|Year : 2020 | Volume
| Issue : 4 | Page : 1421-1423
Missed duodenal web in a patient of malrotation of the gut – a rare case
LD Agrawal1, Dileep Garg2, Sapna Singh3, Hema Mitra3
1 Department of Paediatric Surgery, Jaipur National University, Jaipur, Rajasthan, India
2 Department of Paediatric Surgery and Anaesthesia, SMS Medical College, Jaipur, Rajasthan, India
3 Department of Anaesthesia, Jaipur National University, Jaipur, Rajasthan, India
|Date of Submission||02-Dec-2018|
|Date of Decision||01-Jan-2019|
|Date of Acceptance||08-Jan-2019|
|Date of Web Publication||24-Dec-2020|
MCh, Halwai Khana, Kothi, Dholpur, Rajasthan
Source of Support: None, Conflict of Interest: None
'Always look for duodenal obstruction in a case of malrotation', this dictum has to be followed. The duodenum is the most common site for congenital intestinal obstruction. The duodenal web with a central hole can present without any overt signs of obstruction at a later age. Here, we report a case of duodenal obstruction presented with complain of vomiting. The patient was operated previously for malrotation of the gut at the age of 1.5 years. At surgery we found a duodenal web with central perforation. Web was excised, and the patient was discharged uneventfully.
Keywords: congenital, duodenal, malrotation, obstruction, web
|How to cite this article:|
Agrawal L D, Garg D, Singh S, Mitra H. Missed duodenal web in a patient of malrotation of the gut – a rare case. Menoufia Med J 2020;33:1421-3
|How to cite this URL:|
Agrawal L D, Garg D, Singh S, Mitra H. Missed duodenal web in a patient of malrotation of the gut – a rare case. Menoufia Med J [serial online] 2020 [cited 2021 Apr 18];33:1421-3. Available from: http://www.mmj.eg.net/text.asp?2020/33/4/1421/304505
| Introduction|| |
The duodenum is the most common site of intestinal obstruction, accounting for nearly half of all cases, while the ileum is the least affected. The incidence of duodenal obstruction ranges from 1 in 4000 to 1 in 15 000 live births. Duodenal web is an uncommon disease and occurs in 1 per 20 000–40 000 live births. More common in boys than girls, although in some studies the sex distribution is about even between men and women. Intestinal obstruction due to midgut malrotation in newborns is well known. However, intestinal obstruction due to malrotation associated with the duodenal web is rare.
Congenital duodenal web with a central hole can present without signs of obstruction at a later age. Therefore a high index of suspicion is necessary to diagnose when they present beyond the usual age. Most of the webs occur proximal to or near the ampulla of Vater, with 10% being found proximal to the ligament of Treitz.
| Case report|| |
The case report was approved by the ethical Committee of the hospital and the patient gave an informed consent. A 6-year-old female child brought to the pediatric surgeon with complain of recurrent abdominal pain in the supraumbilical region and bilious vomiting for 10 days. According to her parents the patient was getting relief after vomiting. There was history of decreased appetite with normal bowel habits. The patient was operated outside when she was 1.5-year old for malrotation of the gut.
On examination there was fullness in the upper abdomen. Rest of the abdomen was unremarkable. The patient was admitted and a nasogastric tube was inserted. On insertion of the nasogastric tube about 300 ml of bile was extracted with relief of upper abdominal fullness. The patient was resuscitated with intravenous fluid and antibiotics. On radiological examination there was a double bubble sign with paucity of gas shadow in the lower abdomen in plain radiography flate plate of the abdomen in an erect position. Ultrasound abdomen also reported duodenal obstruction.
Blood investigations showed hypokalemia and hyponatremia. Electrolyte imbalance was corrected with N/2 intravenous fluid with KCl. The patient was prepared for surgery the following day after correction of fluid and electrolyte imbalance.
The patient was explored through the old operation site scar (right supraumbilical incision).
The stomach and the duodenum were densely adherent to the under surface of the liver which were separated. On exploration we found the dilated stomach and the proximal duodenum, and the distal duodenum and the entire small bowel were collapsed with ileocecal junction on the left side of the abdomen without the appendix.
The nasogastric tube was advanced to the lower most part of the distended duodenum but could not be negotiated into the collapsed duodenum. Duodenotomy was done from the dilatated to the narrow part of the duodenum. On duodenotomy we found an intraluminal web with small perforations. Web was excised, and the raw intraluminal mucosa was repaired.
The tip of the nasogastric tube was reposited in the distal part of the duodenum and patency of the distal intestine was checked. Duodenotomy and abdominal wound are closed after putting the ileocecal junction on the left side of the abdomen.
Postoperatively the patient was shifted to the pediatric ICU. Nasogastric tube was removed on the 5 postoperative day. Oral feeding was allowed the following day and the patient was discharged on the seventh postoperative day. On follow-up, the patient was normal and tolerating orally well [Figure 1] and [Figure 2].
|Figure 1: Erect radiography of the abdomen suggestive of high intestinal obstruction.|
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| Discussion|| |
Duodenal web was first reported by Boyd in 1845. It is believed to develop secondarily to a failure in recanalization of the duodenal lumen between the eighth and 10th week of gestation. Lesions that cause congenital duodenal obstruction are classified as either intrinsic or extrinsic. The intrinsic causes include duodenal stenosis, atresia, or web. The extrinsic causes include malrotation with Ladd's bands, annular pancreas, anterior portal vein, and duodenal duplication.
Partial duodenal obstruction may be produced by duodenal stenosis, duodenal web, Ladd's bands, and midgut volvulus. Chronic duodenal obstruction related to a congenital web is a rare anomaly that is sometimes difficult to diagnose preoperatively. High-grade obstructions will obviously present within the first few days of life. Less severe obstructions may allow a child to go several months or even years prior to diagnosis.
In our case, the duodenal web was associated with malrotation. Duodenal web was missed during the first surgery done in early childhood. The patient had recurrent episodes of upper gastrointestinal tract obstruction due to congenital duodenal web.
| Conclusion|| |
Always look for duodenal obstruction in a case of malrotation. Congenital duodenal web should be kept in mind as a possibility whenever chronic obstruction of the duodenum in childhood is diagnosed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]