Case Presention

Distended Proximal Bowel loop – Antenatal diagnosis at 33 weeks.
Dr. Hema Divakar Consultant Obstetrician
Dr. Chitra Ganesh Consultant Sonologist
Dr. Ramesh Consultant Paediatric Surgeon

Mrs.B, 27 years, Primi
No history of consanguinity or birth of anomalous babies in her family.
Mid trimester scan (18-19 weeks) reported normal.
III trimester scan (33-34 weeks) had following findings:

     

  • dilated fetal stomach and the first part of fetal duodenum
  • dilated duodenum shows hyper peristalsis and a tapered distal
  • arrowing
  • Remaining bowel loops were normal.
  • Liquor volume is normal.
  • No other anomalies detected.

Provisional Scan diagnosis was:

  1. Dilated stomach and first part of Duodenum with hyperperistalses.
  2. As there is no polyhydramnios the possibility of total duodenal obstruction is unlikely.
  3. The possibility of the subtotal obstruction due to band or annular pancreas is to be considered.

Possiblities considered at this point : Incomplete Duodenal obstruction

  • Malrotation
  • Duodenal stenosis

Further management would include Counselling to rule out Trisomy
Delivery at term
Review at birth

Patient was admitted for emergency LSCS for PIH and delivered a female baby weighing 1.8kgs.

Paediatric Surgical opinion taken and the baby shifted to Tertiary care center further investigation and management.

 
Post Alnatly   Barium Study

Post natal Investigations:
X-ray studies with the feeding tube inside appeared normal.
Contrast Barium studies revealed Distended stomach and grossly distended proximal duodenum with the dye passing through highly suggestive of a web.

Fetal Karyotype : Normal

Final Diagnosis: Duodenal WEB.
Management :
Surgical removal of the web. The baby survived well there after.
 
 


Discussion: Duodenale atresia is the most common perinatal intestinal obstruction.

Incidence: 1 in 2710 to 1 in10,000 live births.

Embryology: First part and proximal half of second part of duodenum develops from foregut. Rest of the duodenum from midgut.

During 5th and 6th week after conception, the lumen of the duodenum is temperorily obliterated by rapidly replicating epithelium and patency is restored by the end of embryonic period. Failure of this luminal recanalisation results in duodenale atresia.

Etiology: Mostly sporadic. In some autosomal recessive pattern of inheritance noted.

Ultrasound appearance and Prenatal diagnosis
“ Double bubble” appearance of dilated stomach and proximal part of duodenum by late 2nd or early 3rd trimester [ by 25 wks] —Associated with Polyhydraminos.

Normal appearing stomach with Polyhydraminos doesnot ruleout duodenale obstruction-Intermittent “ Double bubble” appearance could be due to fetal vomiting.

Partial duodenale obstruction due to band on diaphragm as in the index case need not be associated with polyhydraminos.

Prognosis: Duodenale atresia is an isolated anomalyin 30-52%
In the rest associated GI, skeletal, Cardiac, renal abnormalities are noted.
Survival after surgery in cases with isolated duodenale atresia is more than 95%.

Establishment of diagnosis in Pre-natal period helps in reducing the morbidity associated with diagnostic delay in duodenale atresia in Neonatal period.

Outcome