A Rare Case of a Congenital Duodenal Web in an Adult Patient

Abstract

Case: A 24 year-old female presented with postprandial bloating, heartburn and occasional vomiting for the last couple of months. Her abdomen is distended on exam with no significant tenderness. She underwent an upper endoscopy that showed erosive esophagitis and a large phytobezoar in the stomach that prevented advancing the scope further. A repeat esophagogastroduodenoscopy revealed a dilated stomach and duodenal bulb with suspected duodenal stricture. X-ray of the stomach with gastrograffin demonstrated significant dilation of the duodenal bulb with delay of the contrast material passage beyond this region raising the possibility of a congenital duodenal web. Computed tomography of the abdomen reported significantly distended first and second portions of the duodenum. Patient underwent a repeat EGD that showed again a web-like constriction in the third part of the duodenum that was balloon dilated to 12 mm. The standard upper endoscope did not reach to the stricture area; therefore this was exchanged for a pediatric colonoscope for dilation. The patient never had anemia or nutritional deficiencies of any kind. Post dilation, the patient felt improvement in her symptoms and she is planned to have a second dilation later on. Discussion: Congenital duodenal anomalies are rarely diagnosed in adulthood. Patients with duodenal webs usually present with epigastric discomfort, bloating and postprandial emesis. These malformations infrequently cause intestinal obstruction. Because of the gastric outlet obstruction, acid reflux symptoms and heartburn are very common. Occasionally, they remain asymptomatic until adulthood and, because they are unusual, may not be diagnosed. Most of patients with duodenal webs have weight loss, nutritional deficiencies and anemia. Our patient was gaining weight instead, which made the suspicion for her having a gastrointestinal malformation unlikely on presentation. Acquired duodenal webs reported in the literature are mostly associated with NSAIDs use, previous abdominal surgeries or pancreatitis. Our patient does not have any medical problems and her symptoms started during her childhood but went unnoticeable till her reflux symptoms were refractory to acid suppression therapy. Management strategies are related to the degree of obstruction; they range from balloon dilation to duodenal web excision. Surgical correction is usually the definitive treatment to restore the intestinal continuity.