CASE REPORT
Endoscopic Treatment of Duodenal evidence of bile. An Olympus GIF-Q180 video gastroscope was
Web in Association With Annular
Pancreas in an Infant
Jessica Dodkins, Joseph Meredith,
§
z
Scott Nightingale, and yzAniruddh V. Deshpande
W e report the rare diagnosis of a fenestrated duodenal
membrane with annular pancreas at the same level, and
successful endoscopic management with balloon dilatation. In
presenting this instructive case we outline unique imaging findings
of a delayed presentation and approach to management of congeni-
tal duodenal stenosis.
CASE REPORT
An 8-month-old, nonsyndromic girl presented with delayed
Downloaded from http://journals.lww.com/jpgn by BhDMf5ePHKbH4TTImqenVHwt3+2Cz0wZHDu0wN1HNm7St1LMYQ1k6Mj+BHGpmV20wcK+4DrQRUc= on 09/12/2020
symptoms of partial upper gastrointestinal (GI) obstruction. These
included persistent and forceful nonbilious vomiting since birth
and history of failure to thrive. The infant had been treated with
acid-suppressive therapy for gastro-oesophageal reflux without
improvement. History of polyhydramnios was noted on
antenatal screening.
The patient was unwell at presentation with continued non-
bilious vomiting, signs of acute dehydration, nil hematemesis and
biochemical changes of hypochloremic alkalosis, consistent with
gastric outlet obstruction (venous pH 7.5, CO2 43 mmHg, base
excess 9.2 mmol/L), and hypokalaemia (2.7 mmol/L). Complete
blood count, C-reactive protein, serum lipase, and liver function
tests were normal. Abdominal ultrasound performed in the emer-
gency department showed pneumobilia and a subsequent abdominal
X-ray depicted gastroduodenal pneumatosis (Fig. 1). A nasogastric
tube was successfully placed, with no reported difficulty or exces-
sive trauma, to decompress the bowel. A contrast CT scan of the
abdomen was suggestive of duodenal stenosis, an annular pancreas
without signs of malrotation (Fig. 2). Given the history of non-
bilious vomiting and nil hematemesis, in conjunction with the
finding of pneumatosis on imaging before the endoscopy, we
believe that the pneumatosis was because of severe emesis with
upper gastrointestinal obstruction.
After patient stabilization, endoscopy was performed ini-
tially with an Olympus XP-180N (Olympus Medical Systems Corp,
Tokyo, Japan) to visualize the duodenum. The gastric antrum and
first part of the duodenum were grossly dilated. A membranous
obstruction to the second part of the duodenum proximal to the
ampulla was present with a 2–3 mm luminal opening with no
Received July 23, 2017; accepted February 24, 2018.
From the Department Paediatric Gastroenterology, the yPaediatric Sur-
gery, John Hunter Children’s Hospital, the zHealth and Medicine
(Priority Research Centre, GrowupWell), and the §Joint Medical Pro-
gram, University of Newcastle, New South Wales, Australia.
Address correspondence and reprint requests to Dr Aniruddh V. Desh-
pande, MCh, PhD, FRACS, Paediatric Urologist and Surgeon, John
Hunter Children’s Hospital, School of Medicine and Public Health,
University of Newcastle, Locked Bag 1, Hunter Region Mail Centre,
NSW 2310, Australia
(e-mail: aniruddh.deshpande1@hnehealth.nsw.gov.au).
The authors report no conflicts of interest.
Copyright # 2018 by European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition and North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition
DOI: 10.1097/MPG.0000000000001977
JPGN  Volume 67, Number 4, October 2018
Copyright © ESPGHAN and NASPGHAN. All rights reserved.
then used to complete the balloon dilation under fluoroscopic
guidance using a CRE PRO Wireguided Balloon Dilatation Cathe-
ter (Boston Scientific, Marlborough, MA) with a balloon length of
5.5 cm. Incremental dilatation from 6 to 10 mm (Fig. 3) allowing for
passage of the endoscope to level of D4 and confirming a normal
distal duodenum containing bile. Duration of inflation was 15 sec-
onds at each increment and 10 mm was chosen for the final initial
dilation as this diameter caused a visible tear in membrane and
allowed the endoscope to pass beyond it. A 6Fr nasojejunal feeding
tube was placed under vision with negligible bleeding. Postopera-
tively the patient tolerated oral intake in 24 hours and was not reliant
on the nasojejunal tube. Serum lipase was normal. The patient was
discharged on third postoperative day.
Four weeks later, the patient returned for another planned
procedure. The follow-up dilation was completed because of con-
cerns over; possibility of restenosis and patient being lost to follow-
up. The patient did not become symptomatic again in between
initial and repeat dilations. A larger diameter was chosen for this
dilation to completely obliterate the membrane. The stenosis was
dilated to 13 mm. At 5 weeks post second procedure, barium meal
showed improvement of the stenosis and reduced proximal
duodenal diameter.
Six and 12 months postinitial presentation, the patient’s
weight for age and growth velocity charts improved vastly.
Failure to thrive was evident throughout the first 6 months of
life where weight was persistently below the 5th percentile. At
presentation, the patient’s weight for age was on the 25th
centile, moving to the 50th centile postprocedure at 22 months
of age. The patient is currently on normal diet and remains
symptom-free.
DISCUSSION
We believe this is the first report that confirms the safety and
medium-term efficacy of endoscopic balloon dilatation of duodenal
membrane in conjunction with annular pancreas in an infant.
In any infant presenting with persistent vomiting and
history of failure to thrive, the differential diagnosis of congeni-
tal duodenal obstruction should be considered. It is common for
duodenal stenosis to present in early infancy, and management
traditionally involves a surgical by-pass procedure of the
obstruction site (1).
In this rare case of fenestrated duodenal membrane associ-
ated with an annular pancreas at the same level, it was the cross-
sectional imaging that allowed for differentiation of the primary
cause of the stenosis, prompting endoscopic intervention over
surgery as has been reported in a handful of cases (1–6).
Advancing therapeutic endoscopic techniques have the
capacity to reduce the need for surgical intervention and hence
risk of related complications.
We chose to offer graded dilatation in 2 sessions, which is
similar to that reported by Poddar et al (3). In that series, as in our
case, there were no recorded complications associated with
the procedure.
There are case studies utilizing other endoscopic methods of
managing duodenal membranes, including laser membranotomy,
needle knife, sphincterotome, high-frequency wave-cutting and hot
biopsy forceps that report promising outcomes with minimal com-
plications (1–6). The main possible risks identified include exces-
sive bleeding, perforation, and damage to the ampulla. One
important case to note is Barabino et al (7) where a 20-month-
old girl had complications of profuse bleeding, increased pancreatic
enzymes, and scar formation after 3 failed attempts at endoscopic
incision. The patients eventually required a duodenojejunostomy.
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Case Report JPGN  Volume 67, Number 4, October 2018

