Date of Medical Observation
April 2008

Narration

A 5-day-old patient at the neonatal ICU was referred to pedia-surgery service for evaluation and management of vomiting. Their initial impression was a sepsis neonatorum.

             I together with the pedia-surgery rotator, evaluated the patient.

             The patient was not ill looking and her abdomen was not distended.

             She was able to pass small amount of meconium .

The nasogastrict tube as well as the drainage bottle was empty at that time. The abdominal x-ray done 2 days prior revealed “non obstructing bowel gas pattern”  according to the pediatric   resident.

             Taking into consideration the patient presentation, we agreed for the diagnosis of “sepsis           neonatorum” and signed out the case as a “ nonsurgical abdomen at the time of examination”.

I then asked the pedia surgery rotator to refer the case to our service consultant.

The consultant then ordered us to follow up the patient’s case.

Four days after the said referral, the patient was referred back for persistent bilious NGT output.

I was out for a vacation leave that time so the pedia-rotator together with a more senior resident evaluated the patient again.

             They requested for a repeat x-ray of the abdomen.

             The result revealed a “ double bubble sign” which made Duodenal Atresia the most likely            diagnosis. Too bad, the previous reading was exactly the same as the repeat x-ray.

We then decided to operate on the patient. The intraoperative findings was a duodenal atresia “windsock type”.

INSIGHT

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             I guess what we missed here was a good follow up evaluation.

              Patient with duodenal atresia doesn’t look ill on initial presentation.

              A newborn to present with vomiting even if non-bilious mandates a more aggressive    evaluation.

             Much more if it is bilious for there is a high suspicion of duodenal atresia and many other             obstructive anomalies of the gastrointestinal tract.

                And as always, our consultants have much more to say all of which are worth remembering.

             “Do not rely on the initial reading of the radiologist alone, You must see the plates yourself.”

             I saw the case. I saw the classic windsock type of Duodenal atresia.

              Again, it was another learning experience.

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