Teaching Case

Term newborn baby presenting with abdominal distension and bilious vomit.

This term baby was born in good condition by normal vaginal delivery. A few hours after birth he was noted to develop abdominal distension and bilious vomit. A plain x-ray of the abdomen revealed a typical double bubble sign which was consistent with a diagnosis of congenital duodenal atresia. Oral feeds were stopped and a nasogastric tube was inserted. He underwent a laprotomy and duodeno-duodenostomy was performed later that day. The post operative period was uneventful.

The incidence of duodenal atresia is between 1:7500 and 1:40000. Down syndrome is present in 30 % of the cases. It is also associated with other anomalies such as oesophageal atresia (10%), anorectal anomalies ( 10%), renal and cardiac abnormalities which are particularly common when associated with Down syndrome.Clinical manifestations include, abdominal distension, failure of passage of meconium and bilious vomiting, except when the obstruction is proximal to the Ampulla of vater. Maternal polyhydramnios is a common association. The diagnosis can be confirmed by a plain abdominal x-ray, which shows the double bubble sign with absence of gas distally. Aspiration of the stomach with a nasogastric tube and injection of 20 – 30 ml of air may be useful when there is excess fluid in the stomach or if the baby has vomited. The double bubble appearance can also be detected on antenatal ultrasonographic examination where the stomach and duodenum are distended with swallowed amniotic fluid. Preoperative care involves correction of fluid and electrolyte imbalance and nasogastric suctioning. The operation of choice is duodeno-duodenostomy. In the recent years, survival has improved considerably although factors such a prematurity and other associated anomalies sometimes contribute to mortality.