Gastrointestinal involvement in systemic sclerosis: A spotlight on small bowel involvement, complications and management.

Small-bowel involvement in systemic sclerosis is frequent but often underdiagnosed, largely due to the lack of standardized diagnostic protocols for its evaluation. Small bowel dysmotility manifests with symptoms such as abdominal pain, diarrhea, bloating, and distension, and complications including small intestinal bacterial overgrowth, reduced oral intake, malnutrition, and, in severe cases, intestinal pseudo-obstruction. These complications are associated with significant morbidity, dependence on parenteral nutrition, and poor prognosis. In this review, we summarize the current evidence on the pathogenesis, diagnosis, and management of small-bowel involvement, with a focus on advances in understanding autoimmune neuromuscular mechanisms and their clinical and serological correlates. We discuss diagnostic approaches and propose a structured, multidisciplinary treatment strategy integrating nutritional optimization, targeted prokinetic and antibiotic therapy, and management of acute pseudo-obstructive crises. Finally, we highlight future directions, including the development of biomarkers, advanced motility assessments, and novel therapeutic approaches aimed at earlier diagnosis and personalized care.