Duodenal atresia

Background

• During weeks 6 and 7 of gestation, the GI tract becomes occluded then recanalizes during weeks 8 to 10
• Duodenal atresia is thought to result from failure of recanalization

Clinical Features

• Often presents with gastric distension and vomiting
• Often associated with other malformations such as biliary atresia or gallbladder agenesis
• May also be associated with cardiac, renal, or vertebral abnormalities
• About a quarter of patients born with duodenal atresia have Downs syndrome

Differential Diagnosis

• Malrotation with volvulus
• Hirschsprung disease
• Meconium ileus
• Intestinal atresia

Pediatric Abdominal Pain

0–3 Months Old

• Emergent
  • Necrotizing Enterocolitis
  • Volvulus
  • Testicular torsion
  • Inguinal hernia
    • Incarcerated hernia
  • Trauma
  • Pyloric stenosis
  • Toxic megacolon
  • Hirschsprung's Disease
• Nonemergent
  • Constipation
  • Acute Gastroenteritis
  • Colic

3 mo–3 y old

• Emergent
  • Intussusception
  • Testicular Torsion
  • Trauma
  • Volvulus
  • Appendicitis
  • Toxic megacolon
  • Vaso-occlusive crisis
• Nonemergent
  • Acute Gastroenteritis
  • Constipation
  • Urinary tract infection
  • Henoch-Schonlein purpura

3 y old–adolescence

• Emergent
  • Appendicitis
  • DKA
  • Vaso-occlusive crisis
  • Toxic ingestion
  • Testicular Torsion
  • Ovarian Torsion
  • Ectopic Pregnancy
  • Trauma
  • Toxic megacolon
  • Inflammatory bowel disease
  • Gastric ulcer disease
  • Ovarian cyst
  • Pregnancy
  • Pancreatitis
  • Cholecystitis
  • Intussusception (to age 6)
• Nonemergent
  • Constipation
  • Acute Gastroenteritis
  • Nonspecific viral syndrome
  • Streptococcus pharyngitis
  • Urinary tract infection
  • Pneumonia
  • Renal Stone
  • Henoch-Schonlein purpura
  • Inflammatory bowel disease
  • Vulvovaginitis

Diagnosis

• Presentation is very early in the postnatal period

• History
  • Often includes history of abdominal distention and vomiting
  • Obtain hx of whether vomiting is bilious or nonbilious and if vomiting follows feeds

• Physical Exam
  • Dry mucus membranes, poor skin turgor, and sunken fontanelle
  • Document signs of other congenital anomalies
  • The abdomen is often markedly distended with visible or palpable loops of bowel.
  • Examine perineum and assess for patency of the anus

Management

• Imaging
  • AP, lateral, and cross table XR should be obtained on all infants with concern for obstruction
  • Classic double bubble sign due to dilation of the stomach and proximal duodenum
  • Absent distal gas

• Treatment
  • NPO
  • NG tube to suction
  • Correct fluid and electrolyte abnormalities
  • Ampicillin and gentamicin (to prevent post-op infection)
  • Surgery

Disposition

• Admission

References

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