A case to anchor the episodeA young woman regurgitates recognizable food ten to fifteen minutes after nearly every meal. It is effortless, without nausea or retching, and she has gained weight on twice-daily PPI. What is the diagnosis, what test confirms it, and why is more acid suppression the wrong move? This episode takes the patients who arrive after a structural and reflux workup has already come back clean. Here the history leads and the test only confirms, so the whole skill is recognizing the phenotype on the story. PPI failure in someone who looks like GERD on the surface is the alert that the diagnosis is not GERD. Topics coveredGlobus: the sensation eases or is unchanged by swallowing, the inverse of true dysphagiaGlobus workup is targeted; ENT exam and reassurance, not a default PPIRumination: effortless postprandial regurgitation of recognizable food, no retchingRumination fingerprint on postprandial HRM-impedance: the abdominal-strain R-waveRumination treatment is diaphragmatic breathing, not acid suppression or fundoplicationSupragastric belching: learned air cycle, gone in sleep, retrained like ruminationFunctional chest pain: visceral hypersensitivity treated with a neuromodulator, not more PPIOdynophagia is mucosal injury until proven otherwise, sorted by exposure before EGDPill esophagitis: kissing ulcers at the aortic arch; doxycycline, KCl, bisphosphonatesInfectious esophagitis by host: Candida plaques, HSV volcano-edge, CMV deep serpiginousBiopsy site separates the viruses: HSV from the ulcer edge, CMV from the ulcer base Key decisionsRumination and functional chest pain both defeat escalating PPI because neither lesion is acid: retraining and neuromodulators are the answersGlobus with no alarm features (dysphagia, weight loss, hoarseness, neck mass, smoking) gets ENT exam and reassurance, not endoscopyPill esophagitis is a history diagnosis: sudden retrosternal odynophagia after a specific tablet taken with little water, kissing ulcers at the archHSV biopsies come from the ulcer edge (infected epithelium); CMV biopsies from the ulcer base (infected stroma). Forgetting this misses the organismCandida host pattern (PPI plus inhaled steroid, CD4 under 200, transplant) supports empiric fluconazole; viral or pill features push straight to EGD For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com.Questions or feedback: [email protected]. (00:00) - Opening: the phenotype the history reveals (01:30) - Globus: the inverse of dysphagia (04:00) - Rumination syndrome and the abdominal-strain R-wave (07:30) - Supragastric belching and functional chest pain (10:30) - Functional heartburn and reflux hypersensitivity (12:00) - Odynophagia: sort by exposure before the scope (13:30) - Pill esophagitis: kissing ulcers at the arch (16:00) - Infectious esophagitis: Candida, HSV, CMV by host and biopsy site

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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