1413 Twelve-Year-Old Male With Esophageal Dysphagia: A Diagnostic Dilemma!

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INTRODUCTION: Esophageal dysphagia is defined as any difficulty or abnormality of swallowing with delay in transit of solids or liquids in the esophageal phase. We present an interesting case of a young male evaluated for esophageal dysphagia and failure to thrive who was, after an extensive workup, found to have an esophageal duplication cyst. CASE DESCRIPTION/METHODS: A 12-year-old male was transferred from a local hospital with a 4-week history of sub-sternal pain, worsening dysphagia, odynophagia, a sensation of “food stuck in his chest” and an 8-pound weight loss. He was seen by his primary physician and started on ranitidine for possible gastrointestinal reflux disease (GERD) without improvement in his symptoms. He was admitted a week later due to worsening symptoms, new onset nausea, non-bloody, non-bilious vomiting and a fever (102.5 F). Due to persistent symptoms, an upper gastrointestinal series with contrast was performed, which was concerning for an esophageal diverticulum, an esophageal manometry and ultimately, esophagogastroduodenoscopy (EGD). An EGD revealed congested and friable mucosa throughout the esophagus, and a large opening in the posterior aspect of the middle esophagus. Due to inability to intubate this opening with a regular size endoscope, a neonatal upper endoscope was used. The opening was intubated, and the esophageal cyst was visualized (Video 1). Histology revealed normal basal thickness, papillary congestion and focal hemorrhage in the proximal esophagus. Due to parental preference, the patient was referred to another institution for a second opinion, where patient received fenestration of the cyst and is doing well. DISCUSSION: Esophageal duplication cysts are congenital abnormalities that arise during embryologic development and uncommonly present as dysphagia in an adolescent. Within the GI tract, only 2% arise from the esophagus. Duplication cysts often present as a diagnostic dilemma and thus, a high index of suspicion is needed. If a patient is not responding to standard therapy for esophageal dysphagia or has recurrent respiratory symptoms/infections, it may be necessary to pursue imaging or an endoscopic procedure. Alarm signs indicating a need for advanced diagnostics include failure to thrive, iron deficiency anemia, hematemesis, hemoptysis, weight loss or unresponsiveness to medical therapy. Larger multicenter prospective trials are needed to evaluate the utility of endoscopic ultrasound in both diagnostic and therapeutic management of esophageal duplication cysts.