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Virtual Pediatric Hospital: Correlapaedia - a Correlative Encyclopedia of Pediatric Imaging, Surgery, and Pathology: Case 23

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

Case 23

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

Peer Review Status: Internally Peer Reviewed
Chief Complaint:
One day old full term male with a distended abdomen and bilious aspirates.

Clinical History:
The patient was a term male, 1 day old. Prenatal ultrasound performed just before birth for antenatal fluid assessment demonstrated dilated loops of bowel in the fetus. After delivery the child was found to have a distended abdomen and a nasogastric tube was placed and 100 cc of bilious material was aspirated from the stomach

Clinical Physical Exam:
Distended abdomen.

Clinical Labs:

Clinical Differential Diagnosis:
Proximal bowel obstruction - malrotation with midgut volvulus, duodenal atresia, jejunal atresia

Imaging Findings:
An abdominal film from the first day of life demonstrated a proximal small bowel obstruction, and this was confirmed on an upper GI performed exam later on the same day. A barium enema from the same day demonstrated a fairly normal caliber colon.

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Imaging Differential Diagnosis:
Jejunal atresia

Operative Findings:
On the second day of life the patient had an exploratory laparotomy via a transverse supraumbilical incision. Upon entering the abdomen the proximal jejunum was prominently dilated with a blind end. Distally, an apple-peel deformity with extensive jejunal and ileal atresia was encountered. The ileum was spiraled around the ileocolic artery. The most proximal 5-6 cm of ileum was quite dusky and nonviable in appearance. The small bowel measured only 50 cm in length. The ileocecal valve and colon were unremarkable. The patient had a tapering enteroplasty of the bowel proximal to the atretic segment, a partial small bowel resection and an end-to-end enteroenterostomy.

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Pathological Findings:

Final Diagnosis:
Apple Peel Atresia of Small Bowel

Follow-up and Prognosis:
There was concern that the patient would develop a short gut syndrome. Postoperatively the patient showed signs of persistent bowel obstruction and 2 months after the initial surgery the patient had an exploratory laparotomy with lysis of adhesions. At that time, the patient was noted to have an area of stricture in the small bowel 4 cm distal to the previous area of end to end anastomosis and this stricture was resected. The patient has since done well.

Similar Cases:
Case 4, Case 6, Case 14, Case 18, Case 20


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