FIGURE 1. (A) Ultrasound at presentation showing extensive pneumobilia and (B) plain abdominal X-ray showing gastroduodenal pneumatosis
with a dilated stomach and duodenum suggestive a chronic partial upper GI obstruction. GI ¼ gastrointestinal.

FIGURE 2. (A) Intravenous contrast computer tomography depicting a calibre change because of a membrane in the second part of the
duodenum. (B) Depiction of a near-compete obstruction with no contrast able to pass through with an annular pancreas and (C) CT in axial plane
depicting significant wasting of the preampullary duodenum pancreatic tissue noted on either side of the duodenal segment indicative of an
annular pancreas. Site of narrowing consistent with duodenal membrane (thick arrow) depicting annular pancreas (thin arrow). CT ¼computer
tomography.

FIGURE 3. (A and B) Endoscopic views showing cannulation of tiny fenestration in duodenal membrane and subsequent balloon dilatation with
spacious proximal duodenum and (C) a clear waist seen in the balloon at the level of the duodenal membrane whenever inflated under
fluoroscopic vision.

e84 www.jpgn.org

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JPGN  Volume 67, Number 4, October 2018
Ziegler et al (8) reported a case of failure of endoscopic laser
resection, and Torroni et al (6) reported failed attempt at incision
using a 5F sphincterotome in a patient with previous surgery for
annular pancreas, because of inability to reach the membrane.
In conclusion, in a nonseptic child, gastric pneumatosis and
pneumobilia can be indicators of an underlying chronic partial
upper GI obstruction. Endoscopic balloon dilation has the capacity
to be a safe, minimally invasive approach to the management of
congenital membranous duodenal stenosis even in infants. The case
we put forth adds to the data already available presenting promising
results worldwide. We acknowledge that there is still some uncer-
tainty surrounding the long-term outcomes of the technique, par-
ticularly regarding the associated addition of an annular pancreas.
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www.jpgn.org
Copyright © ESPGHAN and NASPGHAN. All rights reserved.
Case Report
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