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Case of the Month

by Dr Noreen Norfaraheen Lee Abdullah MD (UKM), MMed Radiology (UKM), AM(Mal)

Answer to Case Of the Month 
Duodenal Atresia

Discussion of Findings
The supine abdominal radiograph of the child demonstrates two air bubbles; the large one is the stomach and another on the right, is the distended duodenal bulb. The rest of the abdomen is gasless. No bony abnormality is seen in the visualized thoracolumbar spine. The findings are consistent with complete duodenal obstruction. Duodenal atresia is a likely cause.
Duodenal Obstruction
Duodenal obstruction is a form of intestinal obstruction in the newborn. It may be complete or incomplete. When complete, it is known as duodenal atresia. When the obstruction is partial or incomplete, it is known as duodenal stenosis. The cause may be intrinsic or extrinsic. Intrinsic cause is usually due to a duodenal web or diaphragm. Extrinsic causes are due to Ladd’s bands, choledochal cyst, duodenal tumor or annular pancreas. Sometimes both processes exist. Duodenal obstruction is associated with Down’s syndrome, malrotation, esophageal atresia, imperforate anus, small bowel atresia, renal anomalies and congenital heart disease.

In duodenal atresia, the diagnosis is usually made antenatally. There is often history of polyhydramnios. However, the findings may not be apparent during gestation. During the antenatal ultrasound, the dilated stomach and duodenum may be observed. Postnatally, the symptoms depend on the type and degree of obstruction.

Duodenal atresia presents with symptoms immediately after birth as in this case within 24 hours of life. The vomitus may be bilious. This is due to obstruction below the level of the ampulla of Vater. The child’s abdomen appears scaphoid. Plain abdominal radiograph show gas in the distended stomach and dilated proximal duodenum. This is commonly known as the double bubble appearance. The rest of the abdomen is gasless.

In duodenal stenosis, the clinical symptoms are similar to that of duodenal atresia. However, radiographically there is abdominal gas distally. This is because the obstruction is incomplete. The presentation is also later in childhood depending on the degree of obstruction.

Upper gastrointestinal study may be performed. A small amount of barium is introduced via a small sized nasogastric tube. It is argued that in cases of duodenal atresia, there is no need of contrast study. Plain radiography is sufficient. The reason behind this argument is there is a potential risk of aspiration. However, should the clinician insist upon a contrast study, my suggestion is to use a nasogastric tube and small amounts of barium. It is important to aspirate out the contrast after the procedure. This lessens the possible hazard of aspiration. Ultrasound is increasingly becoming useful and will demonstrate a dilated fluid filled stomach and duodenum.
 
About the Author 
Dr Noreen, a Consultant Radiologist is currently with the Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.
 
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Last Updated:
Tuesday, 01 January 2008