Duodenal atresia and stenosis are rare causes of intestinal obstruction in the newborn; the prevalence of intrinsic duodenal obstruction (atresia, web, or severe stenosis) is 1:6,000. The diagnostic preoperative workup should include a plain abdominal radiograph, upper and/or lower gastrointestinal contrast studies, and ultrasonography (1).
Flexible upper gastrointestinal endoscopy is increasingly accepted as a valuable tool for diagnostic and therapeutic procedures of the upper gastrointestinal tract in newborns and infants, and there are increasing indications for its use (2). This report supports the reliability and advantages of upper intestinal endoscopy as an important contribution in the diagnostic workup of duodenal obstruction.
A full-term male newborn infant was admitted on the 2nd day of life to the neonatal intensive care unit with intermittent bilious vomiting, abnormal weight loss, and upper abdominal distension. There was no history of maternal polyhydramnios, and meconium was normally passed. A plain abdominal radiograph with the child in the erect position showed only scattered small amounts of air in the distal duodenum and no double-bubble image, whereas ultrasonography findings were dubious and results of a study of the colon with a barium enema were normal. An upper gastrointestinal contrast study was not performed because the patient underwent endoscopic examination using an Olympus GIF N-30 (external diameter 5.3 mm) under sedation on the 3rd day of life. The esophagus, stomach, and pylorus did not show any anatomic or mucosal abnormalities. Just distal to the papilla of Vater, a congenital duodenal membrane with a small lateral opening was detected and confirmed by its movement on suction or infusion of air (Fig. 1). Through the small opening, a nasogastric tube was inserted under endoscopic control and a partial transstenotic tube feeding commenced to improve the caloric and protein intake. Two days later, after parenteral correction of fluids and electrolyte abnormalities, the infant underwent surgical excision of the membrane and duodenoplasty. No complications occurred postoperatively, and oral feeding was started in small amounts 4 days after the operation; within the following 12 days, full feeding was tolerated.
Congenital duodenal obstruction is the result of several embryologic defects in foregut development, canalization, or rotation. It still continues to present a unique management challenge. The diagnosis of duodenal stenosis may be delayed, because these infants are able to tolerate small feedings due to the incomplete nature of the obstruction. In some instances, duodenal stenosis goes unrecognized for long periods, leading to recurrent episodes of vomiting, failure to thrive, and aspiration pneumonia. Some cases are not recognized for years until adulthood, usually in association with peptic ulcer, reflux esophagitis, or obstruction of the duodenum proximal to the stenosis (3-5). Reaching a precise and quick diagnosis in a vomiting newborn still remains a unique challenge. Plain radiographs of the abdomen are diagnostic in only half of the patients, and diagnosis can be established by upper and/or lower gastrointestinal contrast studies in 70% of the cases (1). Furthermore, in up to 20% of infants, other upper gastrointestinal congenital anomalies may be associated, such as esophageal atresia, tracheoesophageal fistula, and pyloric stenosis (1,6). Such an association requires an urgent evaluation and operative management of any congenital duodenal obstruction.
In recent years, infants have been evaluated by fiberoptic flexible upper gastrointestinal endoscopy (2,7). This allows the direct observation of anomalies in the duodenum such as duodenal stenosis, atresia, and membrane or extrinsic compression. An immediate and precise diagnosis of the origin of the duodenal obstruction can be made by excluding other possible causes within the upper gastrointestinal tract during the same procedure, although some lesions causing congenital duodenal obstruction will neither be diagnosed or adequately treated endoscopically. The development in recent years of ultraslim fiberscopes with standard 2.0-mm instrument channels extends the indications for neonatal endoscopy and endoscopic surgery, such as duodenal membranectomy, and these procedures might therefore become more widely accepted (7). Its therapeutic relevance or usefulness in selected cases of congenital duodenal obstruction still remains to be proven.
In conclusion, after a careful clinical evaluation, fiberoptic diagnosis together with endoscopic membranectomy using a high-frequency wave cutter could become an alternative option to other more standard diagnostic and therapeutic procedures in managing duodenal intrinsic stenosis. Furthermore, the possibility of detecting other coexisting causes of vomiting through this procedure appears promising.
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7. Okamatsu T, Arai K, Yatsuzuka M, et al. Endoscopic membranectomy for congenital duodenal stenosis in an infant. J Pediatr Surg