Obstruction of duodenum - Clinicals, Diagnosis, and Management

Upper GI

Clinicals - History

Fact Explanation
Commonly occurs in infants Duodenum is the first part of the intestine, and the contents from stomach, the gall bladder, and the pancreas are entered into this. Obstruction is seen mainly near pylorus. When obstruction occurs, passage of food from the stomach doesn't occur. This can occur in adults as well as in infants. In infants under development of the duodenum called duodenal hypoplasia, a narrowed duodenal lumen, which is called duodenal stenosis, and a malformed duodenal lumen, which is called duodenal atresia are common causes and Malrotation or coiling of the duodenum is also a common cause of obstruction as well as volvulus. Malrotation can be caused by Ladd's bands which are congenital bands of fibrous tissue which causes duodenal obstruction. In adults, ingestion of a foreign object, gallstones, Inflammation or infection due to diverticulitis and Crohn's disease are common causes of duodenal obstruction. Benign or malignant tumors, Scarrring due to peptic ulcer disease are also considered as a common causes of obstruction. Rarely Wilkie syndrome or superior mesentric artery syndrome can occur. Commonly occurs in infants
Duodenum is the first part of the intestine, and the contents from stomach, the gall bladder, and the pancreas are entered into this. Obstruction is seen mainly near pylorus. When obstruction occurs, passage of food from the stomach doesn't occur. This can occur in adults as well as in infants. In infants under development of the duodenum called duodenal hypoplasia, a narrowed duodenal lumen, which is called duodenal stenosis, and a malformed duodenal lumen, which is called duodenal atresia are common causes and Malrotation or coiling of the duodenum is also a common cause of obstruction as well as volvulus. Malrotation can be caused by Ladd's bands which are congenital bands of fibrous tissue which causes duodenal obstruction. In adults, ingestion of a foreign object, gallstones, Inflammation or infection due to diverticulitis and Crohn's disease are common causes of duodenal obstruction. Benign or malignant tumors, Scarrring due to peptic ulcer disease are also considered as a common causes of obstruction. Rarely Wilkie syndrome or superior mesentric artery syndrome can occur.
Abdominal pain Pain is intermittent and perumbilical. But when it progresses to strangulation, pain becomes severe and constant. Abdominal pain
Pain is intermittent and perumbilical. But when it progresses to strangulation, pain becomes severe and constant.
Nausea and Vomiting The vomit will be green in color due to the presence of bile and this is due to reflux of food contents back to the stomach due to distal obstruction which causes nausea and vomiting. Nausea and Vomiting
The vomit will be green in color due to the presence of bile and this is due to reflux of food contents back to the stomach due to distal obstruction which causes nausea and vomiting.
Abdominal Distension Because these food contents which are not digested properly get accumulated, abdomen gets distended Abdominal Distension
Because these food contents which are not digested properly get accumulated, abdomen gets distended
Bowel palpitations Rapd peristaltic contractions, which can make it feel like there are palpitations Bowel palpitations
Rapd peristaltic contractions, which can make it feel like there are palpitations
Changes in bowel habits Complete obstruction can result in constipation as well as the inability to pass flatus. But partial obstruction may allow liquids to pass and might cause diarrhea Changes in bowel habits
Complete obstruction can result in constipation as well as the inability to pass flatus. But partial obstruction may allow liquids to pass and might cause diarrhea
Symptoms in infants Duodenal atresia produces billous vomiting within hours of birth. When there's hypertrophic pyloric stenosis, there's projectile vomiting which is non billious. Symptoms in infants
Duodenal atresia produces billous vomiting within hours of birth. When there's hypertrophic pyloric stenosis, there's projectile vomiting which is non billious.

