More Distally Located Duodenal Webs in a neonate
Duodenal atresia (DA) is a common cause of neonatal intestinal obstruction. Obstruction due to duodenal web (type I) is infrequent.The second part of duodenum is commonly involved, while involvement other than second part of duodenum is rare. We came across three patients with duodenal web at unusual location. We propose that, failure of recanalization shifted from the site of "embryological traffic jam" to unusual locations (third part of the duodenum and DJ junction).

A 3-day-old, preterm female neonate, weighing 1.3 kg, born by vaginal delivery was presented to our department with bilious vomiting, failure to pass meconium and epigastric fullness since birth. Antenatal ultrasounds were not done. On examination, the neonate was hemodynamically stable. The abdomen was soft and non-distended. Laboratory investigations were normal. An abdominal X-ray showed gastric and duodenal gas (C-shape) shadow extending beyond the second part of duodenum along with absence of distal air (Fig.1A); Laparotomy revealed dilated stomach and duodenum and increased wall thickness till DJ junction correlating with the X-ray findings (Fig.2). Medial visceral rotation and kocherisation of the duodenum was performed to completely expose the DJ junction. Second part of the duodenum was normal. After palpation of a membranous structure in the lumen in relation to palpable ring extra-luminally at DJ junction, an enterotomy was performed by a longitudinal incision (on the anti-mesenteric border). It revealed a mucosal diaphragmatic web (Fig.2). Luminal patency of the distal bowel was confirmed with normal saline. Excision of web was performed circumferentially. Postoperatively patient had continued downhill course, developed sepsis and died on 3rd postoperative day....