A case to anchor the episodeA patient with severe reflux and dysphagia has absent contractility on nearly every swallow and a hypotensive lower esophageal sphincter. The reflux looks like the dominant problem. Should you offer an antireflux operation? These patients carry a surgical or systemic history the EGD report was never built to surface. The connecting principle is simple: the diagnosis lives outside the scope findings, so the job is to ask the question that reveals it and to read post-surgical anatomy on a barium swallow before an endoscopy. Topics coveredPost-fundoplication dysphagia: slipped, tight, and telescoped wraps each map to a next moveBarium swallow first after fundoplication: it shows wrap geometry the EGD cannot reconstructSleeve gastrectomy: incisura stricture and worsened reflux, not reliefRoux-en-Y as the antireflux bariatric operation; anastomotic stricture and marginal ulcerScleroderma: absent distal contractility plus a hypotensive LES, the cleanest fingerprintScleroderma reflux is a pump failure, so fundoplication fails; aggressive PPI insteadSjogren: dysphagia from lost salivary lubrication and a refractory-reflux clueAmyloid: infiltrative fibrils, macroglossia as the AL hint, treat the underlying processNeuromuscular dysphagia: ALS, myasthenia (fatigable), polymyositis and dermatomyositisDermatomyositis carries a malignancy association warranting age-appropriate screeningChemoradiation: acute mucositis and late fibrotic stricture managed with dilation Key decisionsPost-fundoplication or post-bariatric dysphagia is read first on a barium swallow, not an EGD: geometry drives the diagnosisThe tight wrap gets early pneumatic dilation; the slipped wrap gets PPI for its recurrent reflux, with revision for dilation failureScleroderma physiology (failed peristalsis plus open LES) means fundoplication fails: the pump cannot push a bolus past a wrap, so treat reflux medicallySleeve gastrectomy worsens reflux, so Roux-en-Y is the antireflux bariatric operation in a patient with established GERDNew dysphagia plus macroglossia points to AL amyloid: send immunofixation, free light chains, and marrow biopsy; dermatomyositis triggers cancer screening For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com.Questions or feedback: [email protected]. (00:00) - Opening: the diagnosis outside the EGD report (01:00) - Post-fundoplication dysphagia: three patterns (03:30) - Post-bariatric dysphagia by operation (05:30) - Scleroderma esophagus: the cleanest fingerprint (07:30) - Sjogren and amyloid (09:00) - The neuromuscular dysphagias (10:00) - Chemoradiation injury and the through-line

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

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