CASE OF JH

Cedric Lester Amodia, MD

Johanna Hamnia Poblete-Embalzado, MD
Perpetual Succour Hospital
OBJECTIVES

• Present a case of Duodenal Stenosis

• Discuss the Basic Principles and Surgical

Management of Duodenal Stenosis
GENERAL DATA

 JH
 Newborn
 Male
MEDICAL HISTORY

• Born to a 28 yo G1P0 mother

• Normal Spontaneous Delivery

• 37 1 /7 weeks AOG

• APGAR score 8,9

• 2100grams (4lbs 10 oz)

PRENATAL HISTORY

• Mother had complete prenatal check-up with

a private physician

• No history of HPN, DM, BA, thyroid problems,

Food and drug allergies

• Prenatal UTZ revealed possible duodenal

atresia
DELIVERY

• Normal Spontaneous Delivery

• Apgar 8,9

• 2100g birth weight

• 37 1/7 weeks AOG

DELIVERY

• Standard Newborn Care

• Given:
– Hep B vaccine
– Vit K
– BCG vaccine
– Terramycin eye ointment
PERTINENT NEONATAL PHYSICAL EXAM

• General Appearance:
Active, good cry, no edema noted, pinkish in
color
• Sign: No note of rashes, icterus, or hematoma
• Head and Neck: no note of caput or
cephalhematoma
• EENT: unremarkable
• Thorax: no deformities noted, no note of breast
hypertrophy
PERTINENT NEONATAL PHYSICAL EXAM

• Thorax: no deformities noted, no note of breast

hypertrophy
• Lungs: ECE, CBS
• Abdomen: no distension noted, no mass palpated
• Genitalia: grossly male
• Anus: patent, perforate
• Trunk and Spine: no deformities noted
• Extremities: unremarkable
DAY 1

• S/O:
– 140 BPM
– 54 CPM
– 36.7C
– 99% O2 sat

– A: R/O Duodenal Atresia

DAY 1

• P: NPO
– Abdominal Xray AP view
– Started on D50W 500cc at 16cc/hr on microset
• Xray shows:

• Gas Distended Stomach and Duodenum

• Consistent with Duodenal Atresia
Xray
DAY 1

• P: OGT inserted
– Repeat abdominal xray with flatplate and upright
on Day 2
– Referral to Pedia Surgeon
DAY 2

• S/O
– Stable VS
– Afebrile
– No abdominal Distension
– OGT drain: bilous drainage 35 cc

– Repeat xray: ff-up study no longer shows gas-

dilated stomach, no air fluid levels noted.
DAY 2

• P: Started on Cefuroxime 100mg IV q12H

• For Limited upper GI series
DAY 3

• S/O
– Stable VS
– Afebrile
– No abdominal Distension
– OGT drain: bilious drainage 40 cc

– Upper GI series: Partial bowel obstruction at the

2nd and 3rd part of the duodenum
UPPER GI SERIES
DAY 3

• A: Duodenal Atresia
– Duodenal Stenosis
– Duodenal Webs
– Volvulus
– Ladd bands

• P: Scheduled for EXLAP poss Ladd’s Procedure

• Reserve 1 unit whole blood for possible OR use
• CBC CT BT PROTIME Na K, - within normal
INTRAOPERATIVE FINDINGS

• Procedure Done: Duodenojejunostomy

• Blood loss: minimal
• Operative minutes: 2 hours 3 minutes

• Total fluid input:

• Total Output:

• A: Duodenal Stenosis
• S/P duodenojejunostomy
POD 1

• S/O
– Stable VS
– Afebrile
– No abdominal Distension
– OGT drain: bilious drainage 20 cc
POD 1

• A: Duodenal Stenosis
• S/P Duodenojejunostomy

• P: Double phototherapy Started

• Cefuroxime continued
• NPO
• Parenteral feeding
D10W + CG(30) + AA (2.5) + Na(2) + K (2) at 9.6cc/hour x 3
cycles
POD 2

• S/O:
– Stable VS
– Afebrile
– No abdominal Distension
– OGT drain: bilious drainage 13 cc
POD 2

• A: Duodenal Stenosis
• S/P Duodenosjejunostomy

• P: Double phototherapy Discontinued

• Cefuroxime continued
• Keep NPO
• Parenteral feeding continued
D10W + CG(30) + AA (2.5) + Na(2) + K (2) at 9.6cc/hour x 3
cycles
POD 3

• S/O:
– Stable VS
– Afebrile
– No abdominal Distension
– OGT drain: bilious drainage 5 cc
POD 3

• A: Duodenal Stenosis
• S/P Duodenojejunostomy

• P:
• Cefuroxime IV continued
• Keep on NPO
• Parenteral feeding continued
D10W + CG(30) + AA (2.5) + Na(2) + K (2) at 9.6cc/hour x 3
cycles
POD 4

