Gastrointestinal Manifestations of Systemic Sclerosis: Screening and Management to Improve Outcomes

Gastrointestinal (GI) involvement is among the most common and clinically important manifestations of systemic sclerosis (SSc), affecting up to 90% of patients and substantially contributing to morbidity and reduced quality of life. SSc-related GI disease results from microvascular injury, enteric nervous system dysfunction, and progressive smooth muscle atrophy with fibrosis, producing widespread dysmotility throughout the gastrointestinal tract. Clinical involvement can extend from the oral cavity to the anorectum, with esophageal dysfunction, gastroesophageal reflux disease (GERD), gastroparesis, small intestinal bacterial overgrowth (SIBO), and intestinal pseudo-obstruction among the major manifestations. Recent diagnostic advances, including high-resolution esophageal manometry (HRM), ambulatory pH-impedance monitoring, and improved imaging, have strengthened early detection and characterization of GI involvement. Treatment remains largely supportive and symptom-directed, including acid suppression, prokinetic therapy, nutritional optimization, and endoscopic or surgical management of complications. Growing evidence on the gut microbiome, immune-mediated mechanisms, and the gut-brain axis is expanding understanding of disease pathophysiology and may guide future targeted therapies. This review synthesizes current evidence on the epidemiology, pathophysiology, clinical manifestations, and management of gastrointestinal involvement in systemic sclerosis, emphasizing early recognition and multidisciplinary care. We conclude by outlining persistent management challenges and future directions to improve diagnostic precision, therapeutic development, and patient-centered outcomes.