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Introduction Gastrointestinal (GI) involvement is among the most frequent organ manifestations in systemic sclerosis (SSc), yet the timing of presentation of GI manifestations remains incompletely understood. We aimed to describe the baseline prevalence and the incidence of new GI manifestations over time in a real-life SSc cohort.Material and Methods We included patients from the Zurich cohort fulfilling the ACR/EULAR 2013 criteria for SSc or the VEDOSS criteria. Electronic medical records were searched for data regarding the presence and the time of detection of esophageal disease, gastroparesis, gastric antral vascular ectasia (GAVE), small intestinal bacterial overgrowth (SIBO), chronic intestinal pseudo-obstruction (CIPO), chronic constipation, and chronic diarrhea. Data of the University of California at Los Angeles/Scleroderma Clinical Trials Consortium Gastro-Intestinal Tract instrument 2.0 (GIT2.0) questionnaire were also collected. Based on the GIT2.0 scores, the baseline GI disease burden was categorized into: (1) none-to-mild, (2) moderate, and (3) severe-to-very severe (Khanna D. et al, Arthritis Rheum. 2009; 61:1257-63.).We assessed baseline prevalence of GI diagnoses and used survival curves to investigate the timing of GI diagnoses from SSc onset, defined as occurrence of the first non-Raynaud’s phenomenon sign or symptom.Results We included 658 patients: 83.6% females, mean age 55.4 years, median disease duration 3.6 (IQR 1.2-9.1) years, 566 (86%) with available GIT2.0.At baseline, 318 (48.3%) patients already presented with GI involvement, the most common being esophageal disease (45.0%). All other GI manifestations had a prevalence <4%. According to the GIT2.0 categories, around 20% of patients had moderate or severe-to-very severe GI disease.Over a mean follow-up of 3.3±3.2 years, additional patients developed new GI complications, with the cumulative prevalence increasing to 65% at last follow-up. Esophageal disease increased to 61.1%, Barrett’s esophagus from 3.8% to 7.9%, GAVE from 1.4% to 4.3%, SIBO from 0.8% to 7.0%, anal incontinence from 2.3% to 7.6% and GI bleeding from 1.8% to 5.3%. Only 4 patients developed CIPO.Focusing on patients with known disease duration from SSc onset [n=476 (72%)], we observed that the prevalence of esophageal involvement tended to show a stably steep increase from the early years (median time from disease onset: 7.5 years), while others like Barrett’s esophagus or SIBO occurred later and with a slow, stable trend.Conclusions GI involvement in SSc is frequent and dynamic, with distinct longitudinal time trends for individual complications. This provides important insights into SSc-GI disease natural history and may inform anticipatory management strategies.Abstract P.170 Figure 1