• S/O:
– Stable VS
– Afebrile
– No abdominal Distension
– OGT drain: bilious drainage 5 cc
POD 4

• A: Duodenal Stenosis
• S/P Duodenojejunostomy

• P:
• Cefuroxime IV continued
• Keep on NPO
• Remove NGT
• Parenteral feeding continued
D10W + CG(30) + AA (2.5) + Na(2) + K (2) at 9.6cc/hour x 3 cycles
POD 5-10

• S/O:
– Stable VS
– Afebrile
– No abdominal Distension
POD 5-10

• A: Duodenal Stenosis
• S/P Duodenojejunostomy

• P:
• Cefuroxime IV continued
• Keep on NPO
• Remove NGT
• Parenteral feeding continued
D10W + CG(30) + AA (2.5) + Na(2) + K (2) at 9.6cc/hour x 3 cycles
POD 11

• S/O:
– Stable VS
– Afebrile
– No abdominal Distension
–
POD 11

• A: Duodenal Stenosis
• S/P Duodenojejunostomy

• P:
• Cefuroxime IV continued
• Start trophic feeding with EBM at 2cc q 3Hours
• Remove OGT
• Parenteral feeding continued
D10W + CG(30) + AA (2.5) + Na(2) + K (2) at 9.6cc/hour x 3 cycles
POD 12

• S/O:
– Stable VS
– Afebrile
– No abdominal Distension
– Feeding tolerated
POD 12

• A: Duodenal Stenosis
• S/P Duodenojejunostomy

• P:
• Cefuroxime IV continued
• Start trophic feeding with EBM at 2cc q 3Hours
• Parenteral feeding continued
D10W + CG(30) + AA (2.5) + Na(2) + K (2) at 9.6cc/hour x 3 cycles
POD 13

• S/O:
– Stable VS
– Afebrile
– No abdominal Distension
– Feeding tolerated
POD 13

• A: Duodenal Stenosis
• S/P Duodenojejunostomy

• P:
• Cefuroxime IV continued
• increase feeding with EBM by 1cc q feeding
• Pareneteral feeding discontinued
POD 14

• S/O:
– Stable VS
– Afebrile
– No abdominal Distension
– Feeding tolerated
POD 14

• A: Duodenal Stenosis
• S/P Duodenojejunostomy

• P:
• Cefuroxime IV discontinued
• increase feeding with EBM by 1cc q feeding
• May go Home
CASE DISCUSSION
DEFINITION OF TERMS

• Intestinal atresia
– Complete obstruction of the bowel lumen
– More common in duodenum, jejunum,
ileum and rare in colon
– Accounts for 33% of all cases of neonatal
intestinal obstruction
– Affects males and females equally
• Intestinal stenosis
– Partial block of luminal contents
Wyllie, R. 2004. Chapter 311 – Intestinal Atresia, Stenosis, and Malrotation. In: Nelson Textbook of Pediatrics
17th ed. Saunders, Elsevier Science USA.
DEFINITION OF TERMS

• Duodenal atresia
– Failure to recanalize the lumen after the
solid phase of intestinal development
during the 4th and 5th week of gestation

– Incidence: 1 in 10,000 births

Wyllie, R. 2004. Chapter 311 – Intestinal Atresia, Stenosis, and Malrotation. In: Nelson Textbook of Pediatrics
17th ed. Saunders, Elsevier Science USA.
DEFINITION OF TERMS

• Duodenal atresia
– Accounts for 25-40% of all intestinal
atresias

– Associated with: Down syndrome (30%),

malrotation (20%), esophageal atresia
(10-20%), CHD (10-15%), anorectal and
renal anomalies (5%)

Wyllie, R. 2004. Chapter 311 – Intestinal Atresia, Stenosis, and Malrotation. In: Nelson Textbook of Pediatrics
17th ed. Saunders, Elsevier Science USA.
TYPES

Louw JH. 1959. Congenital Intestinal Atresia and Stenosis in the Newborn: Observation on its Pathogenesis
and Treatment. Moynihan Lecture at Royal College of Surgeons of England.
PATHOPHYSIOLOGY

• Sixth week: gut epithelium proliferates

rapidly  obliteration of intestinal
lumen
– Gradually recanalized over the next
several weeks
• Errors in recanalization
– Total failure: atresia
– Partial failure: stenotic perforate
membrane
Applebaum H, SL Lee, DP Puapong. 2006. Chapter 79 – Duodenal Atresia and Stenosis, Annular Pancreas. In:
Grosfeld Pediatric Surgery. 6th ed. Mosby Elsevier, Philadelphia, USA.
CLINICAL PRESENTATION

• Maternal
polyhydramnios
(30-65%)
– Early clue that
should lead to
further
investigation
– Often leads to
preterm labor

