Image Based Question-66226

The X-ray abdomen as shown in the picture below is indicative of ?

A. Annular pancreas.

B. Ileal atresia.

C. Anal rectal malformation.

D. All of the above.

Correct Answer » A Explanation

Ans:A.)Annular pancreas

“Double bubble” sign is seen in the image .
-Thin arrow: dialated stomach
-Thick arrow: dialated proximal duodenum

Double bubble sign

• It is seen in infants and represents dilatation of the proximal duodenum and stomach.
• It is seen in both radiographs and ultrasound, and can be identified antenatally .
• Causes include :
  • congenital obstruction
    • duodenal web
    • duodenal atresia
    • duodenal stenosis
    • annular pancreas
  • midgut volvulus
  • external compression of the dudenum
    • choledochal cyst
    • mesenteric duplication cyst
    • intramural duodenal haematoma
    • preduodenal portal vein
    • retroperitoneal tumour

Annular pancreas

• It results from a band of pancreatic parenchyma that encircles a section of the second part of the duodenum.
• The embryologic anomaly is secondary to the malrotation of the ventral bud, which wraps around the duodenum to fuse with the dorsal bud.
• This malformation can be isolated or can be accompanied by a digestive tract malrotation or atresia.
• Its frequency is also increased by Trisomy 21.
• The clinical consequences of annular pancreas depend on the degree of duodenal obstruction.
• Early signs of abnormality include polyhydramnios (an excess of amniotic fluid), low birth weight, and feeding intolerance immediately after birth.
• This anomaly may present later, and into adulthood, as partial duodenal obstruction or pancreatitis.
• Plain films reveal two asymmetrical air-fluid levels, one gastric, the other duodenal, with little distal bowel gas. This is the “double bubble” sign.
• The diagnosis can be suggested by prenatal US, which would demonstrate the two constant liquid-containing abdominal structures, possibly accompanied by hydroamnios.
• The treatment of significant obstruction is always surgical: bypassing the obstructed segment of duodenum by duodeno-jejunostomy. Another approach is laparoscopic gastrojejunostomy or duodenojejunostomy