E2204. Duodenum in Children: Normal, Variants and Abnormalities
  1. Preet Sandhu; Le Bonheur Children's Hospital/University of Tennessee Health Science Center
  2. Hiral Banker; Le Bonheur Children's Hospital/University of Tennessee Health Science Center
Congenital anomalies of duodenum consist of intrinsic abnormalities, such as atresia, stenosis, web or extrinsic lesions affecting the duodenum such as midgut volvulus, annular pancreas and duplication cysts. These often result in obstruction and vomiting. Acquired duodenal abnormalities include trauma, inflammatory condition such as ulcer disease and Crohn disease and neoplastic conditions. Imaging plays an important role in diagnoses and management of these conditions.

Educational Goals / Teaching Points
Briefly describe normal anatomy and embryology of duodenum. To discuss normal variants (e.g. duodenum inversum), congenital abnormalities (e.g. duodenal atresia, duodenal stenosis, duodenal web, annular pancreas, malrotation and midgut volvulus, duplication cyst) and acquired pathologies (superior mesenteric artery syndrome, trauma, ulcer, hematoma, bezoar) affecting the duodenum in children. Imaging appearance of these pathologies on various modalities including radiographs, ultrasound (US), Computerized tomography (CT) and Magnetic resonance imaging (MRI) including antenatal US and MRI will be discussed. To discuss imaging algorithm in a child with bilious vomiting.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Intrinsic duodenal abnormalities include duodenal atresia characterized by gaseous distended stomach and duodenum with absent distal gas called the "double bubble" sign. Duodenal web is characterized by "windsock deformity" resulting from ballooning of the web/membrane into the distal collapsed fluid filled duodenum with peristalsis. Similarly, mid-gut volvulus results in classic "cork-screw" appearance on upper gastrointestinal series and "whirl-pool" sign on ultrasound. Though all of these are classic signs, they are not always present or easily identified. Correct diagnostic approach and use of more than one imaging modality is thus sometimes important to make the correct diagnosis. Similarly meticulous and systematic evaluation and correlation with patient history is important to correctly diagnose acquired conditions such as duodenal ulcer, hematoma, traumatic perforation and superior mesenteric artery syndrome.

Duodenum may be affected by various pathologies, congenital or acquired. Duodenal obstruction in a child manifests as bilious emesis. Knowledge of the imaging algorithm and in depth understanding of the imaging appearance of normal appearance, normal variants and conditions affecting the duodenum is of utmost importance for appropriate patient care.