Applebaum H, SL Lee, DP Puapong. 2006. Chapter 79 – Duodenal Atresia and Stenosis, Annular Pancreas. In:
Grosfeld Pediatric Surgery. 6th ed. Mosby Elsevier, Philadelphia, USA.
CLINICAL PRESENTATION

• Repeated bilious emesis

– Characteristic clinical feature

• Subtle upper abdominal fullness

• NGT with return of >30ml of fluid

Applebaum H, SL Lee, DP Puapong. 2006. Chapter 79 – Duodenal Atresia and Stenosis, Annular Pancreas. In:
Grosfeld Pediatric Surgery. 6th ed. Mosby Elsevier, Philadelphia, USA.
DIAGNOSTICS

• Double bubble sign

– Lack of more distal
intestinal gas 
complete
– Presence of gas 
partial

Applebaum H, SL Lee, DP Puapong. 2006. Chapter 79 – Duodenal Atresia and Stenosis, Annular Pancreas. In:
Grosfeld Pediatric Surgery. 6th ed. Mosby Elsevier, Philadelphia, USA.
DIAGNOSTICS

• Upper GI contrast
study
– Helpful in
differentiating
intrinsic duodenal
obstruction from
midgut volvulus

Applebaum H, SL Lee, DP Puapong. 2006. Chapter 79 – Duodenal Atresia and Stenosis, Annular Pancreas. In:
Grosfeld Pediatric Surgery. 6th ed. Mosby Elsevier, Philadelphia, USA.
TREATMENT

• NGT/OGT

• IV fluids
– Replacement of GI losses

• Central catheter line

– Parenteral nutrition

Applebaum H, SL Lee, DP Puapong. 2006. Chapter 79 – Duodenal Atresia and Stenosis, Annular Pancreas. In:
Grosfeld Pediatric Surgery. 6th ed. Mosby Elsevier, Philadelphia, USA.
TREATMENT

• Surgical correction of duodenal

obstruction is not urgent
– Can take place once infant is optimized
hemodynamically and associated
anomalies have been appropriately
studied

Applebaum H, SL Lee, DP Puapong. 2006. Chapter 79 – Duodenal Atresia and Stenosis, Annular Pancreas. In:
Grosfeld Pediatric Surgery. 6th ed. Mosby Elsevier, Philadelphia, USA.
TREATMENT

• Options:
– Duodenoduodenostomy (80%)
• Best corrective option
• Most direct physiologic repair
• Least potential for complications

Applebaum H, SL Lee, DP Puapong. 2006. Chapter 79 – Duodenal Atresia and Stenosis, Annular Pancreas. In:
Grosfeld Pediatric Surgery. 6th ed. Mosby Elsevier, Philadelphia, USA.
TREATMENT

• Options:
– Duodenojejunosto
my (10%)
• When 1st option is
difficult because of
patient anatomy
• Provides post-
operative results
equivalent to
duodenoduodenos
tomy
Applebaum H, SL Lee, DP Puapong. 2006. Chapter 79 – Duodenal Atresia and Stenosis, Annular Pancreas. In:
Grosfeld Pediatric Surgery. 6th ed. Mosby Elsevier, Philadelphia, USA.
TREATMENT

• Options:
– Gastrojejunostomy (rare)
• Associated with frequent late complications of
marginal ulceration and blind loop syndrome
– Web excision (5-10%)
• For those with pathology

Applebaum H, SL Lee, DP Puapong. 2006. Chapter 79 – Duodenal Atresia and Stenosis, Annular Pancreas. In:
Grosfeld Pediatric Surgery. 6th ed. Mosby Elsevier, Philadelphia, USA.
TREATMENT

Applebaum H, SL Lee, DP Puapong. 2006. Chapter 79 – Duodenal Atresia and Stenosis, Annular Pancreas. In:
Grosfeld Pediatric Surgery. 6th ed. Mosby Elsevier, Philadelphia, USA.
COMPLICATIONS

• Intraoperative
– Incorrect identification of the site of
obstruction

– More than one obstruction present

– Careful passage and withdrawal of balloon

catheters both proximally into the stomach
and distally into the jejunum
Applebaum H, SL Lee, DP Puapong. 2006. Chapter 79 – Duodenal Atresia and Stenosis, Annular Pancreas. In:
Grosfeld Pediatric Surgery. 6th ed. Mosby Elsevier, Philadelphia, USA.
COMPLICATIONS

• Post-operative
– Prolonged feeding intolerance
• Most common complication
• Upper GI series after 2-3 weeks

– Persistently poor peristalsis

– Late duodenal obstruction

Applebaum H, SL Lee, DP Puapong. 2006. Chapter 79 – Duodenal Atresia and Stenosis, Annular Pancreas. In:
Grosfeld Pediatric Surgery. 6th ed. Mosby Elsevier, Philadelphia, USA.
 FIN.
Johanna Hamnia B. Poblete-Embalzado, MD
2nd Year Surgical Resident
Perpetual Succour Hospital