Congenital Duodenal Web Presenting With Hematemesis in a Child

Abstract

Partial duodenal obstruction most often presents early in infancy with poor feeding and vomiting. Although rare, some cases of partial duodenal obstruction due to a duodenal web have presented at a later age- up to 12 years of age or with hematemesis. Hematemesis occurs due to stasis of gastric secretions in the proximal duodenum resulting in mucosal ulceration leading to bleeding. A literature search revealed 10 cases of partial duodenal obstruction due to a web that presented with hematemesis. We discuss a 17 month old with a partial duodenal web who presented with hematemesis. A 17-month-old male with Down syndrome presented with a 24-hour history of poor oral intake, decreased activity and multiple coffee ground emesis. He had a prior history of poor weight gain and spitting up undigested breast milk since 3 months of age. A trial of ranitidine and fortification of breast milk failed to improve his symptoms. His abdominal exam was benign. CBC revealed a Hb of 8.5 g/dL and Hct of 26.2%. KUB showed a single dilated loop of bowel in right mid-abdomen with an air-fluid level but no evidence of intra-peritoneal free air. Upper endoscopy revealed a dilated duodenum with two irregular duodenal ulcers with no active bleeding or clots. The endoscope could not be advanced beyond the second portion of the duodenum. Due to inadequate visualization of the lumen beyond the ulcers, an upper GI contrast series was performed which revealed a duodenal web. There was distention and delayed emptying of the proximal duodenum with transition to the decompressed distal duodenum. He was treated with acid suppression and underwent elective surgery for the duodenal web. In children with hematemesis due to duodenal ulceration it is important to consider a partial duodenal web, especially if there is a history of chronic vomiting. Infants with poor feeding and vomiting should undergo GI imaging early in infancy to rule out mechanical obstruction. Partial duodenal obstruction due to a web may cause acute hematemesis- even after infancy.