The double-bubble sign is highly suggestive of duodenal atresia; however, other causes of high-grade duodenal obstruction can mimic the sign on kidneys, ureters, bladder radiographs. ... (US) at 21 weeks of gestation showed an intraabdominal double-bubble sign, suggestive of duodenal atresia. 1). Four neonatal patients had bilious emesis and a double-bubble appearance on radiographs, originally thought to represent duodenal atresia. It is seen in both radiographs and ultrasound, and can be identified antenatally 2. Copyright © 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. Neonatal Intestinal Obstruction, Clinical Observations. Copyright © 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. Intestinal malrotation is a birth defect involving a malformation of the intestinal tract that occurs while a fetus is forming in its mother's uterus. Furthermore, if the patient has bilious vomiting, the diagnosis is basically secured. However, anything other than this sign should be treated with great suspicion for the presence of malrotation and midgut volvulus. A A B B C C. REVIEW The double-bubble sign is highly suggestive of duodenal atresia; however, other causes of high-grade duodenal obstruction can mimic the sign on kidneys, ureters, bladder radiographs. Neonatal Intestinal Obstruction, Review. When there is gas distal to the dilated proximal duodenum, malrotation must be distinguished from duodenal stenosis by ultrasound or an upper GI study. Download Citation | On Sep 1, 2010, Leonard E Swischuk published Double-Bubble Sign | Find, read and cite all the research you need on ResearchGate Fluoroscopy. There was no vascular compromise. At 9 hours of life, a neonate presented with a large emesis, this time with palpable loops of bowel, and no passage of meconium. Imaging of Pulmonary Venous Developmental Anomalies, Pattern of the Month. 2A and 2B). Double bubble sign With sparse distal air* 13* 2* Without distal air 0 3 Nonspecific 4 9 UGI barium diagnosis Positive findings (n = 18) 18 0 Negative findings (n = 13) 2 11 *The double bubble sign with sparse distal air was considered a characteristic feature for malrotation. Duodenal atresia serves as a clinical and radiologic illustration of this sign, since it is the entity most often identified with a double bubble. As a … Duodenal Stenosis (With Annular Pancreas) Partial duodenal obstruction in neonates is usually caused by duodenal stenosis, with or without annular pancreas. Prompt diagnosis of midgut volvulus is important because emergency surgery is needed to prevent the potentially catastrophic complication of intestinal necrosis [1]. failure to thrive and intermittent bile stained vomiting, compared to the patients with volvulus. Malrotation** • Definition: abnormal intestinal rotation and fixation • Occurs in ~ 1-2% of the population • Presentation**: – Symptomatic: bilious emesis, developing to abdominal distention and peritonitis (if untreated) • small bowel obstruction with volvulus The patient was transferred to our institution on day 3 of life. Gilbertson-Dahdal et al. The more common radiographic findings of midgut volvulus are a normal gas pattern, the appearance of gastric outlet obstruction, and proximal small-bowel obstruction with a small amount of distal gas. (C) An upper GI contrast study: contrast is confirmed in the small bowel in the right side of the abdomen with no evidence of crossing the midline to the left. Surgery may be delayed without complication in cases of high-grade duodenal obstruction; the exception, however, is malrotation and midgut volvulus. Prevalence … Intestinal Malrotation in Adolescents and Adults: Spectrum of Clinical and Imaging Features, Review. Neonatal Malrotation with Midgut Volvulus Mimicking Duodenal Atresia, Pictorial Essay. On day 11 of life, the surgical finding was malrotation with midgut volvulus. To the best of our knowledge, this is the first … – Double bubble sign (Pathogenomonic sign of duodenal atresia ). It is particularly important to recognize intestinal malrotation and midgut volvulus as mimics of the double-bubble sign. Causes include 1,2: congenital obstruction. Surgery confirmed one duodenal membrane. It occurs equally in boys and girls. Supine abdominal radiograph of a newborn presenting with billous vomiting shows a distended stomach and duodenal air bubbles "double bubble" sign. Diagnosis, Differential [4, 5] In a study by Sizemore et al, an upper GI series in the detection of intestinal malrotation in infants and youths had a sensitivity of 96%, providing positive results in 156 of the 163 patients with surgically verified malrotation. Other anomalies responsible for the visualization of an antenatal double bubble include, malrotation, volvulus, annular pancreas, duplication cysts, internal hernia, and cystic lesions of the right upper abdomen such as a choledochal cyst. In infants with bilious emesis, plain x-rays of the abdomen should be done immediately. 15, 43 However, even in the neonate with the classic appearance of a “double bubble” without distal air, intrinsic causes of obstruction, especially malrotation, must be considered. It is reproducible with a variety of other imaging modalities, including upper gastrointestinal studies and sonography ( Fig 2 ). The diagnosis can usually be made by a plain x-ray showing a gas-filled stomach and enlarged (dilated) duodenum, but no distal air in the GI tract This is often called a “double bubble sign.” The presence of distal air is concerning for intestinal volvulus and mandates an upper GI to exclude malrotation. [4] found a very low false-negative rate (2%) with ultrasound. An institutionally approved retrospective chart review with review of the imaging and surgical findings was performed on the cases of four patients who between October 2005 and September 2008 had biliary emesis and radiographic findings of high-grade proximal bowel obstruction. 63 The majority of symptomatic cases present in infancy, and the diagnosis is readily made by the presence of the “double bubble” on plain radiograph of the abdomen or malpositioned bowel on upper gastrointestinal series or barium enema. The abdomen was soft, nontender, and slightly distended. The diagnosis of duodenal atresia is usually confirmed by radiography. The obstruction causes the duodenum to expand and this creates the double bubble sign (dilated stomach and duodenum). That series, however, had a high false-positive rate (21%), suggesting the need for a follow-up upper GI study on all patients with ultrasound findings of malrotation. Intestinal malrotation without volvulus in infants and children is often difficult to diagnose because of less dramatic clinical features, e.g. Kidneys, ureters, bladder radiography (Fig. Imaging Pulmonary Infection: Classic Signs and Patterns. The prevalence of duodenal atresia is ~1 in 5,000-10,000 newborns, and there is no sex-associated difference in prevalence. The physical examination at admission showed the abdomen was soft and ovoid with possible gaseous distention. The diagnostic test of choice in a child with possible malrotation, with or without midgut volvulus, is an upper GI series. There was no bowel compromise, and a modified Ladd procedure was performed. PMID: 19380551 [Indexed for MEDLINE] Publication Types: Case Reports; MeSH terms. However, more boys have symptoms by the first month of … malrotation: the double bubble sign is seen with no gas distally. The appearance is in keeping with malrotation. Bilious vomiting in newborns is an urgent condition that requires the immediate involvement of a team of pediatric surgeons and neonatologists for perioperative management. Physical examination showed no peritoneal signs. This is a strong signal that malrotation is present, and one should proceed with further investigation. In jejunoileal atresia abdominal distention with bilious None of the patients with false-negative findings had the surgical finding of a short mesenteric root, and these patients therefore were thought not to be at risk of midgut volvulus. A gastric Replogle tube was placed, and approximately 70 mL of green bile–stained fluid was removed from the stomach. We report the cases of four neonates with the double-bubble sign as a rare radiographic manifestation of midgut volvulus. It is particularly important to recognize intestinal malrotation and midgut volvulus as mimics of the double-bubble sign. 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