A 65-year-old African American male was referred to the gastroenterology clinic for frequent hiccups and heartburn. His medical history included well-controlled type 2 diabetes, hypertension, hyperlipidemia, and Chiari-I malformation with hydromyelia in the cervical cord. His symptoms began at age 50 when he com­plained of frequent hiccups, bland regurgitation, and heartburn that did not respond to proton pump inhibitor treatment. A previous upper endoscopy revealed a mildly tortuous esophagus with a 4–5cm hiatal hernia and Cameron erosions. Ultimately, he underwent laparoscopic Nissen fundoplication with hiatal hernia repair. Unfortunately, after the surgery he continued to have constant belching and bland regurgitation. Six months after surgery, he underwent a timed barium esophago­gram which was notable for a dilated esophagus with severe esophageal dysmotility evidenced by retained contrast to the level of mid intrathoracic esophagus at 5min­utes (Fig.1). This study also revealed a slipped Nissen with migration of the wrap proximally above the level of the diaphragm and mechanical obstruction of the dis­tal esophagus. He subsequently underwent an upper endoscopy which showed a large diaphragmatic hernia along with severe LA Grade C erosive esophagitis, a dilated and tortuous esophagus (Fig. 2). High-resolution esophageal manometry (HREM) was performed and showed high median integrated resting pressure (IRP) and 100% failed peristalsis (Fig.3). The patient was diagnosed with type I achalasia post- Nissen fundoplication and referred for surgical evaluation for Nissen reversal with myotomy. The patient declined surgical intervention and unfortunately did not return to gastroenterology clinic.