Systematic review of immunosuppression for SLE-associated intestinal pseudo-obstruction

IntroductionIntestinal pseudo-obstruction (IPO) is a rare but serious gastrointestinal complication of systemic lupus erythematosus (SLE), often mimicking surgical obstruction. It may be reversible with prompt immunosuppressive therapy but is frequently misdiagnosed.MethodsWe report a patient with SLE-IPO and a history of pulmonary arterial hypertension (PAH), a combination rarely described. A systematic review was conducted via PubMed and EMBASE through March 31, 2025. After deduplication and screening, 30 publications reporting 42 individual cases were included. Combined with our case, 43 cases were analyzed. Clinical characteristics, treatments, and outcomes were extracted and compared by publication date (≤2010 vs. >2010).ResultsAmong the 43 patients, 93.02% were female, with a median age of 32.00 years. IPO was the initial SLE presentation in 62.79%, and more than 90.00% occurred during active disease. Genitourinary involvement was present in 46.51%. All patients received corticosteroids. Cyclophosphamide was used in 37.21%, IVIG in 18.60%, MMF in 16.28%, and rituximab in 4.65%. After 2010, IVIG use increased (32.00% vs. 0.00%), along with broader use of MMF and biologics. IPO relapsed in 39.53%; mortality was low (2.33%). Our case achieved remission after escalation to intravenous methylprednisolone and IVIG, with MMF introduced only after bowel function recovered.ConclusionSLE-IPO is a potentially reversible complication that often coexists with genitourinary dysmotility and only rarely with pulmonary hypertension. Timely diagnosis and aggressive immunosuppression are important to avoid irreversible damage or surgery. Evolving treatment strategies may be associated with improved outcomes, although causal inference is limited by case-level evidence.