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A 34-year-old man who had in the past enjoyed good health was admitted to the surgical department of our hospital for 1-week history of repeated vomiting and abdominal distension. He also had progressive limb weakness, paresthaesia of limbs and tachycardia for 2 days. Physical examination on admission revealed an alert but distressed patient. His blood pressure was 154/110 mm Hg, his pulse was 132/min and his body temperature was 36.4°C. His abdomen was grossly distended and the bowel sound was absent. His upper limb power was medical research council (MRC) grade 5/5 and his lower limb power was MRC grade 3/5. He had decreased pain and temperature sensation of the feet. There was generalised areflexia. ECG showed sinus tachycardia. Serum potassium was normal. Urgent CT abdomen revealed dilated duodenum, jejunum and proximal small bowels with multiple fluid levels (figure 1). Emergency laparotomy was performed revealing a grossly distended stomach and dilated small bowels. No definite pathology was identified. He was put on total parenteral feeding. He had acute retention of urine and labile blood pressure after admission. The patient had persistent lower limb weakness and neurologists were consulted. A nerve conduction test on day 18 revealed demyelinating sensorimotor polyneuropathy. Cerebrospinal fluid examinations showed white cell count <1/cmm³ (<5), protein 2.13 g/L (0.15–0.4) and glucose 3.6 mmol/L (2.2–3.9). Serum anti-GD1b IgG was positive. Stool for campylobacter jejuni was negative. He was diagnosed to have Guillain-Barré syndrome (GBS) and was treated with a course of intravenous immunoglobulin. He did not need ventilator support. His ileus improved and he could resume oral feeding. His lower limb power improved to MRC grade 5/5 and he was able to walk with a cane after 1 month.

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Figure 1

CT abdomen with contrast showed dilated duodenum, jejunum, proximal small bowels with multiple fluid levels.

Autonomic dysfunction is present in up to two-thirds of GBS patients.1 Paralytic ileus occurs in GBS due to the involvement of sympathetic and parasympathetic fibres.2 ,3 Pseudo-obstruction is rarely reported as a presenting symptom of GBS.3 Accurate diagnosis may avoid unnecessary operation and treat the disease at an early stage.