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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 4  |  Page : 142-144

Congenital duodenal obstruction due to duodenal web with annular pancreas: A rarity


1 Department of Pediatric Surgery, AIIMS, Patna, Bihar, India
2 Department of Radiology, AIIMS, Patna, Bihar, India

Date of Web Publication29-Oct-2018

Correspondence Address:
Dr. Amit K Sinha
Department of Pediatric Surgery, AIIMS, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_1_18

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  Abstract 


Congenital duodenal obstruction is one of the common causes of intestinal obstruction in neonates. They are usually due to duodenal atresia, malrotation of gut and annular pancreas. The combination of duodenal web with annular pancreas is very rare. We are presenting a case of congenital duodenal obstruction in a patient having both duodenal web and annular pancreas. A transverse incision on the duodenum was made and a duodenal web partially obstructing the lumen between its first and second part was confirmed. A longitudinal incision over the distal collapsed part of duodenum and Kimura's diamond-shaped duodeno-duodenostomy was done over a transgastric transanastomotic feeding jejunostomy. Baby did well postoperatively and was discharged in stable condition.

Keywords: Annular pancreas, duodenal obstruction, duodenal web, intestinal atresia, nonbilious vomiting


How to cite this article:
Sinha AK, Ahmad MS, Kumar B, Kumar P. Congenital duodenal obstruction due to duodenal web with annular pancreas: A rarity. Arch Int Surg 2017;7:142-4

How to cite this URL:
Sinha AK, Ahmad MS, Kumar B, Kumar P. Congenital duodenal obstruction due to duodenal web with annular pancreas: A rarity. Arch Int Surg [serial online] 2017 [cited 2018 Nov 18];7:142-4. Available from: http://www.archintsurg.org/text.asp?2017/7/4/142/244409




  Introduction Top


Congenital duodenal obstruction is one of the most common gastrointestinal anomalies in newborn. The incidence of congenital duodenal obstruction is 1 in 2500–10,000 live births.[1] Causative factors of congenital duodenal obstruction are usually intrinsic, extrinsic, or both.[2] Different causes of congenital duodenal obstruction are duodenal atresia, malrotation, annular pancreas, etc., 38–55% of congenital duodenal obstruction is usually associated with another significant congenital anomaly.[3] Annular pancreas causing duodenal obstruction is a rare condition in which the second part of duodenum is surrounded by a ring of pancreatic tissue continuous with the head of the pancreas. This portion of the pancreas can constrict the duodenum and block or impair the flow of food to the rest of the intestine, hence the extrinsic cause of congenital duodenal obstruction.[4] Only 4% of cases have distal obstruction.[5] Duodenal web, “a congenital duodenal obstruction,” is a diaphragm or intraluminal diverticulum, which refers to complete or incomplete obstruction at the duodenum due to a membrane, web, or intraluminal diverticulum. There is usually a small aperture at the center differentiating this from a duodenal atresia.[6] Simultaneous occurrence of intrinsic (duodenal web) and extrinsic (annular pancreas) mechanism of congenital duodenal obstruction is rare. Only five such cases have been reported yet.[7],[8] We present a case of female neonate with a simultaneous extrinsic and intrinsic causes of duodenal obstruction.


