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Introduction and Learning Points
Although most newborns have some grade of spitting up, forceful and
repeated vomiting should be taken seriously and practitioners should
suspect a surgical condition like bowel obstruction. is case report
describes a newborn with vomiting, its diagnostic approach and initial
medical management.
Case Report
e patient was a female baby born by c-section due to fetal
decelerations at 35 4/7 weeks gestation to a 24 year-old female G1P1.
e pregnancy was uneventful, and her mother received usual prenatal
care. Her mother experienced reduction in fetal movements few days
before delivery; prenatal ultrasound showed polyhydramnios. During
delivery, APGAR scores were 4 at 1 minute and 6 at 5 minutes. She
required bag mask support and recovered to APGAR of 9 at 10
minutes. She was taken to the nursery for standard care. Her initial
physical examination was within normal limits. Her weight was
1633 gr (<3%), her head circumference was 30 cm (3-10%) and her
length was 43 cm (3-10%). Shortly after initiation of feedings, she
had repeated postprandial vomiting. An abdominal film suggests the
diagnosis. See figure 1.
Discussion
Patient’s abdominal film showed a “double bubble” sign with absence
of gas in the remaining small and large bowel. ese results, and the
baby’s history of repeated postprandial vomiting, were consistent with
the diagnosis of duodenal atresia (DA). Echocardiogram was normal.
Patient was promptly taken to the OR for surgical repair after initial
IV hydration.
e condition
DA occurs in 1 per 5,000 to 10,000 live births. It is an isolated finding
in 30 to 50% of cases, however, it is often associated with other
malformations, including gastrointestinal (biliary atresia, agenesis of
the gall bladder), cardiac (20%), renal, and vertebral anomalies (1). In
25-40% of cases, the anomaly is found in Down syndrome (2).
Prenatally, DA increases the risk of prenatal asphyxia and death caused
by bradycardia/asystole following vagal overactivity due to distension
of the UGI tract (3). Polyhydramnios occurs in 33% to 50% of
patients with duodenal atresia (3) (4).
Most babies are born at term or near term and tend to be small
for gestational age (5). While bilious vomiting is a typical clinical
presentation, it may be nonbilious due to defects proximal to the
ampulla of Vater (3). Babies may have distention or normal abdominal
examination. Complications of poor feeding and vomiting, including
volume depletion, electrolyte imbalance, and aspiration pneumonia
may occur (1).
The Baby Is Vomiting
Janeth Ceballos Osorio, MD
University of Kentucky • Department of Pediatrics
e first study imaging should be a plain abdominal radiograph; a characteristic
finding is a double-bubble image of an air-filled stomach proximal to an air-filled
first portion of the duodenum (6). Differential diagnosis of UGI obstruction
should be in mind. See table 1. (1)
Treatment of DA includes initial medical preoperative management and surgical
correction. Adequate IV hydration, TPN, and gastric decompression are essential
until the neonate has been stabilized for surgical repair (1). e surgical correction
is a duodenoduodenostomy (“diamond shaped”) (7) (4). See Figure 2. (8)
Early mortality rate is 5%. Most deaths are associated with multiple anomalies
(usually complex cardiac defects). Late complications may occur in 12% to 15% of
patients, among them are delayed gastric emptying, severe gastroesophageal reflux,
bleeding peptic ulcer, megaduodenum, duodenogastric reflux, gastritis, blind-loop
syndrome, and intestinal obstruction related to adhesions. Long-term survival is
excellent at rates reported between 86% and 90% (4).
References
1. Bilious vomiting in the newborn: rapid diagnosis of intestinal obstruction. Kimura,
K. and Loening-Baucke, V. 2000, Am Fam Physician, Vol. 61, pp. 2791-2798.
2. Congenital gastrointestinal defects in Down syndrome: a report from the Atlanta and
National Down Syndrome Projects. Freeman, S. B., et al. 2009, Clin Genet, Vol.
75, pp. 180-184.
3. Fetal duodenal obstructions: increased risk of prenatal sudden death. Brantberg, A.,
et al. 2002, Ultrasound Obstet Gynecol, Vol. 20, pp. 439-446.
4. Duodenal atresia and stenosis: long-term follow-up over 30 years. Escobar, Mauricio
A, et al. 2004, J Pediatr Surg, Vol. 39, pp. 867--71; discussion 867-71.
5. Intrauterine growth rate in relation to anorectal and oesophageal anomalies. Cozzi, F.
and Wilkinson, A. W. 1969, Arch Dis Child, Vol. 44, pp. 59-62.
6. e double bubble sign. Traubici, J. 2001, Radiology, Vol. 220, pp. 463-464.
7. Diamond-shaped anastomosis for congenital duodenal obstruction. Kimura, K., et al.
1977, Arch Surg, Vol. 112, pp. 1262-1263.
8. Karrer, Frederick Merrill. Duodenal Atresia: Multimedia. Emedicine. [Online]
Medscape, March 3, 2009. [Cited: April 09, 2009.] http://emedicine.medscape.
com/article/932917-media.
Figure 1 Table 1: Differential Diagnosis of Upper GI
Obstruction in Newborns
Figure 2: Diamond Shape
Duodenoduodenostomy
Type of obstruction Cause and
incidence Presentation
Diagnostic
procedure and
findings
Duodenal atresia
Embryogenic; occurs
in 1 per 5,000 live
births; 25% have Down
syndrome
Few hours after birth;
billious vomiting, no
distention
Abdominal film, “double-
bubble” sign
Malrotation with
volvulus
Incomplete bowel
rotation occurring during
7th to 12th weeks of
gestation
At 3 to 7 days; bilious
vomiting, rapid
deterioration with
volvulus
Upper GI spiral sign on
ultrasound; abnormal
location of the superior
mesenteric vessels
Jejunoileal atresia
Mesenteric vascular
accident during fetal life
in 1 per 3,000 live births
Within 24 hours of birth;
vomiting, abdominal
distention
Air-fluid levels on
abdominal film
Necrotizing ileus Cause unknown in 2.4
per 1,000 live births
10 to 12 days after birth;
distention, vomiting,
bloody stools
Abdominal film;
distention, pneumatosis,
air in the aortal vein
Meconium ileus
Genetic, occurs in 15%
of newborns with cystic
fibrosis, and in 1 per
5,000 to 10,000 live
births
Immediately after birth;
abdominal distention,
bilious vomiting
Abdominal film;
distention, air-fluid
levels, sweat test,
“ground-glass” sign
