congenital causes of intestinal obstruction include duodenal atresia , malrotation , duodenal obstruction from ladd bands , other congenital bands , superior mesentery artery syndrome , enteric duplications as well as several other entities .
congenital anomalous bands resulting in proximal jejunal obstruction are a rare entity that should be considered in the differential in patients with clinical signs of obstruction and no prior history of abdominal surgery .
we present a case of an 8 year - old girl with a nine - month history of intermittent vomiting and no history of prior surgery and review the embryology and radiologic findings of this entity using different imaging modalities .
an 8 year - old girl with a past medical history of constipation presented with a history of vomiting for nine months .
the vomiting was intermittent , non - bloody , at times bilious , and occasionally contained food particles .
an abdominal ultrasound was performed which demonstrated debris within a dilated proximal duodenum . the superior mesenteric artery ( sma ) and superior mesenteric vein ( smv )
were visualized with the sma lying to the left of the smv with normal anatomic alignment [ figure 1 ] .
( a ) ultrasound of mid abdomen shows superior mesentery vein ( arrow ) and superior mesentery artery to the left ( b ) the doppler flow study confirms arterial flow in the superior mesentery artery ( arrowhead ) and the venous flow in the uncompressed superior mesenteric vein ( arrow ) .
a standard barium single contrast upper gastrointestinal ( ugi ) series was performed with the contrast entering the antrum and duodenal bulb . the proximal duodenum and descending duodenum
were markedly dilated in caliber with apparent tapering of the third part