An 11 year old child was referred to our institution with a 3 year history of persistent and distressing regurgitation episodes. A liquid barium study was normal, but a modified, solid based study showed hold up at the lower oesophageal sphincter (LOS). An endoscopy was normal and a dilatation of the LOS to 20mm provided 8 months of symptomatic relief. However, the regurgitation then reoccurred and a repeat dilatation did not result in any symptom improvement.

At our institution, a high resolution oesophageal manometry (HROM) showed intact peristalsis and median integrated relaxation pressures (IRP) of 37.6 mmHg for wet swallows and 34.9 mmHg for solid swallows suggestive of gastro-oesophageal junction (GOJ) outlet obstruction.

An EndoFLIP Topography showed normally propagated contraction, but non relaxing LOS and a repeat LOS dilatation produced no symptomatic relief. A botulinum toxin injection into the LOS resulted in a good symptomatic improvement. A repeat HROM three months later showed normal peristalsis and median IRP had improved to 19.8 mmHg for wet swallows and 14.7 mmHg for solid swallows. There was no bolus hold up in the distal oesophagus.

Nine months after the botulinum toxin injection, the child reported recurrence of regurgitation and a further HROM, 11 months post botulinum toxin injection, showed median IRP values of 6.0 mmHg for wet swallows and 10.5 mmHg for solid swallows. Abdominal contractions with retrograde bolus movement were seen, a feature consistent with rumination syndrome.

In conclusion, we present a partial response to pneumatic dilatation in child with idiopathic GOJ outlet obstruction, but good symptomatic response to botulinum toxin injection and subsequent development of typical clinical and manometric features of rumination syndrome.

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Abstract OC79 Figure 1

A: Manometry pre-intervention, IRP 38mmHg, B: Manometry post-Botox, IRP 15 mmHg