E1737. Duodenal Obstruction in Pediatric Patients
  1. Preeti Prasad; UTHSC
  2. Akosua Sintim-Damoa; UTHSC
  3. Muhammad Khan; University of Texas Health Science Center
  4. Preet Sandhu; UTHSC
Duodenal obstruction in pediatric patients usually presents with bilious emesis. The causes can be congenital or acquired. Congenital causes can further be categorized as intrinsic or extrinsic conditions. Congenital anomalies caused by intrinsic factors include duodenal atresia, web, and stenosis. Extrinsic conditions include malrotation with midgut volvulus, annular pancreas, and duplication cysts. Acquired causes of duodenal obstruction can be vascular like superior mesenteric artery syndrome (SMA syndr), traumatic, inflammatory, and neoplastic. The purpose of this exhibit is to learn about various causes of duodenal obstruction in the pediatric population and to familiarize with imaging findings on various modalities. The aim is also to identify surgical emergencies like malrotation, to facilitate early diagnosis and management.

Educational Goals / Teaching Points
To learn the causes of congenital and acquired duodenal obstruction in the pediatric population. To identify key clinical indicators in cases of emergent duodenal obstruction. To develop a multi-modality approach to imaging and diagnosis.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Various imaging modalities like plain radiography, contrast-enhanced upper gastrointestinal studies (UGI) under fluoroscopy, ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) are utilized for evaluating pediatric duodenal obstruction. Congenital extrinsic causes like malrotation with midgut volvulus on radiographs appear as dilation of the stomach, and duodenum with distal bowel gas. Sonography reveals dilation of the second portion of the duodenum, abnormal relationship between the superior mesenteric artery and vein, and swirling of the mesenteric vessels. Fluoroscopy shows duodenal obstruction, “bird’s beak” and “corkscrew” findings. Duodenal atresia on fetal US appears as “double bubble” sign. Radiographs show “double-bubble” sign with no distal bowel gas. Duodenal web radiographs show “double bubble” sign with distal bowel gas. Sonography and fluoroscopy reveal windsock deformity. Vascular causes of obstruction like Superior Mesenteric Artery (SMA) syndrome on contrast upper GI study is seen as abrupt cut-off of third part of duodenum with proximal dilation. Traumatic causes include duodenal hematoma secondary to accidental trauma, nonaccidental trauma, iatrogenic (endoscopy), or bleeding diathesis. Infectious/inflammatory causes include pancreatitis, histoplasmosis, and Crohn's disease. Neoplastic conditions include pancreatic head/neck neoplasms. Miscellaneous causes of duodenal obstruction include bezoar or intussusception around a gastro-jejunostomy tube.

Pediatric duodenal obstruction can be due to varied causes and conditions. Radiology plays a key role in diagnosing many of these conditions. As such radiologists need to be familiar with these imaging features. Emergent conditions like midgut volvulus require immediate surgical consult. A high index of suspicion and imaging can help diagnose such cases and facilitate patient's treatment and management.