G30 Unusual cause of recurrent vomiting with failure to thrive in an infant. (12th September 2022)

• Record Type: Journal Article
• Authors: Venkatesh, Vybhav; Pradhan, Antaryami
• Is Part Of: Frontline gastroenterology. Volume 13(2022)Supplement 1
• Page Start: A36
• Page End: A36
• Publication Date: 2022-09-12
• Subjects: Gastroenterology -- Periodicals; 616.33005
• DOI: 10.1136/flgastro-2022-bspghan.50
• Languages: English
• ISSNs: 2041-4137

Abstract

Abstract : Introduction and Aim: To describe a case of an infant with recurrent vomiting from an unusual cause, who had significant delay in diagnosis leading to severe failure to thrive Methods and Results: A ten-month-old boy, symptomatic from 1 month of age with recurrent episodes of regurgitation, non-projectile vomiting was admitted for evaluation. There was history of recurrent episodes of cough and breathlessness requiring hospital admissions over the past few months. He was being treated as a case of gastro esophageal reflux disease (GERD). The postnatal history was uneventful and he weighed 2.6 kg at birth. On examination, the child was severely malnourished and weighed 3.8 kg. Systemic examination was unremarkable except for few bilateral fine crackles on chest auscultation. Investigations revealed anemia with a hemoglobin of 9.5 g/dl. The blood gas analysis, liver, kidney and thyroid function tests were with in normal limits. Ultrasonography of the abdomen showed normal pylorus length and thickness as well as normal relationship of superior mesenteric vessels. A barium swallow examination performed to detect any obstructive esophageal pathology like stricture or stenosis, showed a dilated esophagus with hold up of contrast and narrowing of the lower end with a 'rat tail' appearance ( figure 1 ). Upper gastrointestinal endoscopy (UGIE) showed a dilated esophagus and mild resistance while negotiating the gastroesophageal junction ( figure 1A-D ) and there was no evidence of any stricture or web/diaphragm. Esophageal manometry could not be performed due to technical difficulty. With the findings highly suggestive of achalasia cardia, he underwent Heller's myotomy along with fundoplication. Follow up examination one month post procedure showed an asymptomatic child who started to gain weight. Summary and Conclusion: Achalasia cardia is an idiopathic, primary esophageal motility disorder, characterized by the failure of relaxation of lower esophageal sphincter due to degeneration of the inhibitory neurons. It is usually seen in adults and a diagnosis of achalasia is extremely rare in the infantile period. Typical presentations in children include dysphagia, vomiting and weight loss. Diagnosis can be challenging and requires a high index of suspicion, especially in infants as the symptoms of vomiting, regurgitation, feeding difficulties and recurrent pneumonia can be seen with other common disorders like GERD and almost 50% percent are treated with anti-reflux therapies prior to the diagnosis of achalasia. Though barium swallow and UGIE are helpful in the diagnosis, high resolution manometry is the gold standard for diagnosing achalasia, but can be difficult in infants and children. Although pneumatic balloon dilation, botulinum toxin injections and more recently per oral endoscopic myotomy have been used to treat childhood achalasia, surgical treatment is definitive with good long-term results.