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

2. 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:

3. 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

4. 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

5. 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.

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

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

8. 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

9. 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.

10. 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.

11. 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.

12. 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 hours of life, increased enterohepatic circulation that leads to jaundice
Dilated loops of bowel on prenatal US suggests atresia

13. 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

14. 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

15. 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.

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

17. References
"Double Bubble Sign." RadiologyWiki. N.p., n.d. Web. 02 July <
Jones, Jeremy, and Hani Alsalam. "Jejunoileal Atresia." Radiopaedia.org, the Wiki-based Collaborative Radiology Resource. N.p., n.d. Web. 02 July <
Upper GI Study. Digital image. RadAnatomy. Kansas University Medical Center, 14 Aug Web.
Wesson, David E. "Intestinal Atresia." UpToDate. N.p., 10 Dec Web. 2 July <