Prenatal diagnosis of bowel obstruction initially manifested as isolated hyperechoic bowel

Fetal bowel obstruction has a prevalence of 1 in 3000 to 5000 live births. Ultrasonographic diagnosis is made by demonstrating distended loops of bowel. Echogenic bowel, defined as small bowel more echogenic than liver or bone, has been associated with congenital infections, cystic fibrosis, chromosomal abnormalities, and bowel obstruction. Fetal ascites, defined as fluid in the peritoneal cavity partly surrounding the liver and bladder, also has been associated with bowel obstruction. We present a case of jejunal atresia whose presenting appearance consists of echogenic bowel, transient ascites, and massive dilatation of intestinal loops.

Subtotal duodenectomy with jejunal patch for megaduodenum secondary to congenital duodenal malformation

BACKGROUND/PURPOSE

This report describes a technique devised for two children with megaduodenum consisting of subtotal duodenal resection with the proximal jejunum used as an onlay patch.

METHODS

A 2-year-old boy presented after unsuccessful surgical repairs for duodenal stenosis with web. Another 8-year-old boy returned from the United States after several surgical procedures for complicated congenital left diaphragmatic hernia with gastric outlet obstruction. Both boys manifested postprandial right upper abdominal fullness, occasional vomiting, abdominal pain, and failure to thrive. Upper gastrointestinal contrast study findings showed massively dilated duodenums in both patients that were larger than the stomach. During the operative procedures, about 95% of the duodenal wall was resected, leaving the basal portion that was unified with the pancreatic head and the ampulla of Vater as linguiform flap, which was covered with the proximal jejunum as an onlay patch so as to form the anterior wall of the duodenal bulb.

RESULTS

The patients showed markedly improved quality of life and catch-up growth after the operations. The duodenal bulbs were of adequate size in follow-up gastrointestinal series.

CONCLUSION

This technique will be useful in cases of functional duodenal obstruction with megaduodenum secondary to congenital duodenal malformations leading to blind loop syndrome.

Colonic atresia secondary to a choledochal cyst

Colonic atresia and choledochal cyst are both uncommon congenital abnormalities. We report a case in which the two conditions coexisted and propose an aetiological link.

Hereditary multiple atresias of the gastrointestinal tract: report of a case and review of the literature

Hereditary multiple atresia of the gastrointestinal tract is an extremely rare subgroup of intestinal atresia. The aim of this study was to report a new case, to review the literature, and to describe the unique features of this malformation. A computer-generated list of articles on this subject was obtained, and all articles relative to this malformation were reviewed. Thirty-five other well-documented cases were found in the literature. Hereditary multiple atresias have several unique features: (1) the abdominal x-ray shows signs of gastric or duodenal atresia combined with typical large rounded or oval homogeneous calcifications in the abdominal cavity, (2) intraoperatively widespread atresias (exclusively type I and II) extending mostly from stomach to rectum are found, (3) cystic dilatation of the bile ducts can be present in cases with both complete pyloric and duodenal or proximal jejunal atresia, (4) the pathogenesis is still speculative; a combined immunodeficiency should be excluded, and (5) a fatal outcome is the rule.

Distention of the fetal duodenum: abnormal finding?

We investigated whether a fluid-filled duodenum is observed in normal fetuses. In part 1 of the study a view in the region of the duodenum was obtained during routine obstetric ultrasonography from 123 low-risk patients. All examinations demonstrated a collapsed duodenum. No gastrointestinal abnormalities were found in these infants. In part 2 of the study, 1163 fetuses (both high-risk and low-risk) were evaluated with real-time scanning, and duodenal fluid without a "double bubble" was seen in one fetus who had a duodenal web. We conclude that a nondistended fetal duodenum is the norm. If fetal duodenal dilation is visualized, this may allow for earlier detection of duodenal obstructions.

[An unusual course of fetal gastroschisis]

We report on prenatal diagnosis of gastroschisis at 20th gestational week. In addition to gastroschisis intraabdominal intestinal stenosis was detected. As a consequence cesarean section was planned close to term. Control examinations in the last trimester didn't confirm initial diagnosis so that the recommended mode of delivery was changed. However postpartum diagnosis again confirmed the early diagnosis of gastroschisis including spontaneous necrosis of dislocated intraamniotic intestinal parts. The course demonstrates that even at unambiguous prenatal diagnosis control examinations are recommended as dynamic changes may occur in the second and third trimester. Thus mode of delivery may have to be adapted close to term to reduce maternal risk.

