Endoscopic Management of Duodenal Webs in Infants

Abstract

Duodenal atresia and stenosis are rare causes of intestinal obstruction in the newborn with the prevalence of 1:6000. Intrinsic duodenal obstruction typically involves the second portion of the duodenum and occurs as a result of several embryologic defects in foregut development, canalization, or rotation. We report two cases of duodenal obstruction in infants successfully treated endoscopically. A comprehensive 32-year single center experience reported 138 newborns and infants presenting with symptoms of vomiting, abdominal distention, dehydration, and weight loss. Patient 1, a two-month-old neonate presents with vomiting. An upper G I series revealed a dilated proximal duodeneum, with an obstructing web. The adult upper endoscope, (O.D. 9.4 mm) was passed into the stomach. Endoscopy revealed a membranous web-like obstruction with a central 2 mm orifice (Fig. 1B). The delicate diaphragm-like movement demonstrated a membranous web. A sphincterotome was passed over the guidewire and three radial incisions were made. Feeding was resumed and the patient discharged after 24 hours. At 12 months, the patient was tolerating full oral feedings and thriving. Patient 2 was a 7 month old male infant with chronic regurgitation and poor weight gain. Upper GI series demonstrated web-like stenosis or membranous stricture. An upper adult endoscope was passed into the stomach. Endoscopy revealed a dilated first portion of the duodenum with a 3 mm opening. A through-the-scope (TTS) dilation balloon was passed through the scope over a wire through the orifice. The orifice was dilated to 10mm (Fig. 2C). A sphictertome was passed over a wire and two radial cuts were made at 11 and 1 o clock (Fig. 2D). The patient was discharged after 24 hours. At the 9-month follow-up, the patient was doing well with excellent oral intake and weight gain. Endoscopic, non-surgical therapy of non-atretic lesions provides an effective, non-invasive management of duodenal webs and stenosis in pediatric patients. The endoscopic procedure avoids the morbidity associated with surgical duodenotomies, allows for prompt feeding and early hospital discharge.