Early Satiety Research Articles

S577 Comparison of Gastrointestinal Symptoms and Gastric Emptying Scintigraphy Between Postural Orthostatic Tachycardia Patients With and Without Small Fiber Neuropathy

Introduction: Autonomic dysfunction is common in patients with postural orthostatic tachycardia syndrome (POTS) and affects multiple systems, including the gastrointestinal (GI) tract. Various subtypes of POTS exist: autoimmune, hyperadrenergic, and neuropathic. While these subtypes share features of common autonomic symptoms; it remains unclear how symptom presentation amongst other affected systems, such as the GI tract, differ across subtypes. We aimed to compare gastrointestinal symptom presentation and gastric emptying scintigraphy (GES) between POTS patients with and without small fiber neuropathy (SFN). Methods: We conducted a retrospective case series of all POTS patients at our institution who underwent autonomic testing between 2013-2021. Patients were divided into those with SFN (abnormal QSART test) and those without SFN (normal QSART). Demographics, comorbidities, and reported GI symptoms were extracted. GES results were also extracted with percentage emptying at 60-minute intervals (4-hour study). Chi2 and glmnet testing were used to compare the groups. Results: 97 POTS patients (14 men), who underwent autonomic testing for SFN were included. Median age was 36 (21-67). Common comorbidities included hypermobile Ehlers Danlos Syndrome (44%), and chronic fatigue syndrome (22%). POTS patients with SFN were more likely to have nausea (75% vs 55%, p=0.03), poor oral intake (32% vs 9%, p=0.01), parenteral nutrition dependence (9% vs 0%, p=0.01), and early satiety (36% vs 18%, p=0.05) (Table). Most demographics and GI symptoms did not show significance as predictors for SFN. Of the 97 patients, a total of 33 underwent GES for evaluation of reported GI symptoms. The percentage of patients with delayed GES was numerically higher but not statistically significant in POTS patients with SFN (45% vs 23%, p=0.21). There were no significant differences in mean gastric emptying between groups (Table). Conclusion: Our data affirms the high prevalence of GI symptoms in patients with POTS independent of SFN. Patient with SFN were more likely to have upper GI symptoms of nausea, poor oral intake and early satiety despite similarities in GES. This suggests that symptoms may be due to sensory rather than motor dysfunction. While some GI symptoms were more common in those with SFN, there was a lack of predictability of symptoms and demographics for SFN. This suggests the need to have a high clinical suspicion for diagnosing SFN in patients with POTS whose GI symptoms do not respond to conventional therapy. Table 1. - Baseline Demographics and Gastrointestinal Symptom Presentation across POTS patients with and without SFN and Gastric Emptying Results Variable All (n=97) POTS with SFN (n=53) POTS w/o SFN (n=44) p-value Basic Demographics Age: Median (IQR) 36 (30-46) 37 (32-48) 35 (27-40) 0.12 Sex, n (%) 0.59 Female 83 (86) 45 (85) 39 (89) Male 14 (14) 8 (15) 5 (11) Race, n (%) 0.17 White 83 (86) 43 (81) 40 (91) Other 14 (14) 10 (19) 4 (9) Co-morbidities Hypermobile EDS 43 (44) 23 (43) 20 (45) 0.84 CSF Leak 19 (20) 13 (25) 6 (14) 0.18 Chronic Fatigue Syndrome 21 (22) 14 (26) 7 (16) 0.21 Fibromyalgia 15 (15) 9 (17) 6 (14) 0.27 Diabetes 2 (2) 1 (2) 1 (2) 0.89 Hypothyroidism 14 (14) 5 (9) 9 (20) 0.12 Chronic Narcotic Use 7 (7) 1 (2) 6 (14) 0.03 Gastrointestinal Symptoms Abdominal pain, n (%) 63 (65) 37 (70) 26 (59) 0.27 Bloating, n (%) 44 (45) 26 (49) 18 (41) 0.42 Nausea, n (%) 64 (66) 40 (75) 24 (55) 0.03 Vomiting, n (%) 28 (29) 19 (36) 9 (20) 0.10 Dyspepsia, n (%) 9 (9) 7 (13) 2 (5) 0.09 Constipation, n (%) 57 (59) 35 (66) 22 (50) 0.11 Diarrhea, n (%) 34 (35) 23 (43) 11 (25) 0.06 Early Satiety, n (%) 27 (28) 19 (36) 8 (18) 0.05 Dysphagia, n (%) 11 (11) 6 (11) 5 (11) 0.99 Weight Loss, n (%) 26 (27) 16 (30) 10 (23) 0.41 Poor oral intake, n (%) 21 (22) 17 (32) 4 (9) 0.01 Enteral nutrition dependence, n (%) 4 (4) 3 (6) 1 (2) 0.40 Parenteral nutrition dependence, n (%) 5 (5) 5 (9) 0 (0) 0.04 Gastric Emptying Delayed Gastric Emptying, n (%) 12 (36) 9 (45) 3 (23) 0.21 Percentage Emptying at Various Durations 60 minutes: Mean (SD) 32.1 (22.3) 28.9 (24.6) 37.0 (18.2) 0.35 120 minutes: Mean (SD) 57.3 (27.3) 53.3 (29.4) 62.5 (24.6) 0.37 180 minutes: Mean (SD) 74.3 (24.9) 68.7 (26.8) 83.3 (19.2) 0.15 240 minutes: Mean (SD) 85.8 (17.4) 84.1 (18.4) 88.2 (16.6) 0.55

S582 Gastroparesis Is Associated With More Concurrent Gastrointestinal Symptoms and Motility Disorders Than Functional Dyspepsia

