DESCRIPTION

A 3-day-old baby with Down syndrome, who initially fed well, developed bilious vomiting. The abdominal radiograph showed a double bubble appearance but gas was also seen distal to the duodenal cap in loops of the small bowel. This appearance was confirmed by an upper gastrointestinal contrast study. Interestingly, contrast was also seen in the entire biliary system, suggesting a partial but tight duodenal obstruction beyond the ampulla of Vater. The diagnosis was confirmed at operation, with resection of a partial obstruction caused by a duodenal web.

Duodenal atresia and stenosis is known to be associated with a variety of biliary and pancreatic abnormalities.1 Reflux of contrast into the biliary system is a rare occurrence and is usually secondary to a high-pressure duodenal obstruction.2 Competence of the sphincter of Oddi can be compromised by mechanical dilatation of the proximal duodenum or abnormal development of the sphincter itself. This incompetence of the sphincter can lead to acute pancreatitis at a later age.3

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Figure 1

Plain abdominal radiograph showing classical double bubble appearance as well as distal gas shadow.

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Figure 2

Reflux of contrast into the biliary tree is shown in a delayed contrast x-ray.