Clinicals - Examination

Fact Explanation
Signs in infants Scaphoid abdomen, with signs of dehydration and weight loss are seen. The classic "olive" is palpated in hypertrophic pyloric stenosis. Signs in infants
Scaphoid abdomen, with signs of dehydration and weight loss are seen. The classic "olive" is palpated in hypertrophic pyloric stenosis.
Signs of dehydartion such as loss of skin turgor, thirst, Sunken eyes, lack of tears, Dry mucous membranes Due to prolonged vomiting, adults and infants may appear dehydrated. Signs of dehydartion such as loss of skin turgor, thirst, Sunken eyes, lack of tears, Dry mucous membranes
Due to prolonged vomiting, adults and infants may appear dehydrated.
Distended abdomen Because these food contents which are not digested properly get accumulated, abdomen gets distended Distended abdomen
Because these food contents which are not digested properly get accumulated, abdomen gets distended
Visible peristaltic wave Intestinal obstruction results in increases peristalsis and in thin individuals this is particularly visible. Visible peristaltic wave
Intestinal obstruction results in increases peristalsis and in thin individuals this is particularly visible.
Abdominal tenderness This usually indicates strangulation as prolonged obstruction causes loss of blood supply to the bowel and bowel ischemia. Abdominal tenderness
This usually indicates strangulation as prolonged obstruction causes loss of blood supply to the bowel and bowel ischemia.
Tympanitic mass on percussion, in the epigastric area and/or left upper quadrant of the abdomen Due to dilated stomach Tympanitic mass on percussion, in the epigastric area and/or left upper quadrant of the abdomen
Due to dilated stomach
Exaggeration of bowel sounds Intestinal obstruction results in increases peristalsis and exaggeration of bowel sounds. Exaggeration of bowel sounds
Intestinal obstruction results in increases peristalsis and exaggeration of bowel sounds.

Investigations - Diagnosis

Fact Explanation
Full blood count Increases hematocrit value may point towards dehydration. Leukocytosis is also possible in intestinal obstruction. Full blood count
Increases hematocrit value may point towards dehydration. Leukocytosis is also possible in intestinal obstruction.
Serum electrolytes Prolonged vomiting causes loss of hydrochloric (HCl) acid and resultant loss of hydrogen irons are attempted to conserve by the kidney by increased secretion of Potassium ions, resulting in hypokalemia Serum electrolytes
Prolonged vomiting causes loss of hydrochloric (HCl) acid and resultant loss of hydrogen irons are attempted to conserve by the kidney by increased secretion of Potassium ions, resulting in hypokalemia
Blood urea nitrogen/ Serum creatinine High levels are late findings due to dehydration Blood urea nitrogen/ Serum creatinine
High levels are late findings due to dehydration
Arterial blood gas analysis Prolonged vomiting causes loss of hydrochloric (HCl) acid the result is a metabolic alkalosis. Arterial blood gas analysis
Prolonged vomiting causes loss of hydrochloric (HCl) acid the result is a metabolic alkalosis.
Plain abdominal radiograph It may show double bubble appearance in infants with duodenal atresia. And gastric dilatation may be observed and other differential diagnosis can be excluded Plain abdominal radiograph
It may show double bubble appearance in infants with duodenal atresia. And gastric dilatation may be observed and other differential diagnosis can be excluded
contrast upper GI studies (Gastrografin or barium) These studies are helpful because they demonstrate the site of obstruction. Use of contrast studies in suspected obstruction is controversial sometimes. contrast upper GI studies (Gastrografin or barium)
These studies are helpful because they demonstrate the site of obstruction. Use of contrast studies in suspected obstruction is controversial sometimes.
CT with oral contrast This helps to determine the site of obstruction and may show masses such as tumors CT with oral contrast
This helps to determine the site of obstruction and may show masses such as tumors
Abdominal ultrasound scan A midline abdominal mass maybe observed when there's a volvulus. Abdominal ultrasound scan
A midline abdominal mass maybe observed when there's a volvulus.
Nuclear gastric emptying studies Orally administered radionuclide is measured over time to detect any functional abnormalities Nuclear gastric emptying studies
Orally administered radionuclide is measured over time to detect any functional abnormalities
Upper gastrointestinal endoscopy and biopsy This allows the direct visualization of some anomalies in the duodenum such as duodenal stenosis, atresia, and also particularly helpful to take biopsy from suspected intraluminal tumors. . Upper gastrointestinal endoscopy and biopsy
This allows the direct visualization of some anomalies in the duodenum such as duodenal stenosis, atresia, and also particularly helpful to take biopsy from suspected intraluminal tumors. .
Gastrointestinal manometry This is important in excluding intestinal dysmotility syndromes Gastrointestinal manometry
This is important in excluding intestinal dysmotility syndromes
Tests for H- Pylori Urease breath test uses the fact that H. pylori contains the enzyme urease, which breaks down urea in the stomach to ammonia and carbon dioxide and if H. pylori is present in the stomach it will break down the labelled urea into ammonia and carbon dioxide. Since the carbon dioxide is labelled it can be detected in the breath. Also specific antibody tests for H-Pylori can be done in blood. These tests are done as peptic ulcer disease is a common cause for duodenal obstruction. Tests for H- Pylori
Urease breath test uses the fact that H. pylori contains the enzyme urease, which breaks down urea in the stomach to ammonia and carbon dioxide and if H. pylori is present in the stomach it will break down the labelled urea into ammonia and carbon dioxide. Since the carbon dioxide is labelled it can be detected in the breath. Also specific antibody tests for H-Pylori can be done in blood. These tests are done as peptic ulcer disease is a common cause for duodenal obstruction.

