Pediatric Radiology

, Volume 46, Issue 8, pp 1084–1095 | Cite as

Congenital duodenal obstruction: causes and imaging approach

  • Michael F. BrinkleyEmail author
  • Elisabeth T. Tracy
  • Charles M. Maxfield


Bilious emesis is a common cause for evaluation in pediatric radiology departments. There are several causes of congenital duodenal obstruction, most of which require elective surgical correction, but the potential of malrotation with midgut volvulus demands prompt imaging evaluation. We review the various causes of congenital duodenal obstruction with an emphasis on the approach to imaging evaluation and diagnosis.


Children Congenital Duodenum Imaging Obstruction Radiography Surgery Upper gastrointestinal series (upper GI) Volvulus 


Compliance with ethical standards

Conflicts of interest



  1. 1.
    Dalla Vecchia LK, Grosfeld JL, West KW et al (1998) Intestinal atresia and stenosis: a 25-year experience with 277 cases. Arch Surg 133:490–496CrossRefPubMedGoogle Scholar
  2. 2.
    Piper HG, Alesbury J, Waterford SD et al (2008) Intestinal atresias: factors affecting clinical outcomes. J Pediatr Surg 43:1244–1248CrossRefPubMedGoogle Scholar
  3. 3.
    Eustace S, Connolly B, Blake N (1993) Congenital duodenal obstruction: an approach to diagnosis. Eur J Pediatr Surg 3:267–270CrossRefPubMedGoogle Scholar
  4. 4.
    Sarin Y, Sharma A, Sinha S et al (2012) Duodenal webs: an experience with 18 patients. J Neonatal Surg 1:1–5Google Scholar
  5. 5.
    Escobar MA, Ladd AP, Grosfeld JL et al (2004) Duodenal atresia and stenosis: long-term follow-up over 30 years. J Pediatr Surg 39:867–871CrossRefPubMedGoogle Scholar
  6. 6.
    Akhtar J, Guiney EJ (1992) Congenital duodenal obstruction. Br J Surg 79:133–135CrossRefPubMedGoogle Scholar
  7. 7.
    Bailey PV, Tracy TF Jr, Connors RH et al (1993) Congenital duodenal obstruction: a 32-year review. J Pediatr Surg 28:92–95CrossRefPubMedGoogle Scholar
  8. 8.
    Bittencourt DG, Barini R, Marba S et al (2004) Congenital duodenal obstruction: does prenatal diagnosis improve the outcome? Pediatr Surg Int 20:582–585CrossRefPubMedGoogle Scholar
  9. 9.
    Choudhry MS, Rahman N, Boyd P et al (2009) Duodenal atresia: associated anomalies, prenatal diagnosis and outcome. Pediatr Surg Int 25:727–730CrossRefPubMedGoogle Scholar
  10. 10.
    Spigland N, Yazbeck S (1990) Complications associated with surgical treatment of congenital intrinsic duodenal obstruction. J Pediatr Surg 25:1127–1130CrossRefPubMedGoogle Scholar
  11. 11.
    Brantberg A, Blaas HG, Salvesen KA et al (2002) Fetal duodenal obstructions: increased risk of prenatal sudden death. Ultrasound Obstet Gynecol 20:439–446CrossRefPubMedGoogle Scholar
  12. 12.
    Mustafawi AR, Hassan ME (2008) Congenital duodenal obstruction in children: a decade’s experience. Eur J Pediatr Surg 18:93–97CrossRefPubMedGoogle Scholar
  13. 13.
    Papandreou E, Baltogiannis N, Cigliano B et al (2004) Annular pancreas combined with distal stenosis. A report of four cases and review of the literature. Pediatr Med Chir 26:256–259PubMedGoogle Scholar
  14. 14.
    Dwek JR, Teich S (1999) The duodenal dimple: a specific fluoroscopic correlate to the duodenal web. Pediatr Radiol 29:467–468CrossRefPubMedGoogle Scholar
  15. 15.
    Gilbertson-Dahdal DL, Dutta S, Varich LJ et al (2009) Neonatal malrotation with midgut volvulus mimicking duodenal atresia. AJR Am J Roentgenol 192:1269–1271CrossRefPubMedGoogle Scholar
  16. 16.
    Berdon WE, Baker DH, Bull S et al (1970) Midgut malrotation and volvulus. Which films ar most helpful? Radiology 96:375–384CrossRefPubMedGoogle Scholar
  17. 17.
    Lampl B, Levin TL, Berdon WE et al (2009) Malrotation and midgut volvulus: a historical review and current controversies in diagnosis and management. Pediatr Radiol 39:359–366CrossRefPubMedGoogle Scholar
