The treatment of patients with unexplained chest pain is difficult and challenging. After a cardiac etiology has been ruled out, a diligent search for an esophageal etiology-gastroesophageal reflux disease, motility abnormalities, or esophageal hypersensitivity-should be undertaken with judicious use of a diagnostic (therapeutic) trial of therapy, ambulatory pH monitoring, or esophageal manometry. The recent literature discusses the use of high-dose omeprazole in diagnosing and treating chest pain associated with gastroesophageal reflux disease, correlates abnormal ambulatory pH monitoring with response to omeprazole, and provides additional insights into the pathogenesis of esophageal chest pain.