Investigations - Management

Fact Explanation
Plain abdominal radiographs Diameter of loops of small bowel is important as it predicts the perforation in serial x-rays and air-fluid levels may be seen. Plain abdominal radiographs
Diameter of loops of small bowel is important as it predicts the perforation in serial x-rays and air-fluid levels may be seen.
Serum electrolytes Prolonged vomiting results in loss of hydrochloric (HCl) acid and produces a hypokalemia and to monitor potassium levels this is helpful. Serum electrolytes
Prolonged vomiting results in loss of hydrochloric (HCl) acid and produces a hypokalemia and to monitor potassium levels this is helpful.
Full blood count This also helps in evaluation of hematocrit as an indicator of dehydration and white cell count as a indicator of strangulation Full blood count
This also helps in evaluation of hematocrit as an indicator of dehydration and white cell count as a indicator of strangulation
Blood urea nitrogen/ Serum creatinine Elevation of these levels indicate dehydration. Blood urea nitrogen/ Serum creatinine
Elevation of these levels indicate dehydration.
Prothrombin time and international normalization ratio To exclude any coagulopathy and correction is done Prothrombin time and international normalization ratio
To exclude any coagulopathy and correction is done
Renal function tests including estimated glomerular filteration rate, serum creatinine, blood urea nitrogen To assess fitness for anesthesia and to exclude any renal dysfunction Renal function tests including estimated glomerular filteration rate, serum creatinine, blood urea nitrogen
To assess fitness for anesthesia and to exclude any renal dysfunction
Full blood count To exclude anaemia. Full blood count
To exclude anaemia.

Management - Supportive

Fact Explanation
Correction of dehydration Normal saline is used for fluid resuscitation to replace the hypovolemia and followed by potassium replacement Correction of dehydration
Normal saline is used for fluid resuscitation to replace the hypovolemia and followed by potassium replacement
Stomach decompression Nasogastric tube with a large bore is placed to decompress the stomach. Stomach decompression
Nasogastric tube with a large bore is placed to decompress the stomach.
Close observation Patient should be monitored with regard to heart rate, respiratory rate, blood pressure, urine output, temperature and the clinical condition until a definitive management is undertaken. Close observation
Patient should be monitored with regard to heart rate, respiratory rate, blood pressure, urine output, temperature and the clinical condition until a definitive management is undertaken.
Analgesic therapy administration of analgesia is important as patient is in pain. Analgesic therapy
administration of analgesia is important as patient is in pain.
antiemetic therapy Antiemetics are given as there's severe vomiting. antiemetic therapy
Antiemetics are given as there's severe vomiting.
Antibiotic therapy administration of antibiotics are to cover against gram-negative and anaerobic organisms. Antibiotic therapy
administration of antibiotics are to cover against gram-negative and anaerobic organisms.

