A case of congenital duodenal web causing duodenal stenosis in a down syndrome child: endoscopic resection with an insulated-tip knife

Abstract

A 35-month-old girl visited our hospital with repetitive vomiting and abdominal distention; this was especially aggravated after the introduction of solid and semisolid foods. At 5 months of age, the patient, who had Down's syndrome, had undergone surgery for ventricular septal defect, atrial septal defect, and patent ductus arteriosus, and had subsequently been frequently hospitalized for respiratory infections and other viral infectious diseases. After her admission, the abdominal distension improved with fasting and intravenous fl uid therapy. Radiograph from a small-bowel series revealed a thin fi lling defect with a dilated duodenal bulb in the distal region of the second portion of the duodenum, suggesting a duodenal web, and endoscopy revealed duodenal stenosis. We therefore performed endoscopic resection with an insulated-tip knife because of the history of prior operations, fasting problems after operations, and respiratory infections. Seven days later, scar formation was noted on the second portion of the duodenum, the scope passed well at the excision site, and no retained food material was noted on the follow-up endoscopy. After the procedure, the patient's abdominal distention and repetitive vomiting subsided, and she was discharged with the ability to eat eat an age-appropriate normal diet. There were no specifi c symptoms or other complications for 1 year after the procedure.

Keywords: Down syndrome; Duodenal stenosis; Duodenal web; Endoscopic electrocauterization; Insulated-tip knife.

Fig. 1

The findings of the gastrointestinal barium study. (A) A beak-like narrowing of the distal esophagus up to the gastroesophageal junction with mild passage disturbance, and a thin filling defect are noted on the distal region of the second portion of the duodenum. (B) Contrast is retained on the dilated stomach and duodenal bulb.

Fig. 2

Findings of the small-bowel series. A thin filling defect with a dilated duodenal bulb is noted in the distal region of the second portion of the duodenum.

Fig. 3

Initial endoscopic findings. (A) A mucosal diaphragm is seen on the second portion of the duodenum, suggesting a duodenal web. (B) A mucosal diaphragm in the second portion of the duodenum shows a stenotic lumen.

Fig. 4

Endoscopic findings. (A) The mucosal diaphragm of a stenotic lumen caused by a duodenal web was resected and electrocauterized with an insulated-tip (IT) knife. (B) A stenotic lumen is dilated after the removal of the diaphragm with an IT-knife.

Fig. 5

The follow-up endoscopic findings. (A) Scar formation is noted on the second portion of the duodenum at the site of cauterization. (B) The lumen is shown in the second portion of the duodenum with no passage disturbance.