A 28-year-old female with a history of postural orthostatic tachycardia syndrome (POTS) and Ehlers-Danlos syndrome presented to gastroenterology clinic for con­tinued management of long-standing dysphagia, nausea, and vomiting. She initially started having problems with recurrent nausea and vomiting at the age of 15. Her main complaints included sensation of dry foods sticking in throat and choking and regurgitation after initiating a swallow. EGD at the time showed mild gastritis. She also had a normal gastric emptying study and a barium swallow that showed a tablet lodged in the mid-esophagus. A pH impedance test was also normal. She was evalu­ated by ENT, and laryngoscopy was normal. Her symptoms persisted despite treat­ment with high-dose pantoprazole prompting further testing with high-resolution esophageal manometry (HREM). Her ndings did not meet criteria for an esopha­geal motility disorder, but she demonstrated several episodes of post-swallow decrease in intraesophageal pressure, consistent with rumination events (Fig.1). She was diagnosed with rumination syndrome. The patient was referred to speech therapy for diaphragmatic breathing exercises and continued taking pantoprazole.

An 86-year-old male with coronary artery disease, prior coronary artery bypass graft (CABG), congestive heart failure, atrial brillation, hypertension, and a his­tory of gastric ulcer presented to the esophageal clinic for episodes of fainting that occurred during eating. The patient reported developing dysphagia to solids and pills, but not to liquids, soon after his CABG.His dysphagia symptoms progressed after suffering several transient ischemic attacks and a pontine ischemic stroke. Subsequently, he began experiencing syncopal episodes during meals, which resulted in avoidance of socializing and the need to use a safety helmet during meals. The syncopal episodes occurred four times over the span of 2months, and each was associated with choking and coughing spells prior to fainting, without any other prodromal symptoms. He also reported weight loss due to his dysphagia, but no odynophagia, hoarseness, or chronic cough. A modied barium swallow was performed with speech pathology evaluation, revealing normal oral and pharyngeal phases of swallow. He also underwent an upper endoscopy, which showed no esophageal abnormality. He was evaluated by otolaryngology and had laryngoscopy which showed no abnormality. A high-resolution esophageal manometry (HREM) was then performed and showed normal esophageal motility.