From the Sundaram Medical Foundation, Dr Rangarajan Memorial Hospital, Annanagar West, Chennai 600 040, India.

Correspondence to: Dr. So Shivbalan, F 49, First Main Road, Annanagar East, Chennai 600 102, India. E-mail: [email protected]

Manuscript received: July 10, 2006; Initial review completed: August 30, 2006;
Revision accepted: March 30, 2007.

Abstract:

A 6-year-old boy presented with nocturnal cough of 8 months duration. Upper gastrointestinal endoscopy (UGIE) showed an esophagogastric polyp and esophagitis. The 24 hours ambulatory pH recording revealed moderate gastro esophageal reflux (GER) and esophageal manometry demonstrated hypotensive lower esophageal sphincter (LES). A diagnosis of gastroesophagel reflux disease (GERD) with hypotensive LES and inflammatory esophagogastric polyp was made. The child’s symptoms subsided with antireflux treatment.

Key words: Esophagogastric polyp, Gastro esophageal reflux, Nocturnal cough.

Gastroesophageal reflux disease (GERD) has a wide spectrum of clinical manifestations which includes both esophageal and supra esophageal symptoms. Depending on the age of the child respiratory symptoms such as apnea, stridor, reactive airway disease, cough or laryngitis can occur. Knowledge of the link between GERD and respiratory disease is essential for effective therapy.

A 6-year-old boy presented with nocturnal cough of 8 months duration. The cough was insidious in onset, disturbed his sleep and was more on lying down. This symptom did not occur during the day nor was it induced by exercise, however his school performance was affected as his sleep was disturbed. He had no fever, nasal catarrh, sneezing or watering of eyes. He had not lost weight though occasionally he had post-tussive vomiting. There was no history of wheeze, chest pain, palpitation, regurgitation, vomiting, retrostemal burn, gastrointestinal bleed, contact with tuberculosis. There was no history of atopy or asthma in the family. He had been treated with several antibiotics, antitussives and broncho-dilators but had not responded to therapy; at times bronchodilators even aggravated the cough.

On examination he was comfortable with a weight of 17 kg (<10th centile), height 120 cm (75th centile NCHS chart) without pallor, clubbing or cyanosis. ENT evaluation was normal. He had no wheeze or rales on auscultation of his chest. Other systemic examination was normal. The complete blood count, Mantoux test and radiography of the sinuses and chest were normal. Upper gastro-intestinal endoscopy revealed an esophagogastric polyp 0.5 × l cm (Fig. 1.) on a vertical fold at the squamo-columnar junction (Z line) with grade I esophagitis (Savary Miller grading) with prolapse of the gastric mucosa into the esophagus noticed during retching. The polyp was biopsied and the histopathology revealed gastric mucosa with minimal inflammation whereas the esophageal biopsy demonstrated mild esophagitis with no evidence of Barrett’s epithelium or malignancy. 24 hours ambulatory pH revealed moderate GER occurring more during sleep with reflux index of 8.3% (i.e. % of recording time with a pH less than 4). The esophageal manometry showed hypotensive LES (pressure <7 mm Hg) with appropriate response to swallow and normal peristalsis in the body of esophagus.

Fig. 1. Esophago-gastric polyp in UGI scopy

A diagnosis of GERD presenting as nocturnal cough was entertained with hypotensive LES being the cause of GERD and inflammatory esophagogastric polyp the sequel of GERD. He was started on omeprazole at 1 mg/kg/day and domperidone 0.2 mg/kg/dose thrice a day 30 minutes before each meal. Within a week, the child showed remarkable improvement with complete cessation of symptoms. His school performance and attentiveness also improved. UGIE done after 3 months of regular therapy showed no change in the size of the polyp however the child gained 4 kg after 7 months of therapy. He has been on follow up for over 18 months and the symptoms recur within 2 to 3 days of stopping medications. The parents have been counseled and adviced to continue medication till definitive surgery such as fundoplication was done.

GER has been identified as the causative factor in 4 to 52% of chronic cough in children and is more common when nocturnal symptoms are present(1). However cough, as a sole manifestation of GERD is uncommon in children(2). The respiratory symptoms in GERD may be due to the bronchospasm induced by macroaspiration, microaspiration induced stimulation of the upper airway receptors or stimulation of the acid sensitive vagal chemoreceptors in the esophagus.

The lower esophageal sphincter (LES) a high pressure zone (average pressure 18 to 20 mm Hg, 8.5 mmHg at 31 weeks gestation, 12.2 mmHg at 35 weeks and 18.1mmHg at 37 weeks and above.) is an important defence mechanism in the patho-physiology of GERD(3). Transient lower esophageal sphincter relaxation (TLESR), hypotensive LES and hiatus hernia are some of the adverse factors which affects the function of the LES resulting in GERD and its complications such as Barrett’s epithelium, peptic stricture and esophageal adenocarcinoma, This boy had a documented hypotensive LES which was probably initiating and perpetuating the reflux and GERD and the inflammatory polyp was secondary to GERD.

Upper gastrointestinal endoscopy in GERD may be normal or show features of esophagitis in 27%-76%(4). The inflammatory polyp-fold complex (IPFC) is an uncommon endoscopic finding in children. In this complex, an inflammatory polyp at the gastroesophageal junction is present, often in continuity with a prominent gastric fold(s). 1t is a sequel of GERD but is rarely reported in the studies of children with GERD though isolated case reports are available in literature. These polyps may regress in size with antireflux treatment(5,6). If symptomatic either presenting with dysphagia or bleed they can be removed by endoscopic mucosal resection(7), endoscopic polypectomy(8) or surgery(9).

Pediatricians should be aware of the fact that isolated respiratory symptoms like nocturnal cough may be due to GERD. Endoscopy with histology, 24 hours pH monitoring will help in confirming the diagnosis and in proper management. This case is being presented because of the unusual combination of a common symptom like cough and a rare finding on endoscopy. Inflammatory esophagogastric polyps due to GERD are rare in children and if identified should be biopsied to differentiate it from carcinoma.