<prompt> A 37-year-old woman presents with complaints of severe heartburn with or without meals. She has a history of hypertension, which has been treated with captopril. She also has a history of Raynaud disease, multiple facial telangiectasias, and very taut skin on the dorsum of both hands. She has failed to obtain relief for her heartburn with large doses of antacids, or omeprazole. Esophageal manometry is ordered. Most likely results of this test is ?Decreased esophageal peristalsis and decreased LES pressureDecreased esophageal peristalsis and increased LES pressureIncreased esophageal peristalsis and decreased LES pressureIncreased esophageal peristalsis and increased LES pressure  <response>: This patient has the classic presentation of gastroesophageal reflux disease GERD in association with scleroderma. These patients have the deposition of collagen in the body of the esophagus, as well as the lower esophageal sphincter LES. This results in the typical pattern of decreased esophageal peristalsis and the reduced ability of the LES to maintain its high pressures between swallowing. These patients are therefore at risk for severe GERD and subsequent complications of peptic stricture and Barretts esophagus. Although there is no corrective therapy to improve esophageal motility or increase LES pressure, aggressive treatment is generally aimed at reducing acid production with the use of high doses of proton pump inhibitors. Nevertheless, many of these patients develop the long-term consequences of GERD. Achalasia, in which impaired esophageal peristalsis is often accompanied by a lack of lower esophageal sphincter relaxation. 