Endoscopy Challenge #6 - May '12

NASPGHAN Endoscopy Challenge #6
Benjamin Sahn, MD
Sudha Anupindi, MD
Michael Nance, MD
Petar Mamula, MD

13-year old boy with a complicated past medical history presented with dysphagia. His course began in infancy with severe gastroesophageal reflux symptoms. Throughout his childhood he continued to have symptoms of reflux and difficulty with swallowing and had Nissen fundoplication followed by two revisions along with a hiatal hernia repair complicated by esophageal perforation. At the age of 11 years he redeveloped a hiatal hernia and again underwent surgical repair of the hernia and revision of the fundoplication. He had a gastrostomy tube placed as well as a central intravenous line for long-term parenteral nutrition which were subsequently removed. An upper endoscopy demonstrated two esophageal diverticuli.

At this point, the patient transferred care to our institution. He was found to have a gastro-peritoneal fistula and abdominal abscess and underwent surgery to close the fistula. One year prior to the current presentation he underwent takedown of the fundoplication due to dysphagia symptoms which provided significant improvement allowing him to eat regular diet. Three weeks prior to this presentation he first developed dysphagia for solids, which then progressed to liquids, too.

Xray and Endoscopy Image