Introduction: Gastroparesis (GP) and functional dyspepsia (FD) present with overlapping upper gastrointestinal (GI) symptoms, such as: nausea, vomiting, early satiety, postprandial fullness, epigastric pain, and bloating. Other gastrointestinal motility disorders may be concurrent in patients with GP. The goal of study was to compare the presence of GI symptoms and other motility disorders in patients with GP and FD. Methods: A retrospective cohort study was performed on IBM Explorys (1999-2022), which contains de-identified healthcare information from more than 64 million patients across the United States. Adult patients who have completed gastric emptying study were selected, and subsequently divided into GP and FD cohorts. GP cohort consists of patients with a diagnosis of gastroparesis, with exclusion criteria: cyclical vomiting syndrome, psychoactive substance abuse, eating disorder, factitious disorder, malignant tumor of esophagus and stomach, neoplasm of abdomen, gastric or intestinal obstruction, IBD, adhesion of intestine, carcinomatosis, perforation of intestine, Roux-en-Y gastrojejunostomy, and gastrectomy. FD cohort was similarly constructed with additional exclusion criteria: gastroparesis, gastrointestinal ulcer, brain neoplasm and pancreatitis. The presence of GERD, IBS, GI symptoms and common GI medications were collected. Odds ratios (ORs) with 95% confidence interval were used to compare the cohorts. Results: GP and FD cohort consisted of 17,570 and 60,230 patients respectively (Table). There was a higher prevalence of concurrent motility disorders in patients with GP than FD, including GERD and IBS (65.1 vs 50.9%, 18.6 vs 13.3%). Patients with GP tend to present with more upper and lower GI symptoms than FD, including nausea (65.1 vs 46.3%), vomiting (53.0 vs 33.3%), epigastric pain (36.9 vs 27.2%), heartburn (8.6 vs 7.5%), diarrhea (34.6 vs 23.3%) and constipation (37.2 vs 21.8%) (P< 0.0001) (Figure). However, there was no difference in terms of early satiety and bloating when comparing the two groups. Acid reducing medications, anti-nausea medications and prokinetic agents were more commonly prescribed for patients with GP than FD, including proton pump inhibitors (PPIs), H2 receptor antagonists (H2RA), Metoclopramides and Ondansetron (p< 0.0001). Conclusion: GP is associated with more concurrent GI symptoms and motility disorders compared with FD. Acid reducing medications, anti-nausea and prokinetic medications are more commonly prescribed for patients with GP.Figure 1.: Comparison of GI symptoms between gastroparesis and functional dyspepsia Table 1. - Comparison of GI motility disorders, symptoms and medications between gastroparesis and functional dyspepsia GP (N=17570) % FD (N=60230) % OR P GI diseases GERD 11430 65.1% 30650 50.9% 1.74-1.86 < 0.0001 IBS 3260 18.6% 8030 13.3% 1.42-1.55 < 0.0001 Symptoms Upper GI symptoms Nausea 11430 65.1% 27910 46.3% 2.08-2.23 < 0.0001 Vomiting 9310 53.0% 20060 33.3% 2.18-2.34 < 0.0001 Early satiety 1660 9.5% 5780 9.6% 0.93-1.04 0.5556 Epigastric pain 6490 36.9% 16380 27.2% 1.51-1.62 < 0.0001 Heartburn 1510 8.6% 4500 7.5% 1.10-1.24 < 0.0001 Lower GI symptoms Diarrhea 6070 34.6% 14050 23.3% 1.67-1.80 < 0.0001 Constipation 6540 37.2% 13110 21.8% 2.06-2.21 < 0.0001 Bloating 60 0.3% 170 0.3% 0.90-1.63 0.2039 Medications PPI 13680 77.9% 35430 58.8% 2.37-2.56 < 0.0001 H2RA 7710 43.9% 18310 30.4% 1.73-1.85 < 0.0001 Metoclopramide 8630 49.1% 12490 20.7% 3.56-3.82 < 0.0001 Ondansetron 12570 71.5% 31330 52.0% 2.24-2.41 < 0.0001

S3590 Emphysematous Gastritis

Introduction: Emphysematous gastritis is a rare and severe condition characterized by the presence of air and bacteria in the gastric wall. It usually presents with severe abdominal pain and diagnosed by presence of gas within the gastric wall on imaging. It has a high mortality rate of about 60-80%. Conservative management is the mainstay of treatment. Case Description/Methods: A 36-year-old male with a past medical history of alcohol use disorder and major depressive disorder presented with severe diffuse abdominal pain with post-prandial worsening, intractable nausea, and vomiting. This was preceded by binge drinking of alcohol. He reported poor appetite over one month associated with 17lb weight loss and early satiety. No history of liver disease, peptic ulcer disease, excessive NSAID or aspirin use. He was tachycardic and normotensive. No signs or symptoms of overt GI bleeds. Physical exam was negative for guarding or tenderness. Labs were remarkable for lactic acidosis of 3.6 mmol/L with an anion gap of 21. Lipase and LFTs were normal. CT abdomen showed gastric emphysema and mild diffuse circumferential thickening with fat deposition through the cecum and sigmoid colon, suggestive of emphysematous gastritis. General surgery was consulted but recommended no acute surgical intervention. He was started on a clear liquid diet, pantoprazole drip, empiric IV Piperacillin-Tazobactam, pain medications, and IV fluids. EGD showed moderate gastritis, no necrosis, mild duodenitis. Biopsy showed mild chronic gastritis. Patient improved clinically and repeat CT abdomen in 2 days showed improvement in gastric emphysema. He was discharged with a 7-day course of oral Amoxicillin-Clavulanate and indefinite pantoprazole 40mg BID (Figure). Discussion: Emphysematous gastritis starts with disruption of the integrity of gastric mucosa with secondary infection. Isolated organisms include Streptococci, S. Aureus Enterococci, Clostridium, Klebsiella, Pseudomonas, E.Coli, Enterobacter. Ischemia is an inciting event as seen in volvulus, SMA occlusion, acute gastric dilation. Mechanical causes include forceful emesis, gastric outlet obstruction, malignancy, and iatrogenic causes like gastrostomy or NG tube insertion, myotomy and biliary stents. Risk factors are alcohol use, NSAID and steroid use, cytotoxins, diabetes, abdominal surgery, and burns. Optimal conservative management with diet management, IV fluids, antibiotics has good outcomes as demonstrated by the above case and additional recent cases in literature.Figure 1.: A- Gastric emphysema and mild diffuse circumferential thickening with fat deposition through the cecum and sigmoid colon, suggestive of emphysematous gastritis B- Significantly decreased air locules along the periphery of the proximal gastric mucosa.

