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Images in emergency medicine
recovered fully and brain MRI showed near-complete resolution
of oedema (figure 1G,H). Hypertension-associated posterior
reversible encephalopathy syndrome(PRES) is a challenging
condition that may well expand beyond posterior borders and
might be misdiagnosed as encephalitis.
Farid Salih,1 Christoph Leithner,1 Georg Bohner,2
Christoph J Ploner1
1
Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Germany; 2Institut für
Radiologie, Abt. für Neuroradiologie, Charité-Universitätsmedizin Berlin, Germany
Double bubble sign
A 4-day-old full-term male neonate presented with postprandial
non-bilious vomiting. Delayed meconium passage had been
Figure 1 Abdominal radiograph showing two distended air bubbles,
indicating the stomach (S) and duodenal bulb (D).
A misleading chest plain radiograph
acquired after the return of
spontaneous circulation
A 77-year-old man with a history of end-stage renal disease
collapsed suddenly during his routine haemodialysis at a local
clinic. The patient experienced choking while drinking water
just before collapsing. He immediately received cardiopulmo-
nary resuscitation. Return of spontaneous circulation occurred
1084
Correspondence to Dr Farid Salih, Department of Neurology, Charité, University
Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin,
Germany; farid.salih@charite.de
Competing interests None.
Patient consent obtained.
Provenance and peer review Not commissioned; internally peer reviewed.
Accepted 7 April 2011
Published Online First 26 May 2011
Emerg Med J 2011;28:1083e1084. doi:10.1136/emermed-2011-200136
recorded at 36 h of age. Progressive abdominal distention was
noted. A supine radiograph of the abdomen showed marked
distention of the stomach and proximal duodenum with double
bubble sign (figure 1). Air density was not identified distal to the
duodenum. Duodenal obstruction was strongly suspected.
Exploratory laparotomy revealed duodenal atresia proximal to
the ampulla of Vater and severe dilatation in the first part of the
duodenum, which were repaired by duodenoduodenostomy.
The double bubble sign is a classic radiographic manifestation
of duodenal obstruction, the cause of which could be intrinsic
(such as duodenal atresia, duodenal stenosis or duodenal web) or
extrinsic (such as annular pancreas or rotational anomalies).
Identification of the typical double bubble sign requires imme-
diate investigation, as any cause of duodenal obstruction may
require surgical treatment.
Haw-Chiao Yang, Shyh-Jye Chen, Kao-Lang Liu
Department of Medical Imaging, National Taiwan University Hospital and National
Taiwan University College of Medicine, Taipei, Taiwan
Correspondence toDr Kao-Lang Liu, Department of Medical Imaging, National
Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan;
lkl@ntu.edu.tw
Competing interests None.
Patient consent Obtained.
Contributors KLL, HCY: study concept and design. HCY: acquisition of data. HCY:
drafting of the manuscript. KLL: critical revision of the manuscript for important
intellectual content. Statistical analysis: None. KLL, SJC: study supervision.
Provenance and peer review Not commissioned; not internally peer reviewed.
Accepted 18 March 2011
Published Online First 25 May 2011
Emerg Med J 2011;28:1084. doi:10.1136/emermed-2011-200050
soon, and he was transferred to our hospital. In the emergency
department, chest plain radiography revealed hyperdense
lesions resembling a removable partial denture with both sharp
ends inside the gastric bulb (figure 1A). His care givers could
not find his denture. An abdominal CT was performed instead
of oesophagogastroduodenoscopy.1 CT revealed a torturous and
calcified splenic artery (axial view in figure 1B and coronal
view in figure 1C) and no obvious foreign body inside the
stomach. His family members found his denture at home later.
Emergency physicians often encounter pitfalls when inter-
preting plain radiographs. Further imaging studies should be
performed to confirm the diagnosis before conducting invasive
procedures.
Emerg Med J December 2011 Vol 28 No 12
 Downloaded from http://emj.bmj.com/ on May 2, 2015 - Published by group.bmj.com

Double bubble sign

Haw-Chiao Yang, Shyh-Jye Chen and Kao-Lang Liu

Emerg Med J 2011 28: 1084 originally published online May 25, 2011
doi: 10.1136/emermed-2011-200050

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