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Year : 2020  |  Volume : 33  |  Issue : 4  |  Page : 1421-1423

Missed duodenal web in a patient of malrotation of the gut – a rare case

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 Submission02-Dec-2018
Date of Decision01-Jan-2019
Date of Acceptance08-Jan-2019
Date of Web Publication24-Dec-2020

Correspondence Address:
Dileep Garg
MCh, Halwai Khana, Kothi, Dholpur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_390_18

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'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 Top

The duodenum is the most common site of intestinal obstruction, accounting for nearly half of all cases, while the ileum is the least affected[1]. The incidence of duodenal obstruction ranges from 1 in 4000 to 1 in 15 000 live births[2]. Duodenal web is an uncommon disease and occurs in 1 per 20 000–40 000 live births[3]. More common in boys than girls, although in some studies the sex distribution is about even between men and women[4]. 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[3]. Most of the webs occur proximal to or near the ampulla of Vater, with 10% being found proximal to the ligament of Treitz[5].

  Case report Top

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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Figure 2: Intraoperative picture showing the duodenal web.

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  Discussion Top

Duodenal web was first reported by Boyd in 1845[6]. It is believed to develop secondarily to a failure in recanalization of the duodenal lumen between the eighth and 10th week of gestation[2]. 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[7].

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 Top

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.

  References Top

Mirza B, Ijaz L, Saleem M, Sheikh A. Multiple associated anomalies in a single patient of duodenal atresia: a case report. Cases J 2008; 6:215.  Back to cited text no. 1
Talabi AO, Sowande OA, Tanimola AG, Adejuyigbe O. Situs inversus in association with duodenal atresia. Afr J Paediatr Surg 2013; 10:275–278.  Back to cited text no. 2
Jiménez-Moreno MA, Fernández-Crehuet C, Ferreiro-Argüelles B, Calle-Calle J, Andrade-Bellido R. A rare cause of intestinal obstruction in the adult: duodenal diaphragm. Rev Esp Enferm Dig 2012; 104:445–446.  Back to cited text no. 3
Norman CH, Pacis AB. Congenital duodenal web in an adult. J Natl Med Assoc 1978; 70:797–798.  Back to cited text no. 4
Aguayo A, Ostlie DJ. Ashcraft pediatric surgery. 6th ed. Philadelphia: Saunders; 2014. 414–417.  Back to cited text no. 5
Boyd R. Description of a malformation of the duodenum, with notices of analogous cases. Med Chir Trans 1845; 28:329–335.  Back to cited text no. 6
Bailey PV, Tracy TF, Connors JRH, Mooney DP, Lewis JE, Weber TR. Congenital duodenal obstruction: a 32-year review. J Pediatr Surg 1993; 28:92–95.  Back to cited text no. 7


  [Figure 1], [Figure 2]


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