Question: A 77-year-old woman with gastroesophageal reflux disease, hypertension, and recurrent aspiration pneumonias presented as a referral for evaluation and management of persistent dysphagia. She reported having dysphagia to liquids more than solids for last 8-9 years with associated heartburn, regurgitation, and chest pain. She had 25-lb weight loss over the last 6 months and had 4 hospitalizations over the last 4 years for volume depletion and 2 hospitalizations for aspiration pneumonia. She underwent multiple empiric esophageal dilatations (Maloney 49-50 Fr dilators) over last several years without any improvement.