S2469 The Big Stretch: A Report of Three Cases of Gastroparesis as an Uncommon Complication of Hypermobile Ehlers-Danlos Syndrome

Introduction: Ehlers-Danlos syndrome (EDS) is a rare autosomal dominant connective tissue disorder that affects the gastrointestinal system, skin, joints, and vasculature. Hypermobile EDS (hEDS) is a subset of EDS with a prevalence of 1 in 5000 people. Major GI features of hEDS include abdominal pain, nausea, constipation, heartburn, and irritable bowel syndrome-like symptoms. Gastroparesis is a debilitating disorder defined as delayed gastric emptying in the absence of a mechanical obstruction. However, hEDS as a cause of gastroparesis is not well established in the literature. Here we report 3 cases of gastroparesis in patients with hEDS to demonstrate its uncommon and varying presentations. Case Description/Methods: Our first patient is a 20-year-old woman who was diagnosed with hEDS at a young age and then developed severe epigastric postprandial abdominal pain with bloating, intractable nausea, early satiety, and unintentional weight loss. She had multiple ER admissions over the past few years for similar symptoms. Physical examination revealed hyperflexible joints, normal bowel sounds with nontender abdomen. Lab values were within normal limits. Esophagogastroduodenoscopy (EGD) and gastric emptying studies both confirmed Grade III gastroparesis. She was initially started on Metoclopramide and Ondansetron without improvement. Patient ultimately achieved symptom control with Azithromycin, Ondansetron, Promethazine as needed and diet modifications. The second patient is a 24-year-old man who was also diagnosed with hEDS at an early age and presented with recurrent postprandial abdominal pain with bloating and heartburn, but no weight loss. He underwent EGD and was found to have gastritis, hiatal hernia and reflux esophagitis. Subsequent gastric emptying scintigraphy later confirmed Grade II gastroparesis and his symptoms improved with diet modifications as well as Metoclopramide. Lastly, our third patient is a 26-year-old woman also with known history of hEDS who presented with mild intermittent postprandial abdominal pain and abdominal bloating. Prior work-up with EGD and gastric emptying scans confirmed the diagnosis of Grade I gastroparesis. Fortunately, her symptoms clinically resolved with regular cannabis use. Discussion: Gastroparesis should be considered in patients with hEDS complaining of severe postprandial abdominal pain. Due to its uncommon presentation and multi-system organ involvement, EDS should be considered in patients with idiopathic gastric dysmotility and joint hypermobility.

S1951 An Uncommon Case of Smoldering Pancreatitis

Introduction: We describe a rapid onset, poorly differentiated, invasive pancreatic carcinoma with histiocytoid features diagnosed post-pancreaticoduodenectomy, after endoscopic ultrasound (EUS) guided fine needle biopsy failed to identify it. Case Description/Methods: A 69-year-old male with a history of alcohol abuse, and tobacco use, initially presented with epigastric pain and early satiety, diagnosed with acute pancreatitis. Computed tomography (CT) scan and Magnetic resonance imaging (MRI) of the abdomen/pelvis at this time were significant for a cystic lesion in the tail of the pancreas with fat stranding (Figure A). EUS was performed however had extremely limited visibility given inflammatory changes, main pancreatic ductal dilation was noted but no clear mass was identified. Fine needle aspiration (FNA) of the cystic structure was suggestive of a pseudocyst on cytology (CEA 25 ng/ml, amylase 3250 units/L). A portal lymph node was appreciated, and fine needle biopsies (FNBx) yielded only inflammatory cells. Clinical course continued to deteriorate over the next few months with non-resolving smoldering pancreatitis symptoms and >80 lb weight loss. Repeat CT abdomen/pelvis was significant for a 2.7 x 2.1 cm lesion of the head of the pancreas (Figure B). EUS was repeated and revealed a 32 x 29 mm hypoechoic mass in the head of the pancreas with upstream pancreatic ductal dilation to 13 mm with significant parenchymal atrophy as well as an enlarged porta hepatis lymph node. FNBx were obtained and were sent for analysis at a tertiary care center which revealed chronic inflammation with necrohistiocystic debris with atypical cells at both sites (Figure C). Due to clinical deterioration and after multidisciplinary discussion, patient underwent a pancreaticoduodenectomy for smoldering pancreatitis involving the head of pancreas and concerning atypical cells. The final pathology report revealed a poorly differentiated, invasive pancreatic carcinoma with histiocytoid features that extensively involved 6/16 regional lymph nodes after multiple reviews by multiple pathologists. Discussion: To our knowledge, poorly differentiated, invasive pancreatic carcinoma with histiocytoid features has not been previously documented. This presentation with smoldering pancreatitis significantly delayed the diagnosis due to the marked inflammatory changes compromising initial imaging (CT, MRI, EUS). This case highlights the importance of a multidisciplinary approach in managing complicated non resolving pancreatitis cases.Figure 1.: A - Cystic lesion with inflammatory changes near the tail of the pancreas; B - Mass in the head of the pancreas with upstream pancreatic duct dilation; C - Endoscopic Ultrasound with fine needle biopsy of the mass in the head of pancreas

S3669 Spotting the Deceiver: Metastatic Urothelial Carcinoma to the Liver Masquerading as a Well-Differentiated Neuroendocrine Tumor Histologically

Introduction: Metastatic urothelial carcinoma of the bladder is generally considered an aggressive disease. It has the potential to metastasize to lymph nodes, bones, lungs, liver, and peritoneum. The accurate diagnosis of metastatic urothelial carcinoma is challenging especially in the setting of histological mimickers. Without pathological expertise and additional immunohistochemistry, metastatic tumors could remain incorrectly diagnosed and delay therapeutic intervention. Case Description/Methods: Herein, we describe a 62-year-old man who presented with jaundice, elevated LFTs, diffuse abdominal pain, and early satiety. MRI of the abdomen revealed a hilar hyperintense mass involving the common bile duct, bilateral hepatic ducts causing narrowing, a 1.1 cm mass in segment 6, and hydroureteronephrosis with thickening of the renal pelvis. Discussion: Clinical differential diagnosis included cholangiocarcinoma and other tumors including a metastatic neuroendocrine tumor (NET). Microscopic evaluation of liver mass biopsy revealed insular growth pattern with monotonous epithelioid cells arranged in nests morphologically suggestive of well-differentiated neuroendocrine tumor (WDNET). However, neuroendocrine immunohistochemical stains, including synaptophysin, chromogranin, and CD56, were all negative, and the Ki-67 staining was 37%, higher than expected for a WDNET, (see Figure 1) prompting broadening of the differential. Following further workup, a diagnosis of metastatic urothelial carcinoma was confirmed by immunopositivity for immunohistochemical markers P40, and GATA3 (see Figure 1). Familiarity with tumors that are histologically identical is critical. Considering an appropriate differential diagnosis, and following a stepwise immunohistochemical approach will be crucial in spotting the mimickers and rendering appropriate management promptly.Figure 1.: Metastatic urothelial carcinoma, hematoxylin & eosin (A and B), and immunohistochemical markers (C-F).

