Several learning points arise from Mr Neville's case.1 The most important relates to the diagnostic approach when we are challenged with pieces of a clinical puzzle that do not neatly fit together.

Gastro-oesophageal reflux disease usually poses few diagnostic challenges, especially when there is a good symptomatic response to empirical anti-secretory therapy. However, in this case, Mr Neville's poor response to treatment and persistent symptoms led to further investigation and several protracted stays in hospital. The normal oesophageal manometry …