Page 18 of 73 INBORN IMPASSABILITY OF THE DUODENUM
Etiology. It is considered that the gut gleam vacuolation delay during the embryonal period leads to formation of a membrane from a mucous membrane in a duodenum or to its atresia. The atresia can also develop owing to vascular pathology.
Pathogeny. The Atrezirovanny duodenum comes to an end blindly at once behind a big duodenal nipple. In 20 — 30% of cases this pathology is combined with a Down syndrome; in 20% of cases the general bilious channel opens in distal part of a gut below an atresia site. Occasionally, especially at diafragmopodobny type of an atresia, bile comes to intestines, both distalny, and proksimalny impassability zones. The second reason of impassability of a duodenum — incomplete turn of a middle part of intestines at which the caecum is located before duodenal and squeezes it. Serious complication of a malrotation of intestines is gut torsion at newborns; this pathology demands acceptance of urgent measures. The ring-shaped pancreas clasping the descending part of a duodenum can squeeze it, causing partial or full obstruction. This anomaly is almost always combined with an inborn stenosis of a duodenum. The connective tissue membrane of a duodenum can be observed at the wrong turn of an intestinal tube. In rare instances the portal vein is located before a duodenum bulb, squeezing it and causing impassability.
Clinical manifestations. Vomiting can begin the weight painted by bile right after the birth or after a while (especially at partial obstruction). In epigastric area it is possible to observe peristaltic waves, but the stomach is not always increased. As it was stated above, at such children symptoms of a Down syndrome are possible, and their mothers have a pregnancy abounding in water. Repeated vomitings lead to development of a metabolic alkalosis, sharply expressed dehydration and disturbance of water-salt balance. If the zone of an atresia is localized proksimalny a big duodenal nipple, then emetic masses is not painted by bile. Except an atresia, there are also other reasons of impassability, but they prove later, after achievement of monthly age by the child. So, the patient with a stenosis of a duodenum feels well within several months, and at the chronic duodenal impassability which is combined with the wrong turn of intestines, clinical manifestations develop still later.
Diagnosis. The diagnosis is made on the basis of the X-ray inspection conducted at vertical and horizontal position of the patient. In typical cases on the roentgenogram removed at vertical position of the patient "the double bubble" owing to accumulation of air in upper part of a stomach and the stretched duodenum is visible; besides, the horizontal line on border of liquid and gas (fig. 12-12) is defined. At a full atresia in distal part of a digestive tract gas, naturally, is not visible. The same radiological signs are observed also at other listed above forms of duodenal impassability. If impassability of a duodenum radiological is diagnosed, then it is necessary to carry out urgently an irrigoskopiya to exclude pathological rotation of intestines. At not omission of a caecum the reason of impassability it is necessary to consider a duodenum prelum as the peritoneal tyazha of Ladd fixing a caecum.
Treatment. At an atresia and a stenosis of a duodenum surgically create a bypass anastomosis, carrying out a duodenoduodenostomiya or a duodenojejunostomy. If impassability arises owing to Ladd's syndrome, then the patient should be operated. After a section of abnormal folds and a tyazhy peritoneum all large intestine is fixed in the left half of an abdominal cavity, and a small bowel — in right, i.e. recreate a fetalis arrangement of intestines before rotation. The best way of treatment of a ring-shaped pancreas — a duodenoduodenostomiya without gland section; at the same time the nonfunctioning piece of a gut is done as it is possible well. In the presence of a diaphragm of a duodenum it is reasonable to carry out a duodenoplasty.
Fig. 12-12. The survey roentgenogram of the newborn made in vertical position of the patient. Gas bubbles in upper part of an abdominal cavity and lack of gas in distal department of intestines testify to a duodenum atresia.