastro esophageal reflux disease): the presence of gastric acid -- in all the wrong places. GERD is explained by the Sjogren's Syndrome Foundation in another of their excellent fact sheets here:

While the exact reasons are unknown, may patients with Sjogren's suffer from gastro esophageal reflux disease. (GERD). This can cause a wide variety of symptoms that can be mistaken for other conditions. Symptoms may include persistent heartburn and/or regurgitation of acid, stomach pain, hoarseness or voice change, throat pain, sore throat, difficulty swallowing, sensation of having a lump in the throat, frequent throat clearing and chronic cough (especially at night time or upon awakening).

The reader may want to ask their physician a few other questions regarding her GI symptoms, such as, Why did my GERD symptoms get better after stopping protonix (which decreases the acid production in the stomach)? Is it possible that my problem isn't actually GERD, but rather something else? 


Of course, I'm not a doctor and I don't even play one on TV. And I certainly would never play doctor here on Reasonably Well. But the reader may have a good reason to have a new discussion with his/her doctor in exploring options to calm that GI system down.