Congenital duodenal obstruction due to atresia of the duodenum

CONGENITAL DUODENAL OBSTRUCTION ATRESIA OF THE DUODENUM*

DUE TO

LOUIS KAPLAN, M.D. Philadelphia, Pennsylvania

C

ONGENITAL duodena1 obstruction usuahy causes vomiting within a few hours after birth. The vomiting may be projectile and the vomitus may contain biIe if the obstruction is beIow the bihary papiIIa. The infant may pass stools grayish in coIor or resembIing normal meconium. However, normaI meconium contains squamous epitheIium which is ingested with amniotic IIuid in addition to epitheIia1 debris from the intestinal mucosa. The squamous epitheIium is derived from desquamated feta1 skin. Farber? suggested examining the stoo1 for cornified epitheIia1 cells. Absence of these celIs is presumptive evidence of congenital occlusion of the digestive tract. As in this case, when obstruction is complete, x-ray examination shows a distended stomach and no gas in the intestines. PartiaI obstruction causes symptoms similar to these if the Iumen is extremeIy smaI1. Enterostomy for feeding has been tried a few times. It practicaIIy never heIps. Continuity of the gastrointestina1 tract must be estabIished if the infant is to survive. Water, saIt, gIucose and protein (pIasma or amino acid solution) shouId be given to overcome the effects of the vomiting. The stomach shouId be aspirated and Iavaged. At operation the nature of the obstruction shouId be identihed if possibIe. If the obstruction is due to a band, the surgeon must be certain that no major vesseIs such as the superior mesenteric Iie in the band. When the duodenum ends as a bIind pouch, duodenojejunostomy or gastrojejunostomy may be performed. If the duodenum is continuous but diIated above t FARBER, S. Congenital at&a of the alimentary tract. J. A. M. A., IOO:1753-1754, 1933. * From the Surgical Services

a given point and very narrow below it, a transverse membranous septum must be suspected. The duodenum may be opened and the septum excised with scaIpe1 or cautery. If the remaining Iumen appears inadequate, gastrojejunostomy is required. Before concIuding the operation the intestine should be traced down to the rectum to excIude congenital occIusion or obstruction of the gut Iower down since congenita1 malformations are frequentIy muItipIe. Such instances have been described. * * * * SuccessfuI operations for compIete congenitaI duodenal obstruction have been reported with increasing frequency. The author has found twenty-four such cases in the Iiterature. In twenty-one cases either anterior or posterior gastrojejunostomy or duodenojejunostomy were done; in two cases bands were divided. Other types of operation have not been successfu1. FoIIowup examinations were reported in twenty cases from two months to eIeven years after operation; a11 of the patients were in satisfactory condition. The foIIowing is a report of a case in which gastrojejunostomy was done and in which a foIIow-up x-ray examination after thirty months showed satisfactory function. CASE

R. L., a maIe, born hlarch 28, 19-14, weighed 5 pounds 635 ounces and appeared to be one month premature. Meconium stooIs were passed on March 29th. ProjectiIe vomiting began on March 30th and jaundice developed. X-ray examination after barium was given through a tube showed distention of the stomach and the first portion of the duodenum.

of the hlount 452

REPORT

Sinai IIospitaI,

PhiIadeIphia,

American

Pa.

Journal

oj’ Surgery

Kaplan-CongenitaI

Duodenal

Obstruction

I

2

FIG. 1. Anteroposterior view of abdomen after administration of barium; the hugeIy distended stomach and first portion of the duodenum aImost HI the entire abdomen. Neither barium nor gas is present in the intestines. FIG. 2. LateraI view of the abdomen made immediately after Figure I ; no intestinal Ming is visible.

No barium left the stomach after three hours; no gas was present in the intestines. (Figs. I and 2.) After preparation with glucose-salt soIution and vitamin K operation was performed on March 3rs.t under IocaI anesthesia. The stomach was exposed through an upper abdominal incision. It was enormously distended and was emptied by suction through a tube passed from the mouth. The stomach ended in a blind pouch probably just a IittIe beyond the pylorus. The smaII intestine was 3 to 4 mm. in diameter and appeared hypopIastic. No other intestinal anomaIy was found. An antecolic anastomosis was made between the distal end of the stomach and the jejunum with fine chromic catgut, using one continuous suture Iine, reinforced by a few interrupted sutures. Parentera Auids were given on the first postoperative day and feedings of breast milk were started on the second day. Occasional vomiting occurred. X-ray examination showed considerabIe barium in the stomach and a smaII amount in the small intestine. The residua1 barium was removed from the stomach by

Iavage. Temperature became and remained normal after the fifth postoperative day. The infant was discharged from the hospita1 on the twenty-sixth postoperative day in good condition. A foIIow-up examination was made on August 16, 1944. The child appeared we11 nourished. 19, 1945, X-ray examination on November showed that the stomach was Iaw.Md that barium left it quite sIowIy so that at the. end of five hours a considerable residue was still present. On October 14, 1946, the child was readmitted to the hospita1 for treatment of umbiIica1 and right inguinal hernias. He appeared adequateIy developed for his age and in good heaIth. X-ray examination at that time showed norma gastrointestina1 motility. The hernias were repaired a few days later and inspection of the smaI1 intestine at this time showed it to be of norma caIiber. Recovery was uneventful.* *References for this article will be included in the author’s

reprints.