  18. 18.
    Shew SB (2009) Surgical concerns in malrotation and midgut volvulus. Pediatr Radiol 39:S167–S171CrossRefPubMedGoogle Scholar
  19. 19.
    Berrocal T, Torres I, Gutierrez J et al (1999) Congenital anomalies of the upper gastrointestinal tract. Radiographics 19:855–872CrossRefPubMedGoogle Scholar
  20. 20.
    Schmidt H, Abolmaali N, Vogl TJ (2002) Double bubble sign. Eur Radiol 12:1849–1853CrossRefPubMedGoogle Scholar
  21. 21.
    Tryfonas G, Young DG (1975) Extrinsic duodenal obstruction in infants and children. Br J Surg 62:125–129CrossRefPubMedGoogle Scholar
  22. 22.
    Applegate KE (2009) Evidence-based diagnosis of malrotation and volvulus. Pediatr Radiol 39:S161–S163CrossRefPubMedGoogle Scholar
  23. 23.
    Millar AJ, Rode H, Cywes S (2003) Malrotation and volvulus in infancy and childhood. Semin Pediatr Surg 12:229–236CrossRefPubMedGoogle Scholar
  24. 24.
    Millar A, Rode H, Cywes S (1987) The deadly vomit: malrotation and midgut volvulus. Pediatr Surg Int 2:172–176CrossRefGoogle Scholar
  25. 25.
    Traubici J (2001) The double bubble sign. Radiology 220:463–464CrossRefPubMedGoogle Scholar
  26. 26.
    Green P, Swischuk LE, Hernandez JA (2007) Delayed presentation of malrotation and midgut volvulus: imaging findings. Emerg Radiol 14:379–382CrossRefPubMedGoogle Scholar
  27. 27.
    Nixon HH (1989) Duodenal atresia. Br J Hosp Med 41:134, 138, 140PubMedGoogle Scholar
  28. 28.
    Poki HO, Holland AJ, Pitkin J (2005) Double bubble, double trouble. Pediatr Surg Int 21:428–431CrossRefPubMedGoogle Scholar
  29. 29.
    Swischuk LE (2004) Imaging of the newborn, infant, and young child, 5th edn. Lippincott Williams & Wilkins, PhiladelphiaGoogle Scholar
  30. 30.
    Mali V, Wagener S, Sharif K et al (2007) Foregut atresias and bile duct anomalies: rare, infrequent or common?! Pediatr Surg Int 23:889–895CrossRefPubMedGoogle Scholar
  31. 31.
    Stefanutti G, Gamba P, Midrio P (2006) Intestinal atresia and agenesis of the gallbladder in 2 siblings. J Pediatr Surg 41:e31–e32CrossRefPubMedGoogle Scholar
  32. 32.
    Mikaelsson C, Arnbjornsson E, Kullendorff C (1997) Membranous duodenal stenosis. Acta Paediatr 86:953–955CrossRefPubMedGoogle Scholar
  33. 33.
    Yoon CH, Goo HW, Kim EA et al (2001) Sonographic windsock sign of a duodenal web. Pediatr Radiol 31:856–857CrossRefPubMedGoogle Scholar
  34. 34.
    Materne R (2001) The duodenal wind sock sign. Radiology 218:749–750CrossRefPubMedGoogle Scholar
  35. 35.
    Melek M, Edirne YE (2008) Two cases of duodenal obstruction due to a congenital web. World J Gastroenterol 14:1305–1307CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Mahajan S, Kashyap R, Chandel U et al (2004) Duodenal diverticulum: a review of literature. Indian J Surg 66:140–145Google Scholar
  37. 37.
    Ortiz-Neira CL (2007) The corkscrew sign: midgut volvulus. Radiology 242:315–316CrossRefPubMedGoogle Scholar
  38. 38.
    Free EA, Gerald B (1968) Duodenal obstruction in the newborn due to annular pancreas. Am J Roentgenol Radium Ther Nucl Med 103:321–325CrossRefPubMedGoogle Scholar
  39. 39.
    Zyromski NJ, Sandoval JA, Pitt HA et al (2008) Annular pancreas: dramatic differences between children and adults. J Am Coll Surg 206:1019–1025CrossRefPubMedGoogle Scholar
  40. 40.
    Hays DM, Greaney EM Jr, Hill JT (1961) Annular pancreas as a cause of acute neonatal duodenal obstruction. Ann Surg 153:103–112CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    McCollum MO, Jamieson DH, Webber EM (2002) Annular pancreas and duodenal stenosis. J Pediatr Surg 37:1776–1777CrossRefPubMedGoogle Scholar
  42. 42.
    Jimenez JC, Emil S, Podnos Y et al (2004) Annular pancreas in children: a recent decade’s experience. J Pediatr Surg 39:1654–1657CrossRefPubMedGoogle Scholar
