A 12 year old boy presents with non projectile bilious vomiting, abdominal distension and colicky epigastric pain for 2 days. There is no history of constipation, fever or jaundice. He gives a longstanding history of similar but much milder episodes after large meals, none of which required hospital admission. He also suffers from intermittent dyspeptic symptoms. His medical history is otherwise unremarkable and his full blood count is normal.
The erect x-ray of the abdomen shows generalized haziness with no bowel shadows visible. A distended gastric air bubble is noted, without a visible fluid level. There is no evidence of pneumoperitoneum.
Na+ : 133 mEq/l (normal) K+ : 4.0 mEq/l (normal) Cl- : 98 mEq/l (normal) Urea: 38 mg/dl (normal) Serum Creatinine: 0.44 mg/dl (normal)
The Serum Lipase is 45 U/l (normal)
There is dilation of the stomach and proximal duodenum, with an abrupt decrease in the width of the third part of the duodenum beyond the crossing of the superior mesenteric artery (SMA). The aortomesenteric angle is reduced.