An 81-year-old man with idiopathic PD (diagnosed in 2021) presented in March 2024 with one month of persistent daytime nausea occasionally disrupting sleep. He denied constipation but noted unintentional weight loss. Proton pump inhibitors and ondansetron were ineffective. Importantly, nausea occurred independently of levodopa dose timing and did not improve with typical management including additional carbidopa, reduction of dopaminergic medications, or administration with food, suggesting symptoms were unrelated to dopaminergic therapy. EGD revealed a 14 mm GE junction stricture (dilated to 15–18 mm) and a 4 cm hiatal hernia. A gastric emptying study confirmed mild gastroparesis. Trials of CBD/THC, scopolamine, and vagal nerve stimulation (GammaCore) provided limited benefit. Mirtazapine 7.5 mg nightly was initiated, later titrated to 15 mg.