  43. 43.
    Kim SH, Cho YH, Kim HY (2013) Preduodenal portal vein: a 3-case series demonstrating varied presentations in infants. J Korean Surg Soc 85:195–197CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Knight HO (1921) An anomalous portal vein with its surgical dangers. Ann Surg 74:697–699CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Talus H, Roohipur R, Depaz H et al (2006) Preduodenal portal vein causing duodenal obstruction in an adult. J Am Coll Surg 202:552–553CrossRefPubMedGoogle Scholar
  46. 46.
    Choi SO, Park WH (1995) Preduodenal portal vein: a cause of prenatally diagnosed duodenal obstruction. J Pediatr Surg 30:1521–1522CrossRefPubMedGoogle Scholar
  47. 47.
    Esscher T (1980) Preduodenal portal vein--a cause of intestinal obstruction? J Pediatr Surg 15:609–612CrossRefPubMedGoogle Scholar
  48. 48.
    Georgacopulo P, Vigi V (1980) Duodenal obstruction due to a preduodenal portal vein in a newborn. J Pediatr Surg 15:339–340CrossRefPubMedGoogle Scholar
  49. 49.
    John AK, Gur U, Aluwihare A et al (2004) Pre duodenal portal vein as a cause of duodenal obstruction in an adult. ANZ J Surg 74:1032–1033CrossRefPubMedGoogle Scholar
  50. 50.
    Mordehai J, Cohen Z, Kurzbart E et al (2002) Preduodenal portal vein causing duodenal obstruction associated with situs inversus, intestinal malrotation, and polysplenia: a case report. J Pediatr Surg 37, E5CrossRefPubMedGoogle Scholar
  51. 51.
    Pathak D, Sarin YK (2006) Congenital duodenal obstruction due to a preduodenal portal vein. Indian J Pediatr 73:423–425CrossRefPubMedGoogle Scholar
  52. 52.
    Shukla RM, Mukherjee PP, Mukhopadhyay B et al (2013) Congenital duodenal obstruction with preduodenal portal vein and situs inversus totalis: report of two cases and literature review. Indian J Surg 75:74–76CrossRefPubMedGoogle Scholar
  53. 53.
    Merrett ND, Wilson RB, Cosman P et al (2009) Superior mesenteric artery syndrome: diagnosis and treatment strategies. J Gastrointest Surg 13:287–292CrossRefPubMedGoogle Scholar
  54. 54.
    Sozubir S, Kahraman H, Arslan A et al (2006) Incomplete duodenal obstruction in a newborn. Indian J Pediatr 73:364–366CrossRefPubMedGoogle Scholar
  55. 55.
    Burrington JD, Wayne ER (1974) Obstruction of the duodenum by the superior mesenteric artery — does it exist in children? J Pediatr Surg 9:733–741CrossRefPubMedGoogle Scholar
  56. 56.
    Agrawal GA, Johnson PT, Fishman EK (2007) Multidetector row CT of superior mesenteric artery syndrome. J Clin Gastroenterol 41:62–65CrossRefPubMedGoogle Scholar
  57. 57.
    Altman DH, Puranik SR (1973) Superior mesenteric artery syndrome in children. Am J Roentgenol Radium Ther Nucl Med 118:104–108CrossRefPubMedGoogle Scholar
  58. 58.
    Taylor MT, Hollander RJ (1963) Arteriomesenteric duodenal obstruction in the newborn infant. Pediatrics 31:1049–1050PubMedGoogle Scholar
  59. 59.
    Dinan D, Epelman M, Guimaraes CV et al (2014) Proximal duodenal obstruction associated with compression from a replaced right hepatic artery. Pediatr Radiol 44:226–229CrossRefPubMedGoogle Scholar
  60. 60.
    Kassner EG, Sutton AL, De Groot TJ (1972) Bile duct anomalies associated with duodenal atresia; paradoxical presence of small bowel gas. Am J Roentgenol Radium Ther Nucl Med 116:577–583CrossRefPubMedGoogle Scholar
  61. 61.
    Tashjian DB, Moriarty KP (2001) Duodenal atresia with an anomalous common bile duct masquerading as a midgut volvulus. J Pediatr Surg 36:956–957CrossRefPubMedGoogle Scholar
  62. 62.
    Maxfield CM, Bartz BH, Shaffer JL (2013) A pattern-based approach to bowel obstruction in the newborn. Pediatr Radiol 43:318–329CrossRefPubMedGoogle Scholar
  63. 63.
