David Gessert, MS4 Maria Daniela Martin, MD Newborn with Emesis July 5, 2013 David Gessert, MS4 Maria Daniela Martin, MD

Clinical History Newborn male born at 36 1/7 weeks to a 26yo G4P2012 mother from an uncomplicated pregnancy Birth weight of 2760g APGARS 9 and 9 Spontaneous rupture of membranes, delivered via repeat C-section Breast fed 3 times and then developed milky, NBNB emesis Previously seen dilated loops of bowel on prenatal US Transferred to NICU after presenting MRN: 6568255

Focused Physical Exam Gen: active and reactive for age Head: normocephalic, anterior fontanel is open, soft and flat, sutures overriding Abd: Soft, Non-distended, Non-tender, Normal active bowel sounds, No masses palpated and No hepatosplenomegaly CV: regular rate and rhythm, normal S1 and S2, no murmur, femoral pulses equal, brisk capillary refill Anus is present, normally placed and appears patent Labs: Blood type B+, Negative Coombs Test

Clinical differential diagnoses Intestinal Atresia Pyloric Stenosis Malrotation Volvulus Hirschsprung Disease Diagnostic Plan Babygram Labs: CBC with diff, ABG, blood culture Treatment Plan NPO, NG Tube, IVF, TPN

Initial Babygram NG tube is in place. Cardiac silhouette and lung fields appear normal. Bony structures appear normal. Gas is present in the stomach but absent from the rest of the abdomen. Likely indicates some kind of bowel obstruction.

Normal Upper GI Next step is upper GI fluoroscopy series. Contrast seen ranging from the stomach, through the pylorus, into the duodenum and jejunum.

Patient’s Upper GI Series 4 cc of contrast given via NG tube. Contrast pools in the fundus of the stomach in supine position.

Upper GI Series Lateral View Patient rotated so contrast will move into the duodenum. First portion of the duodenum is in the proper location and orientation in the retroperitoneal space. Lateral View

Upper GI Series Patient rotated into supine position. Pylorus is visualized as normal in this patient. Second portion of the duodenum appears in appropriate orientation and location.

Upper GI Series Third portion of the duodenum crosses the midline and appears normal. Fourth portion of the duodenum seen reaching the level of the pylorus. This is the location of the ligament of Treitz and duodeno-jejunal junction. With the previously seen normal 1st and 2nd portions, the 3rd portion crossing the midline and 4th portion reaching the level of the pylorus, malrotation is ruled out.

Upper GI Series After waiting and the addition of 4 more mL of contrast, the duodenum is distended. The contrast remains in the duodenum and tapers off towards the ligament of Treitz. The contrast does not advance into the distal small bowel. Imaging is indicative of intestinal atresia in the area of the duodeno-jejunal junction.

Intestinal Atresia Complete congenital obstruction of the lumen of a hollow viscus Jejunum and ileum are the most common locations Occurs in 1 in 1500 to 12,000 births Duodenal atresia occurs in 1 in 10,000 to 40,000 births. 30% of which have a chromosomal abnormality. Caused by abnormal development of GI tract Clinical features: abdominal distension, emesis within 24-28 hours of life, increased enterohepatic circulation that leads to jaundice Dilated loops of bowel on prenatal US suggests atresia

Textbook KUB Double Bubble Sign Double bubble sign seen in duodenal atresia, shows gas in the stomach and first portion of the duodenum with no air distally. Not seen in our patient. Likely due to the placement of an NG tube. Double Bubble Sign

Upper GI Series Triple Bubble Sign Triple bubble sign seen during jejunal atresia. Stomach, duodenum and jejunum are distended with no air distally. Triple Bubble Sign

Outcome Patient underwent surgery with resection of 5 segments of atretic jejunum. Patient is doing well post op. Follow up upper GI series was done.

Follow Up Upper GI Series Contrast seen to advance into the jejunum and ileum following removal of the atretic bowel.

References "Double Bubble Sign." RadiologyWiki. N.p., n.d. Web. 02 July 2013. <http://www.radiologywiki.org/w/index.php?title=Double_Bubble_Sign>. Jones, Jeremy, and Hani Alsalam. "Jejunoileal Atresia." Radiopaedia.org, the Wiki-based Collaborative Radiology Resource. N.p., n.d. Web. 02 July 2013. <http://radiopaedia.org/articles/jejunoileal-atresia-1>. Upper GI Study. Digital image. RadAnatomy. Kansas University Medical Center, 14 Aug. 2002. Web. http://classes.kumc.edu/som/radanatomy/image.asp?Image=4903-002.jpg&Film=4903&Features=1 Wesson, David E. "Intestinal Atresia." UpToDate. N.p., 10 Dec. 2012. Web. 2 July 2013. <http://www.uptodate.com.ezproxy.rush.edu/contents/intestinal-atresia?detectedLanguage=en&source=search_result&search=jejunal+atresia&selectedTitle=1~9&provider=noProvider>.