Interactive Quiz: Failure to Thrive and Nonbloody Vomiting
Welcome to Gastroenterology Consultant's latest interactive diagnostic quiz. Over the next few pages, we'll present a case and ask you to make the diagnosis and treat the patient. Along the way, we'll provide details about the case, and at the end, we'll share the patient's outcome.
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First, let’s meet the patient…
A 2-year-old boy presented to the emergency department (ED) with significant failure to thrive and nonbloody, nonbilious vomiting. The boy had been experiencing emesis with each meal and could only tolerate fluids, which began when he was 2 weeks of age. The boy was afebrile, without any sick contacts, showed no evidence of diarrhea, and no infectious symptoms.
On examination, the patient appeared fatigued. He was tachycardic; all other vital signs were within normal limits. His abdomen was soft, nontender, and nondistended, and no masses were palpated. The remainder of the physical examination findings were normal.
Laboratory test results were largely unremarkable except for microcytosis, with a mean corpuscular volume of 67 µm3. A liver function panel was performed, the results of which were normal. Additionally, electrolytes and creatinine levels were within normal limits.
Are you correct? >>
Answer: Double-contrast upper GI study
The boy successfully underwent a double-contrast upper GI study (Figures 1 and 2). An esophageal stricture was identified involving the lower one-third of the esophagus. The esophagus was foreshortened, with a moderate-sized hiatal hernia secondary to traction. Proximal esophageal dilatation was present. While no GER was noted during examination, the findings were in keeping with chronic/recurrent longstanding GER with secondary esophageal stricture. The child was referred to a pediatric surgery for evaluation. Gastroenterology and surgery together evaluated the patient.
The boy underwent an esophagogastroduodenoscopy (EGD), during which a peptic stricture was identified and subsequently dilated. Biopsies of the proximal and distal esophagus were taken, which showed chronic nonspecific ulceration of the distal esophagus on pathology results. The proximal esophagus demonstrated normal histologic findings.
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Answer: Proton-pump inhibitor therapy
Proton-pump inhibitor (PPI) therapy was then initiated for 4 months. The patient improved but presented to the hospital again 3 months later with vomiting. A repeat EGD was performed, which made note of the foreshortened esophagus, hiatal hernia, a mild circumferential narrowing proximal to the lower esophageal sphincter, and severe esophagitis.
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Answer: Increase PPI dosage
The PPI dosage subsequently was increased.
A third EGD was performed 1 month later, the results of which showed marked improvement of the esophagitis. Biopsy of the duodenum did not identify any pathologic abnormality. Stomach biopsy results were normal and were negative for Helicobacter pylori infection. A biopsy taken from the esophagus demonstrated mild esophagitis consistent with gastroesophageal reflux disease (GERD). He was subsequently seen in follow up by the gastroenterologist.
The patient was still experiencing occasional vomiting, but much less than at the time of his initial presentation. Moreover, he was gaining weight appropriately. Surgical intervention has not been required.
The child in this case had been born in a region of civil unrest and with limited health care access; as a result, his GERD remained undiagnosed for a significant time. As a result of his longstanding GERD, the child developed an esophageal stricture that was identified by way of an upper GI series and EGD.
To read the full case report, see:
Mannina D, Agrawal RR. Esophageal stricture secondary to gastroesophageal reflux disease in a 2-year-old boy [published online December 19, 2018]. Gastroenterology Consultant. https://www.consultant360.com/article/gastroenterology/pediatric-gastroenterology/esophageal-stricture-secondary-gastroesophageal.