Unusual cause of recurrent vomiting with failure to thrive in an infant

Vybhav Venkatesh·Antaryami Pradhan

A 10-month-old boy,symptomatic from 1 month of age with recurrent episodes of regurgitation,non-projectile vomiting,and recurrent episodes of cough and breathlessness requiring frequent hospitalizations was admitted for evaluation.He weighed 2.6 kg at birth,but was severely malnourished weighing 3.8 kg on examination.

Ultrasonography of the abdomen showed normal pylorus length and thickness and normal relationship of superior mesenteric vessels.A barium swallow showed a dilated esophagus with hold up of contrast and narrowing of the lower end,with a “rat tail” appearance (Fig.1).Upper gastrointestinal endoscopy (UGIE) showed a dilated esophagus with puckered appearance of the gastroesophageal junction,which does not open on air insufflation (Fig.2 b),and with mild resistance,scope could be negotiated into the stomach (Fig.2 c,d).Thus,a diagnosis of achalasia cardia was made,and he underwent Heller’s myotomy with fundoplication.Follow-up examination one month post procedure showed an asymptomatic child who started to gain weight.

Fig.1 Barium swallow image showing dilated esophagus with contrast hold up and “rat tail” appearance of the lower end of esophagus(black arrow)

Fig.2 Upper gastrointestinal endoscopy images showing dilated esophagus (a),gastroesophageal junction not opening on air insufflation (b),negotiating the gastroesophageal junction with mild pressure (c),and stomach (d)

Achalasia cardia is an idiopathic primary esophageal motility disorder,which is characterized by the failure of relaxation of lower esophageal sphincter [1,2].Diagnosis can be challenging in infants and requires a high index of suspicion,as the symptoms of vomiting,regurgitation,feeding difficulties and recurrent pneumonia can be seen with other common disorders like gastroesophageal reflux disease [3].Pneumatic balloon dilation,botulinum toxin injections and more recently per oral endoscopic myotomy have been used to treat childhood achalasia and surgical treatment is definitive with good long-term results [2,4].

Author contributionsVV:conceptualization,data curation,formal analysis,investigation,writing—original draft and writing—review and editing;AP:data curation,supervision,administration,resources and writing—review.Both the authors read and approved the final version of the manuscript.

FundingNone.

Declarations

Ethical approvalEthical approval was waived for this manuscript by the ethics committee of Institute,as it an anonymized clinical image and all the procedures done for the patient were part of the routine care and necessary consents for them have been appropriately obtained.

Conflict of interestNo financial or non-financial benefits have been received or will be received from any party related directly or indirectly to the subject of this article.

Consent for publicationWritten consent for publication of the case details together with imaging has been obtained from the parent.