A 27-year-old female with a history of morbid obesity, thyroidectomy, and smoking presented to clinic for regurgitation of solids associated with chest pain for 1year. The pain is sharp, located at the lower end of the sternum, and most prominent after eating or drinking. Her symptoms have progressed and increased in frequency and now occur after any ingestion of solids or liquids. She has lost 20 pounds since the onset of symptoms. The patient denies odynophagia, hematemesis, or abdominal pain. Omeprazole 20mg daily and sucralfate three times per day did not improve her symptoms. A chest X-ray showed moderate- to large-size hiatal hernia. An upper endoscopy was performed and demonstrated a moderate-size paraesophageal hernia (Fig.1). There was no esophagitis or any other esophageal abnormalities. A pH impedance test was also performed with no pathologic acid exposure and nega­tive symptom indices. High-resolution esophageal manometry (HREM) showed normal peristalsis with an elevated integrated relaxation pressure (IRP) (Fig.2). The IRP remained elevated in the supine and upright positions, consistent with esopha­gogastric junction outlet obstruction (EGJOO). It is likely that the patient’s EGJOO was due to paraesophageal hernia. She was eventually referred for surgical evalua­tion for hernia repair and underwent a laparoscopic repair of her paraesophageal hernia with signicant postoperative improvement in her dysphagia and postpran­dial pain.