Fig. 21.1
a and b, Bile-stained vomiting in a newborn with congenital duodenal obstruction
Rarely, the vomiting is non-bilious if the obstruction is proximal to ampulla of Vater.
Features of trisomy 21 (Down’s syndrome).
Milder degree of partial duodenal obstruction as in those with duodenal diaphragm with a hole or duodenal stenosis may be recognized late in infancy or childhood (Fig. 21.2).
Fig. 21.2
Contrast study showing partial duodenal obstruction (duodenal diaphragm with a central hole). Note the thin contrast seen distally
Examination
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Upper abdominal distension or scaphoid abdomen if the stomach is empty or the child is on nasogastric drainage.
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Bilious aspirate in the nasogastric tube.
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Look for evidence of Down’s syndrome, dehydration, and associated cardiac malformation.
Associated Anomalies
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Trisomy 21 (Down’s syndrome) → 28.2 %
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Congenital heart disease → 22.6 %
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Annular pancreas → 23.1 %
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Intestinal malrotation → 19.7 %
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Esophageal atresia/tracheoesophageal fistula → 8.5 %
Diagnosis
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A plain abdominal X-ray showing double bubble is sufficient to confirm the diagnosis of complete duodenal obstruction (Fig. 21.3). Further contrast studies are not necessary.Fig. 21.3Plain abdominal X-ray showing dilated stomach (a) and double bubble sign (b; arrows) indicative of congenital duodenal obstruction
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If the plain abdominal X-ray shows distal bowel gas, the diagnosis is less certain and needs a contrast study especially to rule out the presence of malrotation (refer to algorithm in chapter on intestinal obstruction; Fig. 21.4).Fig. 21.4Contrast study showing complete duodenal obstruction. Note the absence of air or contrast distally
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The presence of a duodenal diaphragm with a central aperture is confirmed by the incomplete duodenal obstruction in absence of malrotation (Fig. 21.5).
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