Management - Specific

Fact Explanation
Surgical management with resection of the obstructed part and anastomosis. This is the definitive therapy where the obstructed part is resected and the two ends are anastomosed. Repair of hernia, Removal of gall stones, foreign bodies are also done Surgical management with resection of the obstructed part and anastomosis.
This is the definitive therapy where the obstructed part is resected and the two ends are anastomosed. Repair of hernia, Removal of gall stones, foreign bodies are also done
palliative gastrojejunostomy When the lesion removal is not possible, this is done. This is also done as a treatment for annular pancreas. palliative gastrojejunostomy
When the lesion removal is not possible, this is done. This is also done as a treatment for annular pancreas.
Insertion of stents Stents help to relieve obstruction for a short period of time. Insertion of stents
Stents help to relieve obstruction for a short period of time.
H-Pylori eradication therapy This regime is carried out if the patient is having peptic ulcer disease and H-Pylori infection is suspected. H-Pylori eradication therapy
This regime is carried out if the patient is having peptic ulcer disease and H-Pylori infection is suspected.

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  1. AL SHAHWANI N., MANDHAN P., ELKADHI A., ALI M. J., LATIF A.. Congenital duodenal obstruction associated with Down's syndrome presenting with hematemesis. Journal of Surgical Case Reports [online] December, 2013(12):rjt108-rjt108 [viewed 14 August 2014] Available from: doi:10.1093/jscr/rjt108
  2. BARSOUM M. K, SHEPHERD R. F., WELCH T. J. Patient with both Wilkie syndrome and nutcracker syndrome. Vascular Medicine [online] 2008 August, 13(3):247-250 [viewed 14 August 2014] Available from: doi:10.1177/1358863X08092272
  3. CALVET XAVIER, et al. Accuracy of Diagnostic Tests for A Reappraisal . CLIN INFECT DIS [online] 2009 May, 48(10):1385-1391 [viewed 14 August 2014] Available from: doi:10.1086/598198
  4. CARLSON DOROTHY S., PFADT ELLEN. Postoperative intestinal obstruction. Nursing [online] 2010 August [viewed 14 August 2014] Available from: doi:10.1097/01.NURSE.0000386598.46169.e0
  5. CHEN HUA-DONG, JIANG HONG, KAN ANNA, HUANG LI-E, ZHONG ZHI-HAI, ZHANG ZHI-CHONG, LIU JUN-CHENG. Intestinal obstruction due to dual gastrointestinal atresia in infants: diagnosis and management of 3 cases. Array [online] 2014 December [viewed 14 August 2014] Available from: doi:10.1186/1471-230X-14-108
  6. CHEN S.-C.. Nonsurgical management of partial adhesive small-bowel obstruction with oral therapy: a randomized controlled trial. Canadian Medical Association Journal [online] 2005 November, 173(10):1165-1169 [viewed 14 August 2014] Available from: doi:10.1503/cmaj.1041315
  7. CRUZ RUY J, VINCENZI RODRIGO, KETZER BERNARDO M. Duodenal obstruction - an unusual presentation of Strongyloides stercoralis enteritis: a case report. Array [online] 2010 December [viewed 14 August 2014] Available from: doi:10.1186/1749-7922-5-23
  8. DAN D, COLLURE DW, HOOVER EL. Bouveret's syndrome: revisiting gallstone obstruction of the duodenum. J Natl Med Assoc [online] 2003 Oct, 95(10):969-973 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2594488
  9. EKSARKO P., NAZIR S., KESSLER E., LEBLANC P., ZEIDMAN M., ASARIAN A. P., XIAO P., PAPPAS P. J.. Duodenal web associated with malrotation and review of literature. Journal of Surgical Case Reports [online] December, 2013(12):rjt110-rjt110 [viewed 14 August 2014] Available from: doi:10.1093/jscr/rjt110
