Quadruple bubble- a sign of three concomitant malformations
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A 30-year-old pregnant woman underwent a fetal MRI at 33 gestational weeks due to suspicion of combined duodenal and esophageal atresias (a double bubble sign in the abdomen, and a “bubble” in the lower thorax, respectively). MRI revealed an interrupted esophagus with a linear gap between the upper (arrow) and lower pouches, the latter resembling an intrathoracic “bubble”. An intrabdominal “triple bubble” was also seen.

After birth, the diagnosis of concomitant duodenal atresia and esophageal atresia without tracheoesophageal fistula was confirmed. The baby underwent duodenal atresia repair (bubbles 2 and 3); additionally, a duodenal duplication cyst was also resected (bubble 4). Afterward, a thoracotomy was performed to successfully correct esophageal atresia. An intrathoracic bubble may result from esophageal atresia without tracheoesophageal fistula in the presence of duodenal atresia (double abdominal bubble); a third abdominal bubble may be due to a coexisting duodenal duplication.

Source: https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1002/pd.5733
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