Case of the Day(sm)

1 of 6

Newborn boy with abnormal prenatal ultrasound.

Our appreciation is extended to Dr. Jeremy Cardinal,
Indiana University Department of Radiology,
for contributing this case.

History: Newborn boy with abnormal prenatal ultrasound.

Review the image below. Of the choices given, which one most likely localizes the salient abnormality?

Pylorus.Duodenum.Adrenal.Jejunum.Biliary tree.

1 of 6

Case of the Day(SM) Copyright

Case of the Day(sm)

2 of 6

Newborn boy with abnormal prenatal ultrasound.

Please take another look at the image. There is actually another serious abnormality. Which choice best localizes it?

Spine.Pelvis.Mediastinum.Kidney(s).Peritoneum.

2 of 6

Case of the Day(SM) Copyright

Case of the Day(sm)

3 of 6

Newborn boy with abnormal prenatal ultrasound.

Here are some images from a water soluble contrast enema. Click to enlarge.

Which choice is most appropriate?

Colonic atresia.Congenital microcolon.Hirschsprung's disease.Malrotation.No significant abnormality.

3 of 6

Case of the Day(SM) Copyright

Case of the Day(sm)

4 of 6

Newborn boy with abnormal prenatal ultrasound.

Findings: The plain radiograph demonstrates a classic double bubble sign with absence of distal bowel gas. Additionally, there are irregular calcifications diffusely, overlying the peritoneal cavity. The water soluble contrast enema demonstrated rapid filling of the colon, with iliocolic reflux filling much of the small bowel. No obstruction was identified. Smooth, thick linear filling defects were present throughout the colon, consistent with meconium.

Differential diagnosis:

Duodenal atresia
Duodenal web
Annular pancreas
Meconium peritonitis

Diagnosis: Duodenal atresia and meconium peritonitis. At surgery, no underlying cause for the meconium peritonitis was discovered.

4 of 6

Case of the Day(SM) Copyright

Case of the Day(sm)

5 of 6

Newborn boy with abnormal prenatal ultrasound.

Key points:

The patient in our case has two, likely unrelated diagnosis: duodenal atresia and meconium peritonitis.
Meconium peritonitis results from in utero bowel perforation. The two most common underlying causes are meconium ileus and distal bowel atresia (the enema study excluded these entities in our patient). Other underlying causes include malrotation with midgut volvulus, intussusception, internal bowel hernias, congenital bands, and viral infections.
Meconium peritonitis manifests radiographically as linear, curvilinear, and punctuate calcifications in the peritoneal cavity. The calcifications are sequela of chemical peritonitis from leaked meconium. The calcifications become detectable between 1 and 8 days after meconium spillage.
Duodenal atresia is the most common upper bowel obstruction in the neonate.
The pathophysiology of duodenal atresia is a failure to recanalize the duodenum during development.
50% of patients with duodenal atresia have associated malformations. 30% of patients with duodenal atresia have Down's syndrome.

References:

Kraus, Steven J, MD. "Duodenal Atresia or Stenosis." Statdx. https://my.statdx.com/#dxContent;duodenal_atresia_or_stenosis_er.
Kraus, Steven J, MD. "Meconium Peritonitis." Statdx. https://my.statdx.com/#dxContent;meconium_peritonitis_er.

5 of 6

Case of the Day(SM) Copyright