A 73-year-old man presented to the emergency room complaining of difficulty swallowing beginning abruptly after eating a salmon fillet. Four years ago he presented to another hospital with similar symptoms and had a barium esophagogram that showed “narrowing of the esophagus.” Since then he has had 8–10 of these episodes, all of which resolved spontaneously. The patient’s additional medical history was unremarkable. He takes a daily aspirin. His physical examination, blood work, and lateral neck radiograph were normal. Urgent upper endoscopy was performed. At 22 cm from the incisors, boneless salmon was seen proximal to a luminal narrowing in the esophagus. After gently pushing the fish forward, a smooth 1-cm peptic stricture with surrounding edema and erythema was seen (FigureA). Immediately proximal and contiguous with the stricture was an area of velvety, dark pink mucosa (FigureB), which on histology was consistent with heterotopic gastric mucosa (FigureC). A biopsy examination of the strictured mucosa showed gastric and squamocolumnar junctional mucosa with reactive epithelial changes and chronic inflammation (FigureD). The stricture was dilated with Savory dilators (Cook Endoscopy, Winston-Salem, NC) and the patient was started on pantoprazole. One year later he remains asymptomatic. An inlet patch is an island of heterotopic gastric mucosa located in the proximal esophagus, usually within 3 cm of the upper esophageal sphincter. It can be recognized by its salmon-red, velvety mucosa with well-defined margins. The inlet patch was first described by Schmidt in 1805,1Schmidt FA. De mammalium oesophage at que ventriculo. Inaug Dissert, Halle, In: Bathenea, 1805.Google Scholar and can be found in up to 10% of adults undergoing upper endoscopy.2Von Rahden B. Stein H.J. Becker K. et al.Heterotopic gastric mucosa of the esophagus: literature-review and proposal of clinicopathologic classification.Am J Gastroenterol. 2004; 99: 543-551Crossref PubMed Scopus (134) Google Scholar Its cause most likely is congenital, and it rarely has any clinical significance. There are, however, case reports of complications of inlet patches, including ulceration, overt bleeding, esophageal perforation, tracheoesophageal fistula, and even adenocarcinoma.2Von Rahden B. Stein H.J. Becker K. et al.Heterotopic gastric mucosa of the esophagus: literature-review and proposal of clinicopathologic classification.Am J Gastroenterol. 2004; 99: 543-551Crossref PubMed Scopus (134) Google Scholar Multiple studies have shown that the parietal cells of an inlet patch can secrete a clinically significant amount of acid, and it is this acid that likely results in the complications described.3Galan A.R. Katza D.A. Castell D.O. Acid secretion from an esophageal inlet patch demonstrated by ambulatory pH monitoring.Gastroenterology. 1998; 115: 1574-1576Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 4Hamilton J. Thune R. Symptomatic ectopic gastric epithelium of the cervical esophagus Demonstration of acid production with Congo red.Dig Dis Sci. 1986; 31: 337-342Crossref PubMed Scopus (58) Google Scholar By presenting this case, we hope to increase awareness that inlet patches sometimes can be clinically significant, and we remind the gastroenterologist of the importance of inspecting the proximal esophagus, which can be overlooked easily, when performing endoscopy for upper gastrointestinal symptoms.