BY

SHREOSI GHOSH
INTERN
MALDA MEDICAL COLLEGE AND HOSPITAL
INTRODUCTION
 DEFFINITION: Duodenal atresia is the congenital absence
or complete closure of a portion of the lumen of the
duodenum due to the defective fusion of foregut and
midgut with failure of the recanalisation.

 EPIDEMIOLOGY:
 1 Per 5000 to 10000 live births.
 Affecting boys more commonly than girls.
ETIOLOGY
 Intrinsic lesion: Caused by failure of recanalization of
the fetal duodenum

 Extrinsic lesion: Defects in the development of the

neighbouring structures

Teratogens:
Chlordiazepoxide
Thalidomide
Flurouracil
ASSOCIATIONS
1. Prematurity (45%)
2. Growth retardation (33%)
3. Annular pancreas
4. Down’s syndrome (30%) – Trisomy 21
5. Miller-Dieker syndrome
6. More than 50% patients have associated
congenital anomalies –
Congenital heart disease (30%)
Incomplete rotation of gut (20%)
Anorectal malformations (10%)
 CLASSIFICATION
ANATOMICAL CLASSIFICATION:
A. TYPE 1 (92%):Complete atresia

B. TYPE 2 (1%):Fibrous cord separating two ends

C. TYPE 3 (7%):Incomplete or partial obstruction

 Stenosis
 Mucosal web with intact muscular wall-WINDSOCK
DEFFORMITY
Anatomical Types
CLASSIFICATION CONTD…

SITE WISE
CLASSIFICATION:

PREAMPULLARY
(10-15% )

POSTAMPULLARY
(85-90% )
PATHOPHYSIOLOGY
Failure of canalization of the duodenal lumen

Improper formation of vacuoles

Atresia or web may develop

Accumulation of gases and secretions above the

blockage
In intra luminal pressure , venous pressure

Circulatory stasis or edema

Gangrene, Peritonitis
CLINICAL FEATURES
 Bilious or nonbilious vomiting immediately after
birth
 Jaundice
 Features of gastric outlet obstruction
 Dehydration and electrolytes changes
 Abdominal distension and tenderness
 Absence of flatus
 No passage of stool
 Respiratory distress
 Shock
 DIAGNOSIS
 History: Maternal polyhydramnios

Investigations:
1. MATERNAL -
 Prenatal ultrasonography:
a. Detects duodenal atresia between 7th and 8th
month of gestation.
b. Polyhydramnios and associated anomalies can also
be detected.
2. CHILD
Plain X ray abdomen: DOUBLE BUBBLE SIGN
with absence of air in the distal part
 INVESTIGATION CONTD…
Upper GI contrast study:
a. Partial obstruction
with the presence of
air in the distal loop

b. Other associated
anomalies –
Malrotation,Mid gut
volvulus etc
INVESTIGATION CONTD…

 Ultrasonography abdomen:
Distended stomach and proximal
Duodenum – RAIL ROAD TRACK
DUODENUM
MANAGEMENT
GENERAL MANAGEMENT :
IV fluids
Oro or nasogastric aspiration
Stomach wash
NPM
Antibiotics,antiemetics,vitamin K
supplement,PPI
SURGICAL MANAGEMENT :
PREOPERATIVE CARE :

 Appropriate resuscitation
 Correction of fluid imbalance and electrolyte
abnormalities
 Monitoring of the complete metabolic profile
 Gastric decompression
 Perenteral nutrition via central catheter line
 Two dimensional echocardiographic monitoring
TREATMENT
PROPER:
Surgery can be done by:

LAPAROTOMY: Supraumbilical
transverse incision is given to the right
upper quadrant of abdomen

LAPAROSCOPY: Neonatal laparoscopic

instruments (3mm ) and Trocars are
used
TREATMENT CONTD…
 Different Methods are :
DUODENODUODENOSTOMY: Surgical bypass for
the duodenal obstruction is done by Side to side
Duodenoduodenostomy.Associated malrotation
should also be corrected (LADD’S OPERATION).
Megaduodenum or anstomotic dysfunction
can occur.
Kimura’s diamond shaped anstomosis:
Done between transversly opened proximal pouch
and longitudinally opened distal pouch.Presence of
bile and concomittent distal atresia should be
confirmed by saline irrigation.
Less chances of the problems of
anastomosis.
Treatment contd..
Tapering Duodenoplasty: Done with staples or sutures
to reduce the Duodenal caliber when the proximal
Duodenum is markedly dialated.
HEINEKE-MICULICZ DUODENOPLASTY: Partial web
resection is done transduodenally in Duodenal mucosal
web.
DUODENOJEJUNOSTOMY: Previously preferred
technique.
May cause blind loop problem.

GASTROJEJUNOSTOMY: Done previously.

High incidence of marginal ulceration and bleeding.
UPPER GI CONTRAST STUDY AFTER
LAPAROSCOPY
POST OPERATIVE CARE
 Continuation of Total parenteral nutrition (TPN)
 Monitoring of Nasogastric tube output
 Feeding via transanastomotic nasojejunal or
gastrostomy tube after diminution of nasogastric
tube output
 Small feeding with volume and concentration
advanced as tolerated
 Discharge within one to three weeks
COMPLICATIONS
 INTRAOPERATIVE :
 Windsock defformity (Floppy web) : Incorrect identification
of site of obstruction
 Bypass anstomosis entirely distal to true web attachment
 Multiple obstructions

 POST OPERATIVE :
 Megaduodenum (30%)
 Prolonged feeding intolerance
 Poor peristalsis
 Residual obstruction
 Anastomotic stenosis
DIFFERENTIAL DIAGNOSIS

 Late appearing pyloric stenosis

 Incomplete diaphragm
 Other forms of intestinal atresia
 Duodenal duplication
 Midgut volvulus
THANK YOU