S3504 A 64-Year-Old Male With Recurrent Brunneroma

Introduction: Brunneroma (also termed Brunner's gland hyperplasia, adenoma, or hamartoma) is a rare benign tumor arising within the alkaline-producing exocrine glands located in the submucosal layer of the duodenum. Most patients with brunneroma are asymptomatic, but others may present with gastric obstruction-like symptoms or upper gastrointestinal bleed. Less than 200 cases have been reported. We present a case of a patient with recurrent Brunneroma. Case Description/Methods: A 64-year-old male was evaluated for intermittent achy abdominal pain in the umbilical region associated with postprandial bloating and early satiety. He had a similar presentation twelve years ago and underwent esophagogastroduodenoscopy (EGD), which showed a 3 cm polypoid mass within the duodenal bulb. The mass was removed endoscopically through snare polypectomy and Roth basket retrieval, leading to the resolution of his symptoms. Given his previous history, an EGD was obtained, which showed a 4 cm tan-pink polypoid mass prolapsing from the duodenal bulb through the pylorus into the stomach (Figure A). Endoscopic ultrasound revealed a mucosal mass on a stalk with a cystic component and no submucosal involvement (Figure B). He was evaluated by an advanced endoscopist and felt the mass was appropriate for endoscopic removal. Therefore, an Endoloop was placed around the mass initially with the base injected with epinephrine and then removed with cautery, placing a clip on the base afterward. Removal of the mass led to the resolution of his symptoms. The pathology report demonstrated Brunner gland hyperplasia, benign metaplastic cysts arising from Brunner gland ducts, and no dysplasia (Figure C; H&E stain medium magnification). Discussion: Brunner's gland is located in the proximal part of the duodenum above the hepatopancreatic sphincter. The mechanism Brunneroma remains unclear. There is currently no consensus regarding surgical versus endoscopic management of Brunneroma. However, there is increasing endoscopic utilization avoiding a more invasive surgical procedure.Figure 1

MPN-141 Retrospective Comparison of Patient Outcomes on Pacritinib Versus Ruxolitinib in Patients With Myelofibrosis and Thrombocytopenia.

Pacritinib (PAC) is a JAK2/IRAK1 inhibitor for patients with myelofibrosis (MF) and thrombocytopenia. Unlike the JAK1/2 inhibitor ruxolitinib (RUX), which is used at lower doses in patients with thrombocytopenia, PAC has been studied at full dose regardless of platelet count. This analysis focused on PERSIST-2 patients with platelet counts ≤100 × 109/L who were randomized to PAC 200mg BID and patients who received RUX on best available therapy (BAT) prior to week 24. Endpoints included percent of patients with 35% spleen volume reduction (SVR), 50% modified total symptom score (mTSS) reduction (based on early satiety, abdominal discomfort, night sweats, itching, bone pain, and rib pain), and improvement in disease symptoms measured by Patient Global Impression of Change (PGIC). Safety analyses were based on all treated patients; efficacy analyses were based on the intention-to-treat population randomized at least 22 weeks prior to study end. The Fisher Exact test was used to describe differences in response. Logistic and Cox regression was used to adjust for differences in baseline characteristics. Safety analysis included 106 patients on PAC and 44 on RUX; efficacy analysis included 74 on PAC and 32 on RUX (median total daily dose 10 mg). Baseline characteristics were similar between groups, including median platelet count (55 vs 61 × 109/L) and percent receiving RBC transfusion (46% vs 43%). Patients treated with PAC vs RUX achieved higher rates of SVR (22% vs 3%, p=0.02) and numerically higher rates of mTSS response (35% vs 19%; p=0.11) and "much" or "very much" improved symptoms (35% vs 16%, p=0.06) at week 24. Among RUX patients with an available PGIC measure at week 24, 50% reported either no improvement or worsening symptoms, while 76% of PAC patients reported improvement. The adjusted hazard ratio on PAC vs RUX was 0.46 [95% CI: 0.15-1.43]. Bleeding occurred at similar rates (43% vs 41%) on PAC vs RUX. Fatal AEs occurred in 8% on PAC compared to 11% on RUX. PAC yielded higher response rates and a similar safety profile to lower-dose RUX in patients with MF who have moderate or severe thrombocytopenia. This study was supported by CTI BioPharma.

S2173 A Twist of Fate: The Cecal Bascule

Introduction: Cecal volvulus is a rare clinical entity with an incidence of 2.8-7.1 per million per year and accounts for 1-2% of large bowel obstruction. The rarest type of cecal volvulus is cecal bascule, accounting for 5-20% of all cases. It occurs when the cecum folds up over itself in an anteromedial orientation with a competent ileo-cecal valve. This allows for gaseous and fluid distention. The pathogenesis is still unclear but the literature suggests that congenital or acquired adhesion may be responsible as a mobile cecum. Symptoms consist of abdominal pain, distention, nausea and obstipation. Diagnosis may be challenging due to its rarity. Here we present a male with an incidental imaging finding suggestive of cecal bascule. Case Description/Methods: An 82-year-old male patient with history of prostate cancer, atrial fibrillation on Apixaban, diabetes and chronic kidney disease who was consulted to gastroenterology services due to rectal bleeding. He reported an episode of intermittent rectal bleeding in the past year mostly secondary to straining due to constipation. Last colonoscopy on 2010 showed diverticulosis plus internal and external hemorrhoids; no polyps or masses. He denied abdominal pain, weight loss, or early satiety. Hemoglobin was stable and normal rectal exam. In view of risk vs benefits patient opted for CT colonography. Study with evidence of diverticulosis and a large cecal bascule. Upon follow-up, he reported feeling well and denied abdominal pain or recurrence of rectal bleeding. He had a complicated appendectomy 7 years ago. Patient was consulted to general surgery for possible cecopexy. Discussion: Cecal bascule is a rare subtype of cecal volvulus that mostly occur in older patients and usually presents with marked GI symptoms, such as obstruction, needing emergent treatment. Risk factors are mostly due to embryogenic defects or iatrogenic (abdominal surgery). Diagnosis is made via imaging study, such as CT, or laparoscopy showing the cecum folding upward resulting in obstruction. Management is mostly surgical with resection and cecopexy. Here with present a case of cecal bascule with a rare presentation of minimal symptoms. The patient had history of a complicated appendectomy most likely being the inciting factor of the cecal bascule. Most cases in literature present after a more recent surgical procedure. The importance of this case is to bring attention of this rare clinical entity, its diagnosis and how it may present with non-specific chronic symptoms.

