History

Fact Explanation
Vomiting within hours of birth. Due to a lack of recanalization of the solid cord stage of intestinal development causing obstruction at the duodenum [1].
Vomitus most often being bilious. The atresia commonly lies below the entrance of the common bile duct into the duodenum [2].
Lethargy and weight loss. These are features of dehydration and malnutrition respectively which occur due to the sustained vomiting [2].
References
  1. FAIRBANKS TIMOTHY J., SALA FREDERIC G., KANARD ROBERT, CURTIS JENNIFER L., DEL MORAL PIERRE M., DE LANGHE STIJN, WARBURTON DAVID, ANDERSON KATHRYN D., BELLUSCI SAVERIO, BURNS R. CARTLAND. The fibroblast growth factor pathway serves a regulatory role in proliferation and apoptosis in the pathogenesis of intestinal atresia. Journal of Pediatric Surgery [online] 2006 January, 41(1):132-136 [viewed 19 August 2014] Available from: doi:10.1016/j.jpedsurg.2005.10.054
  2. GOUREVITCH A. Duodenal atresia in the newborn. Ann R Coll Surg Engl [online] 1971 Mar, 48(3):141-158 [viewed 19 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2387923

Examination

Fact Explanation
Scaphoid abdomen. Due to the absence of gas in the intestine [1].
Occasionally, epigastric fullness. This may occur initially due to the greatly dilated stomach [1].
Dry mucous membranes, reduced skin turgor, depressed fontanelles, etc. These are features of dehydration which occurs due to the sustained vomiting [2].
Anthropometric examination. Eg: weight Malnutrition could occur due to the sustained vomiting [2].
Low set ears, hypotonia, flat occiput , etc on general examination. These are features of Down's syndrome which is commonly associated with duodenal atresia [3].
References
  1. ROSS A. J.. Intestinal Obstruction in the Newborn. Pediatrics in Review [online] 1994 September, 15(9):338-347 [viewed 19 August 2014] Available from: doi:10.1542/pir.15-9-338
  2. GOUREVITCH A. Duodenal atresia in the newborn. Ann R Coll Surg Engl [online] 1971 Mar, 48(3):141-158 [viewed 19 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2387923
  3. CHITTY L. S., GOODMAN J., SELLER M. J., MAXWELL D.. Esophageal and duodenal atresia in a fetus with Down's syndrome: prenatal sonographic features. Ultrasound Obstet Gynecol [online] 1996 June, 7(6):450-452 [viewed 19 August 2014] Available from: doi:10.1046/j.1469-0705.1996.07060450.x

Differential Diagnoses

Fact Explanation
Infantile pyloric stenosis. It also presents with vomiting in the neonatal period, but symptoms begin usually at around 4 weeks and the vomiting is usually projectile [1].
Esophageal atresia. It also presents with vomiting soon after birth, but there is a clear history of hydramnios in pregnancy and there would be spontaneous attacks of cyanosis since the condition is usually accompanied by tracheo-esophageal fistula [2].
Malrotation of the gut leading to mid gut volvulus. It also presents with bile stained vomiting and is usually clinically indistinguishable from duodenal atresia, until strangulation of bowel has developed, when the abdomen becomes distended and tender and stools bloodstained [3].
References
  1. DODGE J A. Infantile hypertrophic pyloric stenosis in Belfast, 1957-1969.. Archives of Disease in Childhood [online] 1975 March, 50(3):171-178 [viewed 19 August 2014] Available from: doi:10.1136/adc.50.3.171
  2. MYERS NA. Oesophageal atresia: the epitome of modern surgery. Ann R Coll Surg Engl [online] 1974 Jun, 54(6):277-287 [viewed 19 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2388409
  3. MILLAR A.J.W, RODE H, CYWES S. Malrotation and volvulus in infancy and childhood. Seminars in Pediatric Surgery [online] 2003 November, 12(4):229-236 [viewed 19 August 2014] Available from: doi:10.1053/j.sempedsurg.2003.08.003

