Are gastrointestinal problems in Lyme disease due to autonomic dysfunction?

Patients with Lyme disease often complain of gastrointestinal (GI) problems, which are typically dismissed by clinicians as being unrelated to the tick-borne illness. But a new study by Manini and colleagues examining GI symptoms in children with postural orthostatic tachycardia syndrome (POTS), an autonomic dysfunction, provides some supportive evidence and insight into a possible association. [1]

Gastrointestinal symptoms in Lyme disease patients can be fairly common. For decades studies have reported B. burgdorferi bacteria in the gastrointestinal tract of Lyme patients. In fact, a 1999 study found “the presence of Lyme disease in the gastrointestinal tract when confirmed by PCR for B. burgdorferi DNA in 14 of 20 patients with the diagnosis of Lyme and in two of the control subjects with Crohn’s disease.” [2]

Furthermore, the authors reported “Biopsy evidence of gastritis, duodenitis and colitis was found in Lyme patients and associated with the detection of B. burgdorferi in the GI tract.”

Traditionally, clinicians have dismissed gastrointestinal symptoms in Lyme disease patients as unrelated to the illness. But as Stolk and colleagues describe in their case report, Lyme disease can, in fact, induce gastrointestinal problems. [3]

“Although abdominal pain is generally not considered a sign of Lyme disease, in this case report we describe a patient with unexplained severe abdominal pain that eventually turned out to be Lyme disease due to radiculopathy,” writes Stolk.

Pediatric POTS patients and GI problems

Now, a new study by the Mayo Clinic [1] sheds some light on a possible connection between gastrointestinal symptoms and Lyme disease. The authors did not include individuals with Lyme disease in their study, but they did evaluate pediatric patients with POTS, a common condition among Lyme disease patients.

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The authors found that gastrointestinal problems are frequently seen in pediatric patients with orthostatic intolerance (OI) and POTS. Their article, “Gastrointestinal motility evaluation in children with orthostatic intolerance: Mayo Clinic experience,” describes 100 children with POTS who were referred to a pediatric gastroenterology clinic between 2004 and 2017 for GI complaints.

The children with POTS had evidence of autonomic dysfunction using 70-degree head-up tilt testing (HUT). “The POTS group had an increase in HR of ≥40 bpm within 5 minutes of head-up tilt with no significant change in BP,” writes Manini et al.

The study findings suggest that gastrointestinal problems in Lyme disease patients may be the result of an autonomic dysfunction caused by the illness.

Their gastrointestinal symptoms included abdominal pain (63%), nausea (51%), constipation (26.7%), self-reported weight loss (18%), vomiting (17%), diarrhea (7%), and bloating (7%). The most common general symptoms were headache (47%), fatigue (41.6%), and dizziness (23%).

The average age of patients was 15 years old, with 68% being females.

There was a wide range of gastrointestinal problems. Delayed gastric emptying at 4 hours and slow 24-hour colonic transmission were common, according to the study. Other findings included reduced gastric accommodation, slow colonic transit, and dyssynergic defecation.

Dyssynergic is a type of pelvic floor dysfunction. “Pelvic floor dysfunction can cause constipation and difficulty with defecation,” explains Rao and colleagues. [4]

“Subsequently, several terms have been used to describe this entity, including anismus, pelvic floor dyssynergia, obstructive defecation, paradoxical puborectalis contraction, pelvic outlet obstruction, and spastic pelvic floor syndrome.”

Orthostatic intolerance and GI problems

Manini found that even children who did not meet the POTS criteria but suffered from orthostatic intolerance had similar gastrointestinal problems.

“Orthostatic intolerance (OI) can be defined as poor tolerance to upright position, and it results in diverse clinical presentations that include sense of impeding loss of consciousness, cognitive deficits, lightheadedness, visual difficulties, palpitations, headache, fatigue, weakness, pallor, diaphoresis, and tachycardia,” writes Rao.

Conclusion

The study concluded that the autonomic nervous system appears to underlie the gastrointestinal problems described by patients.

Although this study focused on pediatric patients, other studies have reported similar findings in adults, writes Manini. “Disorders of the autonomic nervous system associated with orthostatic hypotension have been associated with diverse gastrointestinal motility disorders in adults.”

Editor’s note: The authors did not investigate whether any of their 100 patients with POTS suffered from Lyme disease.

The study findings suggest that gastrointestinal problems in Lyme disease patients may be the result of an autonomic dysfunction caused by the illness.