An extremely rare variant of congenital jejunoileo-colic atresia

This report presents an unusual case of a congenital long-segment jejunoileo-colic obstruction without mesenteric or intestinal interruption. Histologically, the intestinal lumen was completely or partially obstructed by fibrous or granulation tissue, and the mucosa had disappeared.

Pitfalls of the 'double bubble' sign: a case of congenital duodenal duplication

The 'double bubble' sign in prenatal diagnosis is most often associated with duodenal atresia. However, other causes of upper intestinal obstruction and cystic abdominal masses need to be considered. One possible diagnosis that can mimic the 'double bubble' sign of duodenal atresia is duodenal duplication, but little information is available to guide sonologists in the prenatal diagnosis of this rare congenital anomaly. In this case report we describe the successful prenatal diagnosis of duodenal duplication, by relying on the early gestational age of presentation, the lack of polyhydramnios, the failure to consistently demonstrate a 'double bubble' on transverse images, and the presence of a normal distal bowel pattern.

Antenatal intestinal vascular accident with subsequent small bowel atresia: case report

A woman was referred at 25 weeks' gestation with decreased fetal movements. Ultrasound revealed a large solid fetal abdominal mass and gross fetal ascites. Amniocentesis and viral titers were normal. On subsequent ultrasound examinations, the mass and ascites slowly disappeared, but a small bowel obstruction developed. Spontaneous labor occurred at 35 weeks and the child was born with a distended abdomen. At laparotomy there was type 3 jejunal atresia, indicating that the fetal mass and ascites were secondary to this antenatal small bowel ischemia.

Neonatal ultrasonography to distinguish between meconium ileus and ileal atresia

Meconium ileus can be difficult to distinguish from ileal atresia on plain radiographs and on contrast enema. Both show a microcolon in the face of a small bowel obstruction. The treatment of the two is very different. Meconium ileus obstruction may be relieved medically by contrast enema; ileal atresia requires prompt surgical intervention. This study was made to determine if abdominal ultrasonography might be helpful in distinguishing between these two entities. Abdominal ultrasonograms from the past 10 years of all patients with these two diseases who were studied with preoperative ultrasonography at Arkansas Children's Hospital were reviewed. Six of 16 patients with meconium ileus had preoperative ultrasonograms. All six patients with meconium ileus had multiple loops of bowel filled with very echogenic thick meconium. Four of 22 patients with ileal atresia had preoperative ultrasonograms. These four patients with ileal atresia had dilated loops of bowel filled with fluid and air. None had a dilated bowel filled with thick echogenic contents. Preoperative abdominal ultrasonography is proposed as a simple method for distinguishing between these two disease entities with very different treatment plans.

A new variant of esophageal atresia with tracheoesophageal fistula and duodenal atresia: a diagnostic dilemma

A new variant of esophageal atresia (EA) with tracheoesophageal fistula (TEF) associated with duodenal atresia is reported. The TEF was between the lower pouch and the trachea, with a cystic dilatation in the midportion. The tracheal end of the fistula was obstructed by a membranous septum at both ends of a cystic dilatation, leading to a diagnosis of pure EA (gasless abdomen). After the lower pouch was opened beyond the cystic dilatation, 100 ml nonbilious fluid was obtained. A laparotomy revealed a type III atresia of the first part of the duodenum.

Evaluation of prenatal diagnosis of congenital gastro-intestinal atresias

Prenatal diagnosis performed by fetal ultrasound scan is now a routine part of antenatal care in many countries. That an increasing number of fetal anomalies may be detected on prenatal ultrasound is beyond doubt. However what is theoretically possible is not, always done in practice specially when gastrointestinal atresias (GIA) are concerned and when whole antenatal populations are screened rather than high risk groups. Thanks to our registry of congenital anomalies a retrospective study was undertaken to evaluate the prenatal detection of GIA by ultrasound scan in 118,265 consecutive pregnancies of known outcome. Only 31 out of 129 malformed fetuses with GIA were detected (24.0%). The sensitivity of detection varied from 51.4% for atresia of the small intestine to 24.2% for esophageal atresia and 8.2% for ano-rectal atresia. No isolated case with esophageal atresia and ano-rectal atresia were diagnosed. Our results stress the need to perform scans at > or = 18 weeks gestation and to train sonographers in order to improve prenatal detection of GIA.

Esophageal and duodenal atresia in a fetus with Down's syndrome: prenatal sonographic features

Ultrasound examination of a 22-week fetus demonstrated a grossly distended stomach and proximal duodenum, with a large cystic area in the chest. There was associated polyhydramnios. A presumptive diagnosis of duodenal atresia with a congenital diaphragmatic hernia was made. Analysis of a fetal blood sample showed that the fetus had Down's syndrome. Histological examination after termination of the pregnancy revealed the unusual combination of duodenal and esophageal atresia, with an intact diaphragm.

