Progressive vomiting in a three-week-old infant: What could
The present case has been reported in the journal Pediatrics Child Health.

A 20-day-old female infant reported with progressive vomiting and weight loss. Vomiting began at seven days of age, when nystatin was started for the treatment of oral thrush. The vomiting progressively became more frequent and projectile in nature. By the time of admission, at three weeks of age, the infant had projectile nonbilious vomiting that occurred 1 h to 2 h after every attempted feeding. She appeared hungry immediately after vomiting.

Initial laboratory investigations revealed severe metabolic alkalosis. The infant’s abdominal radiograph showed a small amount of gas in a single, mildly prominent structure in the mid-abdomen and a paucity of bowel gas in the remainder of the abdomen.

An upper gastrointestinal contrast study demonstrated a dilated second portion of the duodenum, with nearly complete obstruction and stasis of contrast material. The duodenum was rounded and bulbous at the point of the obstruction, and only a tiny amount of contrast progressed after significant delay into the collapsed third and fourth portions of the duodenum. A diagnosis of duodenal stenosis was established.

Dehydration and hypochloremic alkalosis were corrected over the following 72 h, and the stomach was decompressed with a nasogastric tube. Laparotomy on the third day of admission revealed duodenal stenosis in the second portion of the duodenum, proximal to the ampulla of Vater.

This was successfully repaired with a diamond-shaped duodenoduodenostomy, with uneventful postoperative recovery. The infant’s vomiting was resolved, and she achieved appropriate weight gain in follow-up.

Clinical pearls:-
• Incomplete duodenal obstruction may present with nonbilious progressive vomiting and hypochloremic metabolic alkalosis, mimicking the much more common presentation of infantile hypertrophic pyloric stenosis.

• The most emergent and potential life-threatening cause of incomplete upper gastrointestinal obstruction is malrotation with midgut volvulus, which usually presents with bilious vomiting and should be ruled out by an upper gastrointestinal contrast study.

• Severe dehydration and electrolyte abnormalities must be corrected slowly before undertaking surgery for duodenal stenosis.

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