S3614 Gastric Linitis Plastica - An Easily Missed Diagnosis

Introduction: Gastric cancer remains one of the most common malignancies worldwide, with large variations based on genetic, ethnic, geographic, and socioeconomic factors. Patients can present with nonspecific abdominal pain, weight loss, early satiety, or anemia from occult gastrointestinal bleeding. Gastric linitis plastica, a diffuse type of gastric adenocarcinoma, results in proliferation of fibrous tissue in the submucosa and muscle layers of the stomach wall. Biopsy will show classic signet ring cells or poorly differentiated tumor cells. Case Description/Methods: A 54-year-old Caucasian male with a past medical history of end stage renal disease, hypertension, type II diabetes mellitus presented to the hospital for fatigue and melena. His hemoglobin was 7.3 g/dL, which was approximately 3g lower than his most recent hospitalization two weeks prior. He underwent upper endoscopy, which revealed a well-demarcated region of severely congested, erythematous, and friable mucosa with a reticular appearance localized to the gastric cardia, fundus, and body (Figure A and B). Histopathology revealed intramucosal adenocarcinoma with high-grade signet ring features (Figure C), consistent with gastric linitis plastica. Staining for Helicobacter pylori was negative. He was treated with acid suppression. The patient had a prolonged hospital course complicated by hypoxic respiratory failure and eventual cardiac arrest resulting in his death. Discussion: We present here a case of gastric linitis plastica. This is a diffuse type of gastric adenocarcinoma that involves the deeper layers of the stomach wall, making the stomach firm and non-distensible. It is not associated with Helicobacter pylori infection. Diagnostic upper endoscopy remains the gold standard for evaluation, however such malignancies that spare the mucosa can be easily missed on endoscopy or histopathology. The lack of mucosal involvement decreases the yield of endoscopy and biopsy, and findings on computed tomography imaging of the abdomen lack specificity. Early diagnosis remains challenging, as endoscopic findings are less sensitive. Clinicians should maintain a high index of suspicion for this condition with findings of localized congested-appearing gastric mucosa, especially with distinct demarcation and regional non-distensibility of the gastric lumen. Deeper biopsies using “bite-on-bite” technique or endoscopic ultrasound guided fine needle biopsy should be considered.Figure 1.: A and B. Reticular appearance of gastric mucosa in linitis plastica. Figure C. Pathology of gastric biopsy demonstrating the classic appearance of signet ring cells in linitis plastica.

S2410 A Case of ADPKD Leading to Extrinsic Compression of the Stomach and Dysphagia

Introduction: Autosomal dominant polycystic kidney disease (ADPKD) is a common inherited disease with incidence of 1 in a 1000 live births. Disease symptoms usually present after 30 years of age and progresses to end-stage renal disease by the fifth decade of life. In addition to development of renal cysts which enlarge the kidneys, these can also form in the liver, pancreas and spleen. In the setting of renal enlargement, serious complications can develop such as extrinsic compression of internal structures. We present a case of massively enlarged polycystic kidneys leading to progressive dysphagia mimicking esophageal dysmotility disorder secondary to extrinsic compression of the stomach. Case Description/Methods: A 43-year-old female diagnosed with ADPKD 4 years prior, presented with progressive dysphagia to solids and liquids for 1 month. Patient suffered from ESRD on hemodialysis. CT abdomen and pelvis showed massively large polycystic kidneys occupying most of the abdominal space, polycystic liver and extrinsic compression of the stomach. EGD from a recent prior hospitalization showed esophagitis and biopsy confirmed gastritis. GI series showed physiologic pattern of swallowing, no strictures or intrinsic obstruction seen in the esophagus, stomach and duodenum. The patient was started on a dysphagia diet which partially controlled her symptoms. Urology was consulted for bilateral nephrectomy (Figure). Discussion: This case reports a rare complication of ADPKD and to the best of our knowledge, this is the first case of massive renal cysts presenting as dysphagia in ADPKD. Mass effect symptoms described in literature were leg edema, abdominal fullness or pain, emesis, early satiety, heart failure, arrhythmia, intestinal obstruction and IVC compression. Dysphagia due to extrinsic compression should be considered as a complication of this disease. Renal cyst size correlates with degree of renal function and mass effect. In such cases, unilateral or bilateral nephrectomy should be strongly considered to decrease morbidity and mortality.Figure 1.: Massive polycystic kidneys.

S1686 Primary Pancreatic Diffuse Large B Cell Lymphoma: A Rare and TreaTable Malignancy

Introduction: Pancreatic lymphoma comprise less than 1 % of pancreatic malignancies. Most common location of diffuse large B cell lymphoma (DLBCL) are lymph nodes. Clinical symptoms and imaging studies have significant similarity resulting in delayed diagnosis or early initiation of comfort care measures. It is important to determine the histology of pancreatic tumor given the differences in management and prognosis. Here we report a rare case of primary DLBCL arising from pancreas. Case Description/Methods: 62-year-old female with history of HTN and DM presented with 30 lbs unintentional weight loss epigastric abdominal pain and early satiety. CT abdomen with IV and oral contrast demonstrated pancreatic mass. Core biopsy of pancreatic head mass demonstrated infiltration by large atypical lymphoid cells with high N/C ratio, round nuclear contour, fine chromatin and variably prominent nucleoli (Figure A). Atypical mitosis and apoptosis seen in background. Lymphoma cells positive for CD 19, CD 20 (Figure B). Final diagnosis Large B cell lymphoma germinal center type. FISH for BCL 2, C MYC were normal ruling out possibility of double or triple hit lymphoma. Cancer antigen 19-9 at the time of diagnosis was within normal limits. FDG PET/CT prior to initiation of treatment showed main foci of increased tracer activity appears to be in the proximal body of the pancreas just medial to the stomach, measures greater than 4 cm in diameter, and has a maximum SUV of 11.86 (Figure C). Rituximab- Cyclophosphamide HydrOxyadriamycin Prednisone (R-CHOP) every 3 weeks initiated. After one cycle of R-CHOP reported significant improvement in epigastric pain and started gaining weight. She completed 6 cycles of R-CHOP. Post treatment FDG PET/CT complete resolution of upper abdominal lymph node mass (Figure D). She remains in remission for the past 1 year. Discussion: Our case is an example of successful biopsy and treatment with aim to cure pancreatic malignancy. Despite radiological differences between pancreas adenocarcinoma and lymphoma, it is crucial to obtain adequate tissue sampling during from pancreas to establish histological diagnosis prior to discussion of prognosis and treatment plan. In general, DLBCL germinal center type has a 5-year survival of 70% with R-CHOP. Differential diagnosis of pancreatic mass that confer better prognosis than adenocarcinoma include neuroendocrine tumor, solid pseudopapillary tumor and lymphoma. Therefore, it is important to obtain biopsy and direct therapy based on histology.Figure 1.: A: Core biopsy of pancreatic head mass demonstrated infiltration by large atypical lymphoid cells with high N/C ratio, round nuclear contour, fine chromatin and variably prominent nucleoli. B: Lymphoma cells positive for CD 19, CD 20. C: FDG PET/CT prior to initiation of treatment showed main foci of increased tracer activity appears to be in the proximal body of the pancreas just medial to the stomach, measures greater than 4 cm in diameter, and has a maximum SUV of 11.86. D: Post treatment FDG PET/CT complete resolution of upper abdominal lymph node mass.