    Samuel M, Wheeler RA, Mami AG (1997) Does duodenal atresia and stenosis prevent midgut volvulus in malrotation? Eur J Pediatr Surg 7:11–12CrossRefPubMedGoogle Scholar
  64. 64.
    Applegate KE, Anderson JM, Klatte EC (2006) Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series. Radiographics 26:1485–1500CrossRefPubMedGoogle Scholar
  65. 65.
    Slovis TL, Strouse PJ (2009) Malrotation: some answers but more questions. Pediatr Radiol 39:315–316CrossRefPubMedGoogle Scholar
  66. 66.
    Phelps S, Fisher R, Partington A et al (1997) Prenatal ultrasound diagnosis of gastrointestinal malformations. J Pediatr Surg 32:438–440CrossRefPubMedGoogle Scholar
  67. 67.
    Jouppila P, Kirkinen P (1984) Ultrasonic and clinical aspects in the diagnosis and prognosis of congenital gastrointestinal anomalies. Ultrasound Med Biol 10:465–472CrossRefPubMedGoogle Scholar
  68. 68.
    Mercado MG, Bulas DI, Chandra R (1993) Prenatal diagnosis and management of congenital volvulus. Pediatr Radiol 23:601–602CrossRefPubMedGoogle Scholar
  69. 69.
    Yousefzadeh DK (2009) The position of the duodenojejunal junction: the wrong horse to bet on in diagnosing or excluding malrotation. Pediatr Radiol 39:S172–S177CrossRefPubMedGoogle Scholar
  70. 70.
    Menten R, Reding R, Godding V et al (2012) Sonographic assessment of the retroperitoneal position of the third portion of the duodenum: an indicator of normal intestinal rotation. Pediatr Radiol 42:941–945CrossRefPubMedGoogle Scholar
  71. 71.
    Taylor GA (2011) CT appearance of the duodenum and mesenteric vessels in children with normal and abnormal bowel rotation. Pediatr Radiol 41:1378–1383CrossRefPubMedGoogle Scholar
  72. 72.
    Orzech N, Navarro OM, Langer JC (2006) Is ultrasonography a good screening test for intestinal malrotation? J Pediatr Surg 41:1005–1009CrossRefPubMedGoogle Scholar
  73. 73.
    Pracros JP, Sann L, Genin G et al (1992) Ultrasound diagnosis of midgut volvulus: the ‘whirlpool’ sign. Pediatr Radiol 22:18–20CrossRefPubMedGoogle Scholar
  74. 74.
    Chandramohan A, Gibikote S, Saxena AK (2010) US as a primary tool in the work-up of malrotation. Pediatr Radiol 40:1844–1845, author reply 1846–1847CrossRefPubMedGoogle Scholar
  75. 75.
    Swenson O, Ladd WE (1945) Surgical emergencies of the alimentary tract of the newborn. N Engl J Med 233:660–663CrossRefPubMedGoogle Scholar
  76. 76.
    Androulakis J, Colborn GL, Skandalakis PN et al (2000) Embryologic and anatomic basis of duodenal surgery. Surg Clin N Am 80:171–199CrossRefPubMedGoogle Scholar
  77. 77.
    Muraoka I, Ohno Y, Kobayashi K et al (2005) Preduodenal position of the common bile duct associated with annular pancreas: case report and literature review. Pancreas 31:283–285CrossRefPubMedGoogle Scholar
  78. 78.
    Fernandes ET, Burton EM, Hixson SD et al (1990) Preduodenal portal vein: surgery and radiographic appearance. J Pediatr Surg 25:1270–1272CrossRefPubMedGoogle Scholar
  79. 79.
    Singh SJ, Dickson R, Baskaranathan S et al (2002) Excision duodenoplasty: a new technique for congenital duodenal obstruction. Pediatr Surg Int 18:75–78CrossRefPubMedGoogle Scholar
  80. 80.
    Barabino A, Arrigo S, Gandullia P et al (2012) Duodenal web: complications and failure of endoscopic treatment. Gastrointest Endosc 75:1123–1124CrossRefPubMedGoogle Scholar
  81. 81.
    Barabino A, Gandullia P, Arrigo S et al (2011) Successful endoscopic treatment of a double duodenal web in an infant. Gastrointest Endosc 73:401–403CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Michael F. Brinkley
    • 1
    Email author
  • Elisabeth T. Tracy
    • 2
  • Charles M. Maxfield
    • 1
  1. 1.Department of RadiologyDuke University Medical CenterDurhamUSA
  2. 2.Division of Pediatric SurgeryDuke University Medical CenterDurhamUSA

Personalised recommendations