A neonate has bilious vomiting on day 2 of life. Abdominal radiograph shows three air-filled lucencies in the left upper quadrant with minimal distal bowel gas. Which level of obstruction does this 'triple bubble' appearance indicate?

• A Pyloric stenosis
• B Duodenal atresia
• C Ileal atresia
• D Proximal jejunal atresia ✓

Explanation

A triple bubble represents gas in the stomach, duodenum, and one or two dilated proximal jejunal loops, localising the atresia to the proximal jejunum. A single duodenal bubble plus stomach gives the double bubble of duodenal atresia. Ileal atresia produces multiple dilated loops throughout the abdomen with a low obstruction pattern. Pyloric stenosis is functional hypertrophy presenting later with a distended stomach but not a fixed triple bubble on plain film.

Reference: Grainger & Allison's Diagnostic Radiology, 7th ed.

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