S3482 Small Bowel Enteropathy Induced by Immune Checkpoint Inhibitors: A Case Series

Introduction: While there is a growing understanding of the identification and management of colonic complications of immune checkpoint inhibitors (ICI), less is known about proximal intestinal complications. In this case series, we present 3 patients who developed small bowel enteropathies (SBE) after initiation of ICI. Case Description/Methods: Case 1: A 68-year-old female with stage IV non-small cell lung adenocarcinoma on pembrolizumab developed diarrhea with 7 watery bowel movements daily. EGD was normal and colonoscopy showed minimal sigmoid erythema endoscopically with histologic duodenitis and colitis. Despite treatment with vedolizumab, she remained steroid-dependent. Repeat EGD and sigmoidoscopy showed variable villous abnormality in the duodenum with associated epithelial lymphocytosis, focal active duodenitis, and resolution of colitis. Serologic evaluation revealed hypogammagobulinemia. Nine months after last dose of pembrolizumab, and ultimately therapy with intravenous immunoglobulin therapy and open-capsule budesonide, her symptoms resolved. Case 2: A 42-year-old male with metastatic melanoma treated with ipilimumab and nivolumab developed grade 2 diarrhea with steatorrhea, nausea, vomiting, and unintentional weight loss. EGD was endoscopically normal with biopsies showing active duodenitis with normal colonoscopy. He was initially treated with steroids, but due to persistent symptoms transitioned to infliximab. After receiving 3 doses of infliximab, he had complete resolution of symptoms. Case 3: A 59-year-old female with celiac disease (CD) and metastatic melanoma was started on nivolumab. She developed abdominal pain, early satiety, softer stools, and unintentional weight loss. EGD revealed non-bleeding duodenal erosions and duodenal mucosal changes consistent with celiac disease. Biopsies showed subtotal villous atrophy with increased intraepithelial lymphocytes. CD typing did not suggest refractory sprue. Her presentation was suggestive of a nivolumab-induced exacerbation of CD. After a year of intermittent steroid therapy and adherence to a gluten-free diet, symptoms resolved. Repeat EGD with biopsies showed normal villi and reduced intraepithelial lymphocytes. Discussion: In this case series, we present three patients who developed SBE, highlighting the challenge of its diagnosis and management. SBE should be suspected in individuals with altered stools and no evidence of classic colitis.

S3664 Russel Body Gastritis: When the Rare Meets the Odd

Introduction: The significance of chronic gastritis is underrated. Even though Helicobacter pylori (HP) has been the main contributing factor to this condition, if testing for it comes back negative, we should always rule out other underlying diseases, especially if the biopsy reveals Russell body (RB) gastritis. Case Description/Methods: A 67-year-old male with a past medical history of immune thrombocytopenic purpura (ITP) on prednisone and eltrombopag, hypertension, and choledocholithiasis status post cholecystectomy complicated by abscess formation and drain placement, presented with worsening nausea, vomiting, and abdominal pain for three days associated with early satiety and weight loss. His symptoms were not related to food or activity. Vital signs and physical exam were unremarkable except for right upper quadrant abdominal tenderness. Labs were remarkable for WBC 55 k/ul, HGB 11 g/dl, and PLT 90 k/ul. Full infectious workup was negative. CT scan showed massive splenomegaly with widespread lymphadenopathy and circumferential wall thickening of the gastric fundus and body. An upper endoscopy was performed and revealed diffuse gastric erythema in a mosaic pattern, most pronounced in the body of the stomach (Fig. 1a). Biopsies were obtained from the gastric antrum and body. Gastric body biopsies revealed gastric oxyntic mucosa with RB gastritis (Fig. 1b), and it was negative for HP, intestinal metaplasia, dysplasia, or malignancy. Kappa and lambda immunohistochemistry stain showed a polyclonal mixed population of plasma cells (Fig. 1c), indicating no underlying malignancy. HP stool antigen was checked twice, and it was negative. His WBC continued to rise, and bone marrow (BM) biopsy was performed. Findings were suspicious for myelodysplastic/myeloproliferative disorder; however, a reactive process could not be ruled out. Since the patient's condition significantly deteriorated, a repeat BM biopsy revealed morphological changes consistent with chronic myelomonocytic leukemia (CMML). After discussing goals of care with the patient, he opted for hospice care and expired after three days.Figure 1.: (a) An upper endoscopy showing diffuse punctuate gastric erythema with mucosal mosaic pattern. (b) A high power stomach biopsy with Hematoxylin and Eosin stain showing atypical plasma cells with Russell bodies (yellow arrow) which are eosinophilic homogeneous immunoglobulin-containing inclusions. (c) A high power stomach biopsy with kappa and lambda immunohistochemistry stain showing polyclonal mixed population of plasma cells (positive for both kappa and lambda). Discussion: RB gastritis is a reactive mucosal infiltration of plasma cells filled with cytoplasmic RB. There is a strong association with HP infection, but there is also an association with hematopoietic malignancies and gastric adenocarcinoma. Our case represents the vital importance of looking for underlying malignancies in HP negative RB gastritis patients.

Wilke's Syndrome

Background: Superior mesenteric artery (SMA) syndrome or Wilke's syndrome is a rare, atypical cause of upper gastrointestinal tract obstruction. It occurs due to acute angulation between SMA and aorta causing compression of the third part of the duodenum inbetween them leading to proximal intestinal obstruction. Clinical Description: SMA syndrome occurs mostly in patients who have significant weight loss. It occurs mostly due to the loss of the retroperitoneal fat pad, which serves as a cushion for the duodenum protecting it from compression between the two arteries. Causes include prolonged supine bed rest, spine surgery, an unusual high insertion of ligament of Treitz, other causes leading to weight loss, and congenital anatomical defects. Symptoms include weight loss, bilious vomiting, pain abdomen, postprandial nausea, early satiety, and anorexia. We report a 14-year-old female, a known case of pulmonary tuberculosis, who developed pneumothorax followed by acute gastric dilatation superadded with septicemia and upper gastrointestinal tract obstructive symptoms during the hospital course. Management: Detailed history and radio imaging such as barium studies or contrast-enhanced computerized tomography abdomen are required for diagnosis. Treatment includes conservative management such as gastric decompression, maintenance of electrolytes, nutritional rehabilitation via nasojejunal feeding, orally or parenterally. Treatment aims to restore the mesenteric fat pad to increases the angle between the two arteries. If it fails, surgery needs to be planned wherein duodenojejunostomy can be performed. Conclusion: An increased index of suspicion should be kept for this rare syndrome in children, especially in cases associated with significant weight loss. This may lead to timely diagnosis and saving a precious life.