  10. EMANUWA OKIEMUTE F, AYANTUNDE ABRAHAM A, DAVIES TONY W. Midgut malrotation first presenting as acute bowel obstruction in adulthood: a case report and literature review. Array [online] 2011 December [viewed 14 August 2014] Available from: doi:10.1186/1749-7922-6-22
  11. GIESE ARND, ZIEREN JüRGEN, WINNEKENDONK GUIDO, HENNING BERNHARD F. Development of a duodenal gallstone ileus with gastric outlet obstruction (Bouveret syndrome) four months after successful treatment of symptomatic gallstone disease with cholecystitis and cholangitis: a case report. Array [online] 2010 December [viewed 14 August 2014] Available from: doi:10.1186/1752-1947-4-376
  12. GISBERT JAVIER P.. Rescue Therapy for Helicobacter pylori Infection 2012. Gastroenterology Research and Practice [online] 2012 December, 2012:1-12 [viewed 14 August 2014] Available from: doi:10.1155/2012/974594
  13. GONG JUN. Malrotation causing duodenal chronic obstruction in an adult. WJG [online] 2009 December [viewed 14 August 2014] Available from: doi:10.3748/wjg.15.1144
  14. HENEYKE S, SMITH V V, SPITZ L, MILLA P J. Chronic intestinal pseudo-obstruction: treatment and long term follow up of 44 patients. Archives of Disease in Childhood [online] 1999 July, 81(1):21-27 [viewed 14 August 2014] Available from: doi:10.1136/adc.81.1.21
  15. HUANG Q, DAI DK, QIAN XJ, ZHAI RY. Treatment of gastric outlet and duodenum obstructions in the uncovered expandable metal stents. World J Gastroenterol [online] 2007;13(40): 5376-5379 [viewed 14 August 2014] Available from: http://www.wjgnet.com/1007-9327/13/5376.asp
  16. KARATEKE FARUK, MENEKşE EBRU, DAS KORAY, OZYAZICI SEFA, DEMIRTüRK PELIN. Isolated Duodenal Crohn's Disease: A Case Report and a Review of the Surgical Management. Case Reports in Surgery [online] 2013 December, 2013:1-3 [viewed 14 August 2014] Available from: doi:10.1155/2013/421961
  17. KUMAR A, SRIVASTAVA U. Role of routine laboratory investigations in preoperative evaluation J Anaesthesiol Clin Pharmacol [online] 2011, 27(2):174-179 [viewed 14 August 2014] Available from: doi:10.4103/0970-9185.81824
  18. LIMDI J K. Evaluation of abnormal liver function tests. Postgraduate Medical Journal [online] 2003 June, 79(932):307-312 [viewed 14 August 2014] Available from: doi:10.1136/pmj.79.932.307
  19. LOFTUS EDWARD V., FARRUGIA GIANRICO, DONOHUE JOHN H., CAMILLERI MICHAEL. Duodenal Obstruction: Diagnosis by Gastroduodenal Manometry. Mayo Clinic Proceedings [online] 1997 February, 72(2):130-132 [viewed 14 August 2014] Available from: doi:10.4065/72.2.130
  20. NARH-MARTEY P., BELLO A., ORR D., GALDYN I.. Laparoscopic management of small bowel obstruction with associated intestinal ischemia. Journal of Surgical Case Reports [online] 2012 August, 2012(8):4-4 [viewed 14 August 2014] Available from: doi:10.1093/jscr/2012.8.4
  21. SORIANO A., DAVIS M. P.. Malignant bowel obstruction: Individualized treatment near the end of life. Cleveland Clinic Journal of Medicine [online] December, 78(3):197-206 [viewed 14 August 2014] Available from: doi:10.3949/ccjm.78a.10052
  22. TAYLOR MARK R., LALANI NADIM, CARPENTER CHRISTOPHER R.. Adult Small Bowel Obstruction. Acad Emerg Med [online] December, 20(6):527-544 [viewed 14 August 2014] Available from: doi:10.1111/acem.12150
  23. TESSIER DERON J, BROPHY COLLEEN M. Causes, diagnosis, and management of duodenal obstruction after aortic surgery. Journal of Vascular Surgery [online] 2003 July, 38(1):186-189 [viewed 14 August 2014] Available from: doi:10.1016/S0741-5214(03)00145-9
  24. VALLICELLI CARLO, COCCOLINI FEDERICO, CATENA FAUSTO, ANSALONI LUCA, MONTORI GIULIA, DI SAVERIO SALOMONE, PINNA ANTONIO D. Small bowel emergency surgery: literature's review. Array [online] 2011 December [viewed 14 August 2014] Available from: doi:10.1186/1749-7922-6-1