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A 10-year-old boy with Costello syndrome, Arnold Chiari malformation, and gastrostomy tube dependence presented with daily vomiting for one year. Coarse facial features, low set ears, downward slanting palpebral fissures, pectus excavatum and scoliosis were noted on physical examination. Esophagogastroduodenoscopy (EGD) showed diffuse mucosal alterations (Panel A). Panel B is a photomicrograph of the biopsy. Surveillance EGD, 3 months and 1 year after, continued to show the same endoscopic and pathologic features despite acid suppression. What is the likely diagnosis?
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