S586 Prevalence and Significance of Restrictive Eating Habits Among Patients Presenting to a Tertiary Care Gastroenterology Clinic

Introduction: Complaints of gastrointestinal (GI) symptoms, such as postprandial fullness, abdominal distention, abdominal pain, gastric distention, early satiety, constipation, vomiting, flatulence, decreased appetite, borborygmi, and nausea, are frequent among patient with eating disorders, including anorexia nervosa and bulimia nervosa. In addition, there is a significant correlation between GI symptoms and hypochondriasis. Despite potential overlap of eating disorders and gastrointestinal disorders, it is unknown how many of these patients have restrictive eating habits and hence may benefit from further therapy including counseling by a specialist in eating disorders. The purpose of this study is to investigate the prevalence of restrictive eating habits in the patients seen an Ohio State University Gastroenterology clinic by conducting a retrospective review of the electronic medical records of patients in clinic. Methods: This is an observational and retrospective IRB approved chart review study. Patients seen in Ohio State University Gastroenterology clinic between August 1, 2021 and March 31, 2022 were screened for eligibility. Those who have completed the SCOFF questionnaire, are 18 years an older, speak English, and attended an appointment during the study time frame were included. Chart review included demographic information, past medical history, current medication use, eating habits, digestive symptoms, stress, and quality of life. Data was entered in RedCap and analyzed using t-tests. Results: A preliminary analysis of 20 patients found 20% screened positive for eating disorder using the SCOFF questionnaire, despite none having a prior established eating disorder diagnosis. Those with positive SCOFF screening had a diagnosis of anxiety more commonly than those with a negative SCOFF (p=0.02). All patients with a positive SCOFF had gastroesophageal reflux, type 2 diabetes mellitus, and prescription for a non-SSRI antidepressant. No significant difference in quality of life, perceived stress, dysphagia, or swallowing was identified in this group. Conclusion: The prevalence of positive eating disorder screen in patients with gastrointestinal disease is more than double the prevalence of eating disorders in the United States. Screening for eating disorders in gastrointestinal patients may be an important, previously unrecognized aspect of care for these patients.

S2436 A Rare Case of a Large Esophageal Gastrointestinal Stromal Tumor

Introduction: Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms, accounting for approximately 1 to 2 percent of primary gastrointestinal (GI) cancers. Presenting symptoms include abdominal pain, nausea, vomiting, early satiety, bleeding, and dysphagia, but vary depending on primary tumor location. Most tumors are discovered incidentally with the majority found in the stomach (40 to 60 percent) followed by small bowel (25-30 percent), colon and rectum (5-15 percent). We present a case of an elderly patient diagnosed with esophageal GIST after he was found to have an incidental esophageal mass on imaging. Case Description/Methods: 80-year-old male with PMH of HTN, HLD, DM2, CKD Stage III, COPD, former tobacco user was referred for an upper endoscopy for evaluation of an incidental finding on CT scan. CT demonstrated a mass arising from the distal esophagus, measuring 6.5 x 7.5 cm. Patient denied any dysphagia, abdominal pain, nausea, vomiting, weight loss, hematemesis, or melena. Endoscopy showed submucosal mass in the distal esophagus (Figure). Biopsy was inconclusive and subsequent EUS-guided fine needle biopsy was performed. Upper endoscopic ultrasound (EUS) showed an intramural lesion in the distal esophagus arising from the muscularis propria. Pathology results confirmed GIST, positive for CD117 and DOG-1. Further testing revealed a mutation in the KIT gene exon 11. Patient is currently undergoing neoadjuvant therapy with imatinib mesylate with anticipated surgical resection. Discussion: This is a rare case of a large esophageal GIST. Most mesenchymal esophageal tumors are leiomyomas, and GIST only accounts for 0.7% of them. EUS with fine need aspiration biopsy is the most accurate method for diagnosis and definite diagnosis is made histologically. Majority of GISTs, expresses the CD117 antigen, a KIT receptor tyrosine kinase. Another commonly found mutation is the platelet derived growth factor (PDGFRA) tyrosine kinase gene. Tumor size and mitotic rate are used for prognostication, with increased malignancy risk seen in tumor size > 3 cm with irregular margins. Tumor location is also a key factor in risk stratification; non gastric primary location has higher rates of metastases. Liver and peritoneum are the most common sites of metastatic GISTs. Treatment focuses on surgical resection and neoadjuvant therapy with imatinib. Given significant implication for its management, esophageal GIST should be considered in differential diagnosis and distinguished from more common esophageal leiomyomas.Figure 1.: Submucosal mass in distal esophagus.

S530 Nutritional Aspects in Patients With Gastroparesis: Normal BMI Despite Abnormal Intake!

Introduction: Patients with gastroparesis have signs and symptoms including nausea, vomiting, and early satiety, thus leading to inadequate food intake and a high risk of malnutrition. The classic clinical picture of gastroparesis is a symptomatic patient losing weight. We performed a systematic review and a meta-analysis to identify average body mass index (BMI) in patients with gastroparesis. Methods: Medline, Embase, Cochrane, CINAHL, and Scopus were searched for longitudinal studies reporting on nutrition in adult patients with gastroparesis. A search strategy was developed with core terms including “gastroparesis”, “BMI”, “calorie”, and “nutrition”. The main outcome was determined to be the average BMI in patients with gastroparesis. The secondary outcome was average calorie intake in these patients. Data was pooled and I^2 values were calculated to determine heterogeneity. No controls were identified for analysis. Results: Initial database search resulted in 3999 studies (n=3999). 16 relevant studies were identified for full text review (n=16). 5 studies were identified eligible to be included in the average BMI meta-analysis after applying inclusion and exclusion criteria (n=5). The weighted average BMI in patients with gastroparesis was calculated at (26.1 kg/m^2). Heterogeneity (I^2 value) for these studies was noted to be moderate at 46.7% (Figure 1A). 3 of the initial 16 studies identified for full review reported on distribution of patients with gastroparesis among different BMI categories with details shown in (Figure 1B). Another 3 studies were identified eligible to be included in the average calorie intake meta-analysis (n=3). Weighted average calorie intake in patients with gastroparesis was calculated at (1161 kcal/day), forest plot is shown in (Figure 2). Conclusion: Weighted average BMI in patients with gastroparesis laid in the overweight category, with most patients noted of normal weight per distribution of patient’s prevalence per category of BMI (Figure 1B). These results contradict with what is commonly thought of these patients being likely underweight for their inability to meet dietary requirements. Average calorie intake in patients with gastroparesis is found to be less than the recommended daily intake for adult males and females in the US. Reasons why patients are mostly of normal weight to overweight despite less than recommended daily calorie intake are not well understood and more investigations of other factors affecting BMI in these patients is warranted.Figure 1.: A) Forest plot of average BMI in patients with gastroparesis meta-analysis, B) Distribution of gastroparesis patients' prevalence among BMI categoriesFigure 2.: Forest plot of average calorie intake in patients with gastroparesis meta-analysis.

