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Virtual Pediatric Hospital: Correlapaedia - a Correlative Encyclopedia of Pediatric Imaging, Surgery, and Pathology: Case 14

Correlapaedia - a Correlative Encyclopedia of Pediatric Imaging, Surgery, and Pathology

Case 14

Michael P. D'Alessandro, M.D.,
Steven J. Fishman, M.D.,
Deborah E. Schofield, M.D.

Peer Review Status: Internally Peer Reviewed
Chief Complaint:
Newborn full term female with bilious aspirates.

Clinical History:
This was a 1 day old full term female that became dusky with the first feeding, after which 40 cc of bilious fluid was aspirated from her stomach via nasogastric tube.

Clinical Physical Exam:
The abdomen was distended but soft and non tender.

Clinical Labs:

Clinical Differential Diagnosis:
Malrotation with midgut volvulus, duodenal atresia, duodenal stenosis

Imaging Findings:
A supine abdominal film showed a "double bubble" sign.

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Imaging Differential Diagnosis:
Duodenal atresia, duodenal stenosis, duodenal web, malrotation with midgut volvulus

Operative Findings:
The patient was explored via a supraumbilical transverse incision on the first day of life to find a cause for the partial duodenal obstruction. Malrotation with midgut volvulus was encountered. There was spiraling of the bowel around the midgut mesentery and the midgut was dusky in color. The midgut was untwisted by rotating it 720 degrees. There was no compromised bowel seen. A Ladd's procedure was then performed. After the Ladd's procedure it was noted that the proximal jejunum had a barber pole type partial twist to it, causing an area of jejunal stenosis, felt to probably be due to chronic in utero volvulus causing the bowel to develop inappropriately in relation to the mesentery. This was not resected as it was thought that the bowel would likely dilate and develop appropriately.

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Pathological Findings:

Final Diagnosis:
Malrotation and Midgut Volvulus

Follow-up and Prognosis:
The patient developed a partial small bowel obstruction in the proximal jejunum at the site of abnormality noted in the operating room 1 week post operatively. An elective exploratory laparotomy was performed at 3 months of age to resect this area and a small bowel resection and tapering enteroplasty were performed. The patient continued to have difficulty feeding due to laryngomalacia and subglottic stenosis.

Similar Cases:
Case 4, Case 6, Case 20, Case 23


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