Make the Diagnosis: Winter 2015

A 12-year-old boy presented to his pediatrician for a 2-month history of cough, postnasal drip, and nasal congestion. His symptoms, initially intermittent, are now persistent and associated with abdominal pain localized to the mid-chest and xiphoid regions. Wheezing was auscultated on physical examination, and he was treated with a bronchodilator. He returned to the office 1 week later with worsening cough, phlegm, nonbloody, nonbilious emesis, and dysphagia for liquids and solids. He described drinking large quantities of fluids to swallow properly and was able to handle his own secretions. He denied oral regurgitation of food, but had unrelenting chest pain. On physical examination, he was nontoxic and afebrile, but was mildly dyspneic with occasional wheezing. Abdominal examination was unremarkable except for tenderness to palpation at the xiphoid area. A chest X-ray was without evidence of pneumonia. He was prescribed an inhaled steroid for asthma and was started on a proton pump inhibitor.

Two weeks later, his dysphagia was not any better, and he now had a foreign body sensation in his mid-chest associated with meals. He was ordered a barium swallow, which showed distal esophageal tapering and spasm. He was referred to a gastroenterologist for further evaluation.

No one submitted the correct answer to last issue’s challenge, which was bariatric surgery and is the topic of this issue’s cover story.