S3657 Primary Gastric Adenocarcinoma With Clear Cell Differentiation Presenting With Melena: A Rare Cancer Treated With Hybrid Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection

Introduction: Primary gastric clear cell carcinoma (GCCC) is an exceedingly rare type of adenocarcinoma. It can often be misdiagnosed as metastatic clear cell cancer with primary lesions in other body organs. We hereby present an interesting case of primary GCCC, successfully removed with hybrid endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Case Description/Methods: A 91-year-old male had ongoing anemia and melena due to intermittent oozing from a gastric body nodule. Previous EGD showed an oozing, nodular lesion in the gastric body (Figure 1A). On EUS, it was a benign, mucosal-based, friable lesion. Pathology revealed gastric intestinal metaplasia. His past history included hyperlipidemia, hypertension, skin cancer, transient ischemic attack, prior colon polyps, and sigmoid resection for diverticulosis. Home medications included cardizem, iron and vitamin C supplements, allopurinol, aspirin, and PPI. He denied recent weight loss, nausea, vomiting, early satiety, chest pain, dyspnea, fever, or dysphagia. He then came to our hospital for endoscopic removal of the gastric lesion. EGD showed a 3-cm sessile polyp on the posterior wall of the gastric body, located along the lesser curvature (Figure 1B, C). The polyp was completely removed by the hybrid EMR and ESD technique. Pathology revealed invasive adenocarcinoma of the intestinal type with clear cell features, arising in a background of extensive intestinal metaplasia (Figure 1; D, E, F). He developed post-procedure urinary retention and underwent temporary Foley's catheter placement, which was removed shortly after. No fever or GI bleeding was noted. After diagnosis, his oncologist recommended concurrent chemoradiotherapy. His most recent PET scan was unremarkable. No melena was reported at the follow-up after 3 months. Discussion: We herein presented a rare and interesting case of primary GCCC. In these patients, it is imperative for endoscopists to differentiate between primary GCCC and metastatic lesions to deliberate upon best therapeutic choice. Pathology with immunohistochemistry is the cornerstone of accurate diagnosis for primary GCCC. Given the extremely rare occurrence, no standard treatment guidelines exist for GCCC. Therefore, the therapeutic approach varies on a case-by-case basis, which largely depends on its localization. For instance, the 3-cm lesion in our patient was located along the lesser curvature and was successfully removed by hybrid EMR and ESD. Therefore, it did not necessitate total gastrectomy.Figure 1.: A: Previous EGD showing an actively oozing, nodular lesion in the gastric body. B and C: EGD showing a 3-cm sessile polyp on the posterior wall of the gastric body, located along the lesser curvature. D, E, and F: Pathologic examination of the polypectomy specimen showing invasive adenocarcinoma of the intestinal type with clear cell features, arising in a background of extensive intestinal metaplasia.

S514 Virtual Reality Improves Symptoms of Functional Dyspepsia: Results of a Randomized, Controlled, Double-Blind Pilot Study

Introduction: Functional dyspepsia (FD) is a common functional GI disorder, characterized by symptoms of abdominal pain, nausea, and/or early satiety. Virtual reality (VR) is a promising intervention which has been shown to alleviate pain in various clinical settings. There are currently no studies assessing VR for the treatment of FD. The aim of this study was to investigate the effectiveness and safety of VR for the treatment of FD. Methods: This is a prospective, single-center, randomized, controlled, double-blinded study of adult patients with FD (Rome IV criteria). Enrolled patients were randomized 2:1 (experimental to control). Experimental patients were given a VR headset with software consisting of immersive audiovisual programs. Control patients were given an identical headset with 2-D nature videos. Patients were asked to use their headset at least daily and completed Patient Assessment of Gastrointestinal Disorders-Symptom Severity Index (PAGI-SYM) and Nepean Dyspepsia Index (NDI) questionnaires at their initial visit, after 1 week of use, and at the conclusion of the 2-week study. Paired sample t-tests were used to compare questionnaire scores. Results: Thirty-seven patients were enrolled in the study (27 experimental, 10 controls); demographic data are shown in Table (Table). Patients used the VR headset an average of 1.3 times/day for a mean of 23.2 minutes/day. Total PAGI-SYM scores significantly decreased for all patients [2.51 (baseline) to 0.62 (week 2); p=0.000]. Notably, patients in the experimental group had greater improvement in mean total PAGI-SYM scores [2.51 baseline) to 1.83 (week 2); mean difference -0.68; p=0.000], compared to the control group [2.50 (baseline) to 2.04 (week 2); mean difference -0.46; p=0.046]. Further, quality of life (QoL) significantly improved for all patients, as the total NDI QoL score increased from 40.97 (baseline) to 57.14 (week 2), p=0.000, though experimental patients saw greater improvement in QoL, compared to control patients (Figure). Seventeen patients (45.9%; 11 experimental, 6 controls) reported non-serious adverse effects (AE), with headache and dizziness being the most common; 1 experimental patient withdrew due to AEs (migraines). Conclusion: In the first randomized, controlled, double-blind study to assess VR for the treatment of FD, VR was shown to be safe and result in statistically significant overall improvement in symptoms and QoL in FD patients. We propose VR as a novel treatment for FD worthy of further investigation.Figure 1.: Total PAGI-SYM and NDI Quality of Life Scores Table 1. - Study Population Demographic Data Mean Age 45 years (± 14) Mean BMI 24.56 (± 6.79) SexFemaleMale 30 (81.1%)7 FD subtypeEPSPDSMixed EPS/PDS 12 (32.4%)20 (54.1%)5 (13.5%) Anxiety 17 (45.9%) Depression 9 (24.3%) PTSD 2 (5.4%) Fibromyalgia 4 (10.8%) Prior H. pylori infection 5 (13.5%) MedicationsPPIAntidepressantsGabapentinOpioidsNSAIDs 16 (43.2%)11 (29.7%)4 (10.8%)2 (5.4%)0 Alcohol Use 7 (18.9%) Marijuana Use 4 (10.8%)