Single or double bubble: sign of trouble! Congenital pyloric atresia: report of two cases and review of literature

Abdominal Plain Radiograph in Neonatal Intestinal Obstruction

A comprehensive all-inclusive resource on plain radiograph in neonatal intestinal obstruction is presented. This is an attempt to develop a protocol and to regain expertise in evaluating a plain radiograph that most often yields more than enough clues to diagnose and to decide a plan of action.

Neonatal gastric outlet obstruction by isolated pyloric atresia, an often forgotten diagnosis

BACKGROUND

Pyloric atresia (PA) is a rare condition, and may be misdiagnosed and especially confused for duodenal atresia pre-operatively. We looked for clues to avoiding pre-operative misdiagnosis and hence allow the best neonatal medical and surgical management.

METHODS

A retrospective case-note review was carried out of the five patients managed in four centres with the diagnosis of isolated PA. We focused on antenatal ultrasound findings, postnatal clinical and radiological features, operative findings, surgical procedures and outcomes.

RESULTS

Four patients had polyhydramnios and one double bubble sign on antenatal ultrasound. After birth, non-bilious vomiting and upper abdominal distension were the main symptoms. Gastric decompression showed non-bilious gastric fluid. Radiological findings were a large gastric air bubble with no gas beyond in all cases. The diagnosis of duodenal atresia was postulated at first in all cases. The diagnosis of PA was established peroperatively. One patient referred late, died 13-day post-operatively of cardiopulmonary failure secondary to a severe pneumonia that may be related to aspiration syndrome. Outcomes were otherwise satisfactory.

CONCLUSIONS

Even though it is a rare diagnosis, PA has a specific clinical and radiological presentation underlined here that should be kept in mind when managing a neonate with a gastric outlet obstruction.

Laparoscopic management of pyloric atresia in a neonate with epidermolysis bullosa

Pyloric atresia (PA) is rare and may be associated with epidermolysis bullosa (EB). This is the first case report of a successful laparoscopic treatment of PA in a full-term 7-day-old neonate with EB. The laparoscopic approach consists of a longitudinal pyloromyotomy and excision of the thick obstructing pyloric membrane with a Heineke-Mickulicz pyloroplasty closure. Oral feeding was resumed at postoperative Day 7, and the child was discharged 5 days later with satisfactory follow-up at 8 months. Recommendations are provided for the management of the neonate with PA/EB.

Closed loop foregut obstruction in a premature neonate

Multiple foregut atresias are exceedingly rare. We present a unique case of combined pyloric and duodenal atresia in a premature neonate. The anomaly appeared to evolve into a closed loop foregut obstruction in the postnatal period. Foregut continuity was established with a gastroduodenostomy, duodenoduodenostomy, and duodenal tapering. The child survived and continued to thrive at 2 years of age.