<h1>Duodenal stenosis and duodenal atresia</h1>

1. Causes 2. Classification 3.Clinical findings 4.Differential diagnosis 5.Treatment 6.Complications

Causes of duodenal stenosis and duodenal atresia

1 in every 5000 newborns suffer from either duodenal stonosis or duodenal atresia and in 85 % of the time the defect is located distal to the ampulla of Vater
According to Tandler's  theory the disease is caused by failure of the primordial duodenum repermeabilization process during weeks 8-10 of intrauterine life
Another cause may be compression of the duodenum by adjacent organs, such as in annular pancreas or biliary tract malformations
 

Classification of duodenal stenosis

Intrinsic duodenal stenosis

1. Segmental agenesia of the duodenum: the two ends close in a finger like form, corresponds to type III in the Gray-Skandalakis classification
2. Duodenal atresia: the two ends are united by fibrous chord or a segment with a very narrow, nonfunctional, lumen. Corresponds to type II in the Gray-Skandalakis classification
3. Stenosis caused by a diaphragm: The diaphragm can be either complete or incomplete, corresponds to type II in the Gray-Skandalakis classification

Extrinsic duodenal stenosis

1. Ladd's bride
2. Annular pancreas
3. Choledocal pseudocyst
4. Duodenal duplication
5. Preduodenal portal vein
6. Aorto-mesenteric forceps

Clinical findings in duodenal atresia and duodenal stenosis

Complete obstruction

1. Escavated abdomnen or a distention in the eigastric region
2. Normal meconium if the obstruction is superior to Vater's ampulla
3. Acolic mucous secretion if the obstruction is inferior to Vater's ampulla 
4. Spirt vomiting, in high amounts
5. Sings of dehydration: depressed fontanelle 
6. Gastric aspiration at birth more then 20 ml (normally it shouldn't be greater than 5)
7. Absence of air in the intestine 

Partial obstruction

1. Normal meconium
2. Progressive emesis, in small amounts
3.  Growth stagnation
4. Air present in intestine in normal amounts

Abdomnal radiography with contrast medium reveals a classic image resembeling a pair of sales
Fetal ultrasound reveals a double bubble aspect

Differential diagnosis of dudenal atresia and dudenal stenosis

Duodenal stenosis superior to ampulla of Vater and duodenal atresia

1. Atresia or agenesis of the small intestine
2. Meconium ileus
3. Meconium peritonitis

Duodenal stenosis inferior to ampulla of Vater

1. Piloric spasm
2. Pyloric hypertrophic stenosis with early manifestation
3. Cardio-tuberosity malposition

Treatment of duodenal atresia atresia and duodenal stenosis

Without treatment dudenal atresia and stenosis leads to severe complications: impairment of narmal groeth and development, aspiration pneumonia and hydroelectrolitique imbalance. This complications lead the death of the child
The treatment purposes are to remove the obstacle and reestablish the intestinal continuity of the digestive tract
The first therapeutic measure is a nasogastric intubation. Prior to surgery hydroelectrolitique reequlibration is needed 
The surgical procedure depends on the malformation

1. Diaphragm: longitudinal duodenectomy
2. Annular pancreas: diamond shaped duodeno-duodenal anastomosis
3. Ladd's syndrome: resection and decompresion

Complications

Immediate complications

1. Anastomosis rupture
2. Local infection
3. Septicemia

Late complications

1. Alkaline reflux 
2. Duodenal stasis 
3. Recurrent abdominal pain
4. Chronic diarrhea  

1. Causes 2. Classification 3.Clinical findings 4.Differential diagnosis 5.Treatment 6.Complications