  Case Report Top


A 1.4 kg full-term female neonate (Gravida 2) delivered at primary health center cried just after birth and passed urine and meconium within 24 hours of birth. Due to low birth weight, baby was kept in intensive care for 5 days. After discharge baby was doing well for almost 15 days. She was taking feeds and passing stool and urine normally. On 26th day of life she started nonbilious projectile, vomiting after each feed, and was always looking hungry. On consulting a physician, diagnosis of gastric outlet obstruction was made and hence was referred to our Outpatient Department of Pediatric Surgery. Child was admitted. On general examination, patient was very sick and dehydrated with feeble peripheral pulses. Her anterior fontanelle was open and mildly sunken. Mild upper abdominal distension was present. She was resuscitated with intravenous fluid, oxygen with nasal prongs, and nasogastric tube that yielded breast milk. Routine investigations came as hyponatremia, hypokalemia, and hypochlorhydria. With provisional diagnosis of idiopathic hypertrophic pyloric stenosis, further investigations were done. Erect abdominal X-ray after instilling air through the nasogastric tube was suggestive of distended stomach with few specks of air in the distal bowel. On abdominal ultrasonography, stomach was mildly distended and pyloric wall thickness of 2.1 mm with collapsed bowel loop distally. This finding ruled out diagnosis of idiopathic hypertrophic pyloric stenosis. On further investigation by upper gastrointestinal contrast study, it showed grossly distended stomach and first part of duodenum with delayed passage of contrast in distal bowel [Figure 1]. After correcting dehydration and electrolyte imbalance patient was posted for exploratory laparotomy with provisional diagnosis of duodenal web. Abdomen was opened with right upper transverse incision. On exploration stomach and first part of duodenum was grossly distended with collapsed distal bowel loops. A ring of pancreatic tissue was constricting the lumen of duodenum between D1 and D2 [Figure 2]. Stomach was partially de-compressible, suggestive of partial distal obstruction. So, an additional finding as duodenal web type 1 windsock deformity was made. A transverse incision over proximal distended duodenum was given and finding of duodenal web partially obstructing the lumen between its first and second part confirmed. Only 8 fr infant feeding tube could be negotiated through the duodenal web. Then a longitudinal incision over distal collapsed part of duodenum was given and Kimura's diamond-shaped duodeno-duodenostomy was done over transgastric transanastomotic feeding jejunostomy (FJ) tube. A large bore nasogastric tube was kept for gastric decompression. Baby did well postoperatively. Feeding started on second postoperative day from FJ tube and achieved on full feeds for weight on postoperative day 6. On postoperative day 9, oral feeds were started and FJ removed on 12th day. Patient was discharged in stable condition and kept in regular follow-up.
Figure 1: Upper gastrointestinal contrast study showing dilated first part of duodenum and passage of contrast in distal small bowel suggesting duodenal web

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Figure 2: Dilated proximal duodenum and collapsed distal part due to constricting annular pancreas- bold arrow

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  Discussion Top


The simultaneous occurrence of duodenal web associated with annular pancreas is extremely rare. In this case duodenal web associated with annular pancreas was considered in the differential diagnosis of congenital duodenal obstruction. Ambiguity arises from the fact that few cases of congenital duodenal obstruction having either intrinsic or extrinsic component as a cause are asymptomatic. This embryological abnormality results due to the growth of bifid ventral pancreatic bud around the duodenum where the parts of the bifid ventral bud fuse with dorsal bud forming a pancreatic ring. Patency of duodenum distal to the apparent obstruction should always be checked in order to avoid misdiagnosis or delayed diagnosis of this combination.


  Conclusion Top


Due to rarity, this combination of congenital duodenal obstruction must always be kept in mind during diagnosis of congenital duodenal obstruction.

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 initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Millar AJW, Rode H, Cywes S. Intestinal atresia and stenosis. In: Ashcroft KW, Holcomb GW, Murphy JP, editors. Pediatric Surgery. 4th ed. Philadelphia, PA: W B Saunders; 2005. p. 416-34.  Back to cited text no. 1
    
2.
Escobar MA, Ladd AP, Grosfeld JL, West KW, Rescorla FJ, Scherer LR 3rd, et al. Duodenal atresia and stenosis: Long term follow up over 30 years. J Pediatr Surg 2004;39:867-71.  Back to cited text no. 2
    
3.
Mustafawi AR, Hassan ME. Congenital duodenal obstruction in children: A decade's experience. Eur J Pediatr Surg 2008;18:93-7.  Back to cited text no. 3
    
4.
Moodley S, Hegarty M, Thomson SR. Annular pancreas. S Afr Med J 2004;94:28.  Back to cited text no. 4
    
5.
Papandreou E, Baltogiannis N, Cigliano B, Savanelli A, Settimi A, Keramidas D. Annular pancreas combined with distal stenosis. A report of four cases and review of the literature. Pediatr Med Chir 2004;26:256-9.  Back to cited text no. 5
    
6.
Yoon CH, Goo HW, Kim EAR, Kim KS, Pi SY. Sonographic windsock sign of a duodenal web. Pediatr Radiol 2001;31:856-7.  Back to cited text no. 6
    
7.
Applebaum H, Sydorak R. Duodenal atresia and stenosis—annular pancreas. In: O'Neil JA Jr, Rowe MI, Grosfeld JL, Fonkalsrud EW, Coran AG, editors. Pediatric Surgery. 7th ed. New York: Mosby; 2007. p. 1051-7.  Back to cited text no. 7
    
8.
Makhija D, Shah H, Kumbhar V, Khedkar K. Annular pancreas with a duodenal web: A rare presentation with simultaneous intrinsic and extrinsic duodenal obstruction. Korean J Pancreas Biliary Tract 2016;21:199-201.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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Case Report
Discussion
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