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Having occasional episodes of reflux is physiologic, whereas pathologic GERD in children consists of frequent or persistent episodes leading to esophagitis and other esophageal and respiratory symptoms [1,2]. Multichannel intraluminal impedance-pH (MII-pH) monitoring has become the gold standard of diagnosis for GERD [3]. GERD should be EPZ-6438 purchase diagnosed with caution, particularly in children with atypical clinical presentation, even after MII-pH monitoring, because GERD might not be the primary disease [4,5]. Achalasia is a neurodegenerative disorder of the lower esophageal sphincter (LES) which occurs less commonly in children as compared to adults, and achalasia can present as progressive dysphagia, vomiting, and weight loss [6]. Esophageal manometry is the gold standard in diagnosing achalasia, but it is not convenient to perform in children. Recently, the development of high-resolution manometry (HRM) is leading to the replacement of conventional manometry. However, the experience with using HRM in children is limited. We report a case that illustrates the pitfalls of diagnosing GERD and the value of HRM in a pediatric patient with achalasia. CASE REPORT A nine-year-old boy presented with a one-year history of heartburn, persistent post-prandial vomiting, infrequent dysphasia, and a nocturnal cough that developed three months prior to presentation. At another hospital, he PD0325901 nmr had an upper gastrointestinal endoscopic examination GRB10 and was diagnosed with acute gastritis; he was also prescribed a medication for the acute gastritis, but his symptoms did not improve. He had no history of allergies, and his family history was unremarkable. His weight was 23.7 kg (5-10th percentile), body mass index was 14.7 (