PEDIATRIC SURGERY NOTES

Congenital Duodenal Obstruction (CDO)

Congenital duodenal obstruction (CDO) is amongst the commonest anomalies in
newborns.

Incidence

 It affects: 1: 2500-10000 live births.

 It accounts about 25-40% of all intestinal atresia
 Half of the patient are born premature
 Down syndrome occurs in 20-30% in
patients with duodenal atresia

Causes

 Intrinsic causes:
 Duodenal atresia.
 Congenital duodenal web.
 Extrinsic causes:
 Malrotation and Ladd’s bands.
 Annular pancreas.

Figure 11: A, Annular Pancreas. B, Ladd's band

Figure 10: A, Visible gastric peristalsis. B, Double bubble appearance

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 PEDIATRIC SURGERY NOTES

Figure 12: A, Two blind ends. B, Two blind ends with a fibrous
band in between. C, two blind ends with a gap between the
blind ends. D, membrane (Windsock). E, Membrane with
central hole

Clinical features

 The clinical features of congenital duodenal obstruction are variable and depend on
the site and degree of obstruction.
 Polyhydramnios is seen in 30–60% of cases.
 The usual presentation is with vomiting that commences within the 24 hours of birth.
 The vomiting is usually bile-stained and occurs in approximately 85% of cases
 Non-bilious vomiting occurs in those with duodenal atresia above the papilla of Vater.
 The passage of normal meconium does not exclude congenital duodenal obstruction.
 Congenital duodenal obstruction is not associated with abdominal distension, but
there may be fullness in the epigastrium, caused by the dilated duodenum and
stomach.
 Neglected and delayed cases may show signs of dehydration and weight loss.

Investigations

 Prenatal diagnosis: prenatal US may demonstrate polyhydramnios and dilated

stomach
 Plain erect X-Ray will demonstrate double bubble appearance.
 Serum electrolytes and blood sugar
 Karyotyping for diagnosis of Down’s syndrome
 Echocardiography and abdominal US

Management

 The definitive management of patients with congenital duodenal obstruction is

surgical correction.
 Prior to surgery, these patients should be resuscitated:
 Orogastric or nasogastric decompression of the stomach.
 Fluid and electrolytes resuscitation and replacement of orogastric tube losses.
 Broad-spectrum antibiotics.

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 1 mg vitamin K.
 Parenteral nutrition is instituted on the first day of life.
 The operative management of duodenal atresia is determined by the type and site of
obstruction.
 The following procedures are used to treat congenital duodenal obstruction:
 Duodenoduodenostomy: This is the commonly performed procedure using a standard
side-to-side duodenoduodenostomy.
 Type 1 duodenal atresia can also be managed by simple duodenotomy and web
excision. The duodenotomy is closed transversely.
 There are reports of duodenal diaphragms treated successfully by endoscopic
excision. This is more feasible in patients who present late and have a duodenal
diaphragm with a hole.
 In cases with Ladd’s bands the Ladd’s procedure should be done.

Figure 13: Duodeno-duodenostomy

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