"As I stood up to examine him, he offered a unique observation." He was my last patient of a long day. Fueled by a second cup of coffee, I opened the door to a pleasant gentleman with medical issues that had markedly impaired his quality of life for decades. His prior testing and treatment had not elicited clinical improvement or a straightforward diagnosis, which is a frustratingly frequent situation in gastroenterology. These are the challenging, yet frequently most rewarding, cases that