Many different pathologies can present with epigastric pain, and the overlap of the symptoms of these varying entities can make diagnosis difficult clinically. This document focuses on scenarios including esophageal and gastroduodenal perforations, those occurring after post reflux surgeries and procedures, gastroesophageal reflux disease (GERD), esophagitis, gastritis, peptic ulcer disease, and hiatal hernias. Also included is recurrent GERD and hiatal hernia post reflux procedures and surgeries. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

The Lyon 2.0 consensus was established to further refine the original Lyon consensus and address gaps in reflux testing and endoscopic diagnosis of GERD. It represents a significant advancement in the diagnostic framework of GERD through modern definition of GERD, endoscopy findings, conclusive of GERD and reflux testing metrics and thresholds.

Persistent chronic cough is a common outpatient symptom, typically caused by gastroesophageal reflux, asthma, or upper airway cough syndrome. Rare causes, including metastatic tumors, may present with nonspecific respiratory symptoms, particularly in patients with a history of malignancy. A 59-year-old man with a prior left frontal grade II solitary fibrous tumor (SFT) resected in 2012 presented with a 2-3-month history of dry cough. Initial empiric therapy for gastroesophageal reflux and post-nasal drip failed. Chest radiograph revealed multiple bilateral pulmonary nodules, and CT chest showed an 8 × 4.5 cm subcarinal mass. Bronchoscopy with transbronchial needle aspiration confirmed metastatic pulmonary SFT. The patient is now being followed by oncology for staging and treatment planning. Persistent cough that does not improve with empiric therapy warrants early imaging, especially in patients with prior malignancy. This case highlights that SFT can metastasize many years after initial treatment, presenting with common symptoms such as cough. Timely reassessment can prevent delays in diagnosis and management.

Proton pump inhibitors (PPIs) are among the most frequently prescribed medications in pediatric practice. While highly effective in acid-mediated disorders, concerns regarding overuse, inappropriate indications, and potential adverse effects have emerged, particularly in infants and children with nonspecific symptoms.

Leiomyomas are rare benign esophageal tumors and represent less than 1% of all esophageal neoplasms. Those located at the esophagogastric junction (EGJ) are uncommon and challenging due to their proximity to the lower esophageal sphincter. Most cases are asymptomatic and discovered incidentally, though symptomatic patients may present with dysphagia, heartburn, regurgitation, or chest pain. Diagnosis typically involves barium swallow studies, upper endoscopy, endoscopic ultrasonography, and computed tomography. Surgical treatment is recommended for symptomatic patients or those with tumors larger than 3 cm or showing rapid growth. Traditionally, open enucleation or visceral resection has been used, but recent advances include endoscopic, laparoscopic, and hybrid methods to achieve tumor enucleation. This report demonstrates a laparoscopic transgastric and endoscopically assisted enucleation of a large, horse-shoe shaped EGJ leiomyoma. The patient complained epigastric pain, occasional solid food dysphagia and mild regurgitation. The upper endoscopy revealed a large horseshoe-shaped subcardial mass at the anterior, left-lateral, and posterior aspects of the subcardial junction. Abdominal computed tomography (CT) showed a large hypointense subcardial mass and endoscopic ultrasound identified a 5 cm submucosal hypoechoic lesion from the muscular layer with diagnosis of leiomyoma at fine needle biopsy. A minimally invasive transgastric enucleation was planned and successfully performed. The technique involved a vertical anterior gastrotomy, incision of the overlying mucosa, blunt tumor dissection with enucleation, and mucosal closure with intraoperative endoscopic assistance. The postoperative course was uneventful with no postoperative complication and patient hospital discharge on postoperative day four. Histological examination confirmed the diagnosis of esophageal leiomyoma. This minimally invasive approach offers a safe, effective alternative to EGJ resection, especially for "plongeant" endoluminal leiomyomas involving the posterior aspect of the EGJ.