Investigations - for Diagnosis

Fact Explanation
Insertion of an orogastric tube which typically yields a significant amount of bile-stained fluid. The atresia which gives rise to obstruction commonly lies below the entrance of the common bile duct into the duodenum [1].
Erect and recumbent plain radiography of the abdomen revealing the typical "double bubble" appearance. due to air within the stomach and the proximal duodenum, with no gas in the distal bowel [2].
Prenatal ultrasonography to detect polyhydramnios. absorption of the amniotic fluid by the fetus is impeded when the duodenum is obstructed [3].
References
  1. GOUREVITCH A. Duodenal atresia in the newborn. Ann R Coll Surg Engl [online] 1971 Mar, 48(3):141-158 [viewed 19 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2387923
  2. POKI H. OKTI, HOLLAND A. J. A., PITKIN J.. Double bubble, double trouble. Ped Surgery Int [online] December, 21(6):428-431 [viewed 19 August 2014] Available from: doi:10.1007/s00383-005-1448-z
  3. ROSS A. J.. Intestinal Obstruction in the Newborn. Pediatrics in Review [online] 1994 September, 15(9):338-347 [viewed 20 August 2014] Available from: doi:10.1542/pir.15-9-338

Investigations - Fitness for Management

Fact Explanation
Serum electrolytes revealing a hypokalemic/hypochloremic metabolic alkalosis. Due to sustained vomiting of gastric contents [1].
Urinalysis revealing an increased urine specific gravity. This is a feature of dehydration which occurs due to the sustained vomiting [1].
References
  1. GOUREVITCH A. Duodenal atresia in the newborn. Ann R Coll Surg Engl [online] 1971 Mar, 48(3):141-158 [viewed 19 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2387923

Investigations - Screening/Staging

Fact Explanation
Chromosome analysis. Down's syndrome is commonly associated with duodenal atresia [1].
Cardiac ultrasonography. Duodenal atresia can manifest as an extracardiac lesion of congenital heart disease [2].
References
  1. CHITTY L. S., GOODMAN J., SELLER M. J., MAXWELL D.. Esophageal and duodenal atresia in a fetus with Down's syndrome: prenatal sonographic features. Ultrasound Obstet Gynecol [online] 1996 June, 7(6):450-452 [viewed 19 August 2014] Available from: doi:10.1046/j.1469-0705.1996.07060450.x
  2. SONG M. S., HU A., DYHAMENAHALI U., CHITAYAT D., WINSOR E. J. T., RYAN G., SMALLHORN J., BARRETT J., YOO S.-J., HORNBERGER L. K.. Extracardiac lesions and chromosomal abnormalities associated with major fetal heart defects: comparison of intrauterine, postnatal and postmortem diagnoses. Ultrasound Obstet Gynecol [online] 2009 May, 33(5):552-559 [viewed 20 August 2014] Available from: doi:10.1002/uog.6309

Management - General Measures

Fact Explanation
Intravenous fluid replacement of the gastric aspirate with one half normal saline with added potassium. To correct the hypokalemic/hypochloremic metabolic alkalosis and dehydration occurring due to sustained vomiting [1].
Suction using a naso-gastric tube. While decreasing abdominal distension, it facilitates operative intervention and diminishes operative shock [2].
References
  1. GOUREVITCH A. Duodenal atresia in the newborn. Ann R Coll Surg Engl [online] 1971 Mar, 48(3):141-158 [viewed 19 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2387923
  2. GROB M. Intestinal Obstruction in the Newborn Infant Arch Dis Child [online] 1960 Feb, 35(179):40-50 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2012500

Management - Specific Treatments

Fact Explanation
Duodenoduodenostomy. The end-to-end anastomosis is done to overcome the duodenal obstruction [1].
Placement of a gastrostomy tube at the time of operation. Infants whose duodenums are obstructed often are slow to open up and tolerate full enteral feeds [2].
References
  1. GROB M. Intestinal Obstruction in the Newborn Infant Arch Dis Child [online] 1960 Feb, 35(179):40-50 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2012500
  2. ROSS A. J.. Intestinal Obstruction in the Newborn. Pediatrics in Review [online] 1994 September, 15(9):338-347 [viewed 20 August 2014] Available from: doi:10.1542/pir.15-9-338