CASE REPORT

DUODENAL STENOSIS IN 3rd MONTH BOY

Compiled By:

Muhammad Khaiuna Syahputra

Andi Roy Situmorang

110100073

1101000193

Supervisor :
dr. Sri Sofyani, Sp.A(K)

CHILD HEALTH DEPARTMENT

H. ADAM MALIK GENERAL HOSPITAL
FACULTY OF MEDICINE
SUMATERA UTARA UNIVERSITY
MEDAN
2015

STENOSIS DUODENUM

Definition : the Incomplete nature of the

obstructions that occurs in newborn.

Etiology : . Instrinsic obstruction result from failure

vacuolization and recanalization (stenosis or atresia)

and extrinsic obtrusction result from the pancreas
annulare, where the head of the pancreas completely
encircles the duodenum and compress it
Epidemiology : Congenital obstructions of
the duodenum are relatively uncommon,
even in active pediatric medical centers.

Pathophysiology

The pathogenesis of duodenal stenosis is

stated as being due to faulty recanalization of
the intestinal lumen in utero.7 During the fifth
week of fetal life, rapid proliferation of the
epithelial cells of the intestinal lumen occurs
with occlusion of the lumen and conversion of
the intestinal tract into a solid tube. Between
the tenth and twelfth fetal week vacuolization
occurs, and these spaces coalesce to
reestablish the normal lumen. If coalescence
is incomplete, atresia or stenosis results

Diagnosis

History :The symptom is bilious vomiting,

some patient present in adulthood with
gastroesophageal reflux, peptic ulceration, or
obstruction of the duodenum proximal to the
stenosis by a benzoar
Physical Examination : Duodenal stenosis
can manifest distension abdomen and
constipation can make peristastis in stomach
hyperactive
Laboratory Finding: Laboratory for
diagnosis duodenal stenosis is radiograph.

Differential Diagnosis

atresia duodenum
hisprung disease
GERD
wilms tumor

Treatment / Supportive Care

Preoperative Care
General Intraoperative Considerations

MEDICAL RECORD

Name
: FS
Age
: 3 months
Sex
: Boy
Date of Admission: Maret 6th 2015

Chief Complaint : Bullous vomiting

History:It problem has already been occurring since birth
patient with frequent more 5 times in 24 hours, the content
of vomiting is what the patient eat and the color is green.
History of diarrhea is not found, history of fever is not found.

History of pregnancy
Age mother at pregnant is thirty years old, never have DM,
or consuming medicine.

History of birth
The patient is normal labor and cry hard.
Weight birth is 2500 gram

History of imunisation
Hepatitis B

Laboratory Result (Samosir General

Hospital) :
Maret, 7th 2015
Hb / Ht / L / T / Ur / Cr : 10.1 / 28.7 /
12700/800.000/518/ 0.28.

Physical Examination

Generalized status
Body weight: 2,1 kg, Body length: 50 cm,
Body weight in 50th percentile according to age: SD < -3
Body length in 50th percentile according to age: 0 < SD < -2
Body weight in 50th percentile according to body length:
Presens status
Consciousness: GCS 15 (E4 V5 M6)
Blood Pressure: 100/60 mmHg
Heart Rate: 132 x/i
Respiratory Rate: 42 x/i
Body Temperature: 36,5oC.
Anemic (-). Icteric (-). Cyanosis (-). Edema (-). Dyspnea (-).

Physical Examination (Localized status)

Head :
Isochoric pupil 3 mm. Inferior palpebra conjunctiva pale (-/-). Icteric sclera
(-/-). Light reflex (+/+). Face edema (-).Inferior and superior palpebra edema
(-/-).Ear andnosewere within normal limit.Mouth : pale mucosa (-)..
Neck :
Lymph node enlargement (-).
Thorax:
Symmetrical fusiformis. Chest retraction (-). HR: 132x/i, regular, murmur (-).
RR: 42x/i, reguler, ronchi (-).Breath sound: vesicular. Additional sound
(-).Ptekie (-).
Abdomen:
Soepel.Liver and spleen unpalpable.Skin pinch returns late.Shifting dullness
(-).Double sound (-).
Extremities:
Pulse 132x/i, regular, adequate pressure and volume, warm, CRT >t 3. BP:
100/60 mmHg. Pitting edema(-).
Urogenital:
Male.Scrotum (+).Edema(-).Penis(+).Anus(+).

Differential Diagnosis:
GERD
HIATAL HERNIA
DUODENAL STENOSIS
Marasmus
Working Diagnosis:
Duodenal Stenosis
Management :
F 75 cc / 3 jam + mineral mix 0,7 cc
Multivitamin fl without Fe
Omeprazole 4.2 mg/ 8 hours
Vitamin A. 1 x 50.000
Resomal 10 cc

Diagnostic Planning

Barium follow through

Laboratory
Findings:
Maret, 7th 2015

Laboratory Findings: Maret, 12st 2015

Duodenal stenosis

FOLLOW UP
February, 2nd February, 11th 2014
S : pale (-)
O:Cons: alert, Temp: 36,6 oC. Anemic (-). Icteric
(-). Edema (-). Cyanosis (-). Body weight: 2,5 kg,
Body length: 50 cm.
A: Stenosis Duodenum
Management:
F 75 cc / 3 jam + mineral mix 0,7 cc
Multivitamin fl without Fe
Omeprazole 4.2 mg/ 8 hours
Vitamin A. 1 x 50.000
Resomal 10 cc

Discussion

Congenital duodenal obstruction may be due to

annular pancreas, atresia or duodenal diaphragm
and the condition may be associated with Down's
syndrome and cardiac defects. The incomplete
nature of the obstruction in duodenal stenosis
results in a variable and often delayed presentation.
In this situation symptoms first occur when
advancing the infant from formula to solid food, or it
may be unmasked much later in infancy, childhood
or, in rare instances, adulthood, when a progressive
decrease in motility or impaction of food or a foreign
body causes more pronounced symptomatology.

The delayed presentation of these anomalies in the adult

is difficult to explain, but the presence of a dilated
stomach and a proximal duodenal bulb with a patulous
pylorus suggests a progressive loss of compensatory
peristaltic action to overcome a small duodenal aperture
or narrowing of the de-scending duodenum. Most studies
of these lesions are single case reports or small series,
which do not allow a single surgeon to accumulate
extensive experience; therefore, reliance on the combined
experience of others in recognition and appropriate
management has been the norm. It usually results in
recurrent episodes of vomiting, aspiration, or failure to
thrive. Some patients present in adult-hood with
gastroesophageal reflux, peptic ulcer-ation, or obstruction
of the duodenum proximal to the stenosis by a bezoar.

Duodenal stenosis could be treated surgical or

endoscopic. The choice of surgical procedure is largely
based on the preference of the surgeon.
Duodenoduodenostomy, duodenotomy with inci-sion
or excision of the diaphragm, duodenojejun or
duodenoplasty can all be considered as different
modes of operative management. We use
duodenoplasty, joining the bowel just proximal and
distal to the obstruction with excision of the duodenal
membrane closed transversely in Heineke-Mikulicz
fashion as we think that it is the best operative
procedure as it is the most direct, physiologic repair
and, of the available options, has the least potential
for later complications

Thank You