A 4-day-old full-term neonate presents with bilious vomiting and failure to pass meconium. X-ray shows 'double bubble sign' without distal gas. Ultrasound shows absence of the 'whirlpool sign'. Which diagnosis explains these findings and what is the definitive treatment?
- A Malrotation with midgut volvulus — emergency Ladd's procedure
- B Annular pancreas — pancreatic division and duodenoplasty
- C Jejunal atresia — double bubble sign is specific and requires jejunojejunostomy
- D Duodenal atresia — elective surgical bypass (duodenoduodenostomy) after stabilisation ✓
Explanation
The classic 'double bubble' sign (distended stomach + first part of duodenum, no distal gas) is pathognomonic for duodenal obstruction — either duodenal atresia (intrinsic) or annular pancreas (extrinsic). The absence of the 'whirlpool sign' (seen in midgut volvulus on Doppler ultrasound where the SMA and SMV wind around each other) effectively excludes volvulus. Duodenal atresia is managed by elective duodenoduodenostomy (diamond-shaped anastomosis) after stabilisation and cardiac evaluation (30% have Down syndrome, 30% have cardiac defects). Dividing an annular pancreas is CONTRAINDICATED; instead, duodenoduodenostomy bypasses the obstruction without touching the pancreatic tissue.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.