Early diagnosis of duodenal atresia and possible sonographic pitfalls

The sonographic diagnosis of duodenal atresia and associated anomalies was made in a fetus at 15 weeks' gestation. A transient double-bubble sign was observed in three other normal fetuses. Sonographers are cautioned that normal intestinal peristalsis may cause a false image of duodenal atresia.

A decade of gastroschisis in the era of antenatal ultrasound

BACKGROUND

Gastroschisis is an uncommon condition in which viscera protrude at the base of the umbilical cord. To investigate the possible relationships between antenatal ultrasound findings, patient demographics, smoking, alcohol consumption and this condition, 21 causes are reviewed.

METHODS

The medical records and antenatal ultrasounds of 21 children diagnosed with gastroschisis at the Adelaide Children's Hospital between 1 January 1985 and 31 December 1992 were reviewed.

RESULTS

Antenatal ultrasound was employed in 15 cases, and the diagnosis was accurately made in 13 (86.7%) of these. There were 17 live births, two elective terminations and two pre-term abortions. Seven of the 21 cases had associated anomalies. The anomalies included five atresias, a ventricular septal defect (VSD), and a dislocated gall-bladder. Postoperative complications (which included one death) occurred in seven of the 17 patients. Bowel dilatation or thickening was first detected on five ultrasound examinations performed before 21 weeks' gestation, and four ultrasounds after 21 weeks. The nine cases with bowel changes on ultrasound were associated with a high atresia rate and a longer hospital stay, but not with an increased complication rate. Maternal race, parity, and alcohol consumption were not associated with increased risk of fetal gastroschisis. All mothers were under 27 years of age. There were nine mothers who smoked during pregnancy and a disproportionate number of mothers who lived outside the metropolitan area with gastroschisis-affected offspring.

CONCLUSIONS

Bowel changes seen on antenatal ultrasound increase the chances of intestinal atresia and longer hospitalization. Smoking during pregnancy may be associated with an increased risk of gastroschisis.

Rectal atresia as rare manifestation in EEC syndrome

A newborn boy presented with bilateral split hand/foot malformation, sparse hair, dry and scaly skin, and nasolacrimal duct obstruction. Despite absence of cleft lip or palate, the findings fit the EEC syndrome. Additionally, the boy had rectal atresia. At least six further patients with EEC syndrome and anal atresia (two published, four unpublished) demonstrate, that anorectal malformation is a further, but rare anomaly in EEC syndrome.

Congenital chloride diarrhoea: a prenatal differential diagnosis of small bowel atresia

We compared ultrasound findings and pre- and postnatal clinical signs in 8 patients with congenital chloride diarrhoea and 14 with small bowel atresia diagnosed in 1977-1991 in order to evaluate the possibility of a prenatal distinguishing diagnostic sign. In the patients with congenital chloride diarrhoea the pregnancy was complicated by marked polyhydramnios, the symphysis-fundus distance exceeded + 2 SD before gestational week 31 and the fetus displayed normal peristalsis in extensively dilated intestines and the "frog position". In the patients with small bowel atresia the symphysis-fundus distance was normal before gestational week 31 and the fetus displayed increased peristalsis in a few dilated intestinal loops.

Mucosal proctectomy and colo-anal anastomosis as treatment of rectal atresia

Rectal atresia is a rare condition in which the anus and sphincter muscles are normally developed. Therefore it seems logical to preserve those structures unaltered during surgical therapy. Mucosal proctectomy and colo-anal anastomosis is a safe, technically well known technique that achieves this goal.

An association of multiple intestinal atresia and biliary atresia: a case report

This is the first report of a 2-day-old girl having an association of biliary atresia and multiple intestinal atresia. She developed intractable vomiting in the first hours of life. An upper gastrointestinal series and barium enema showed jejunal atresia and rectal atresia. A laparotomy was performed on the fourth day of life. The operative findings were multiple sites of atresia of the intestine, 10 atretic sites in the small bowel, and 3 in the colon. The gall bladder was normal in size and position. After the operation, the patient's stool remained acholic and her jaundice did not resolve. On the 58th day of life, another laparotomy was performed with the presumptive diagnosis of biliary atresia. The operative finding was biliary atresia, type 3; the Kasai operation with external jejunostomy was performed. The patient suffered from postoperative cholangitis and enterocolitis because of her short bowel and subsequently died at 9 months of age. This is the first case of biliary atresia associated with multiple intestinal atresia reported in the literature.