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Background Although Guillain-Barré Syndrome (GBS) is known to be associated with a range of autonomic symptoms and possible complications, neurologists do not typically routinely monitor gastrointestinal autonomic function in clinical practice. We present a case of severe, prolonged gastrointestinal pseudo-obstruction in the setting of GBS.Methods Single case report from neurology centreResults A 66-year-old woman presented with bilateral, ascending paresis, aesthesia and areflexia, suggestive of Guillain-Barré Syndrome. Initial tests were consistent with GBS, with an MR Brain + Spine reported as within normal limits, nerve conduction studies showing slowing. The patient was admitted to ICU given concern for rapid neurological deterioration and received Intravenous Immunoglobulin but did not require ventilatory support. The patient’s paresis slowly improved, but she developed pseudo-obstruction, requiring multiple treatment approaches. These included osmotic agents such as macrogol, pharmacological agents such as neostigmine, as well as rectal tube decompression. The pseudo-obstruction had no structural or other cause established on investigation and despite ongoing treatment showed minimal improvements over a period of 1 month. The patient’s condition worsened during her admission given lower gastrointestinal bleeding second to her pseudo-obstruction. She was readmitted to ICU, requiring vasopressor support, multiple blood units, and multiple endoscopic interventions.Conclusion This case demonstrates the degree of dysregulation autonomic dysfunction can cause. Greater awareness and early recognition of this condition could in turn lead to early interventions for patients presenting with a range of autonomic gastrointestinal symptoms in the setting of GBS.