Achalasia^34,35

Incidence = 0.18 cases per 100,000 person-years (average age at diagnosis = 10.9 years)

Gradual dysphagia for solids, then liquids

Eating behaviors to overcome contracted lower esophageal sphincter (moving side to side, stretching, eating slowly, walking after eating)

Difficulty belching

Barium study (classic bird's beak sign)

Manometry

Treatment: pneumatic dilation, onabotulinumtoxinA (Botox) injection, or laparoscopic myotomy of the lower esophageal sphincter

Crohn disease³⁶

Incidence = 9.5 to 11.4 per 100,000 person-years

Abdominal pain, diarrhea, weight loss; dysphagia or odynophagia if esophagus is involved

Extraintestinal manifestations include arthritis, skin disease (erythema nodosum, pyoderma granulosum), eye disease (eposcleritis, uveitis), liver disease

Endoscopy with biopsy

Male:female ratio = 1.5:1 in prepubescent children

Incidence in childhood increases with age

Cyclic vomiting syndrome^37,38

Prevalence estimated at 0.3% in school-aged children

Diagnostic criteria:

5 or more attacks in any interval, or 3 or more attacks over 6 months

Episodic attacks of intense nausea/vomiting lasting hours to days, occurring at least 1 week apart

Vomiting 4 or more times per hour for at least 1 hour during attacks

Clinical diagnosis

Preventive measures: avoid excitation, fatigue, fasting, and food triggers; regulate menses

Pharmacologic prevention options include tricyclic antidepressants or propranolol

For acute attacks: consider antiemetics, triptans (off-label) in adolescents

Eosinophilic esophagitis^39,40

Incidence = 0.7 to 10 per 100,000 person-years

Atopy in up to 60% of children

Endoscopy with biopsy

Consider in children with symptoms that do not improve with acid suppression therapy

Intestinal atresia⁴¹

Duodenal atresia: 0.9 per 10,000 live births

Jejunoileal atresia: 0.7 per 10,000 live births

Abdominal distension, bilious vomiting in first days of life

Failure to pass meconium

Delayed or protracted symptoms when there is a partial obstruction

Barium study (classic double bubble sign)

Often observed on prenatal ultrasonography with polyhydramnios

Duodenal atresia is associated with Down syndrome

Jejunoileal atresia is typically due to vascular compromise

Intestinal malrotation⁴²

1 in 500 live births

Abdominal pain and bilious vomiting

Older infants and children may have chronic colicky abdominal pain, solid food intolerance, failure to thrive, recurrent nonbilious vomiting, gastrointestinal bleeding

Barium study

Male:female ratio = 2:1

40% present within first week of life; 50% by 1 month of age; 75% by 12 months of age

Pyloric stenosis⁴³

2 to 5 per 1,000 live births in developed countries

Nonbloody, nonbilious projectile vomiting

Often presents at 2 to 4 weeks of age

Olive-sized abdominal mass

Upper abdominal ultrasonography

Male:female ratio = 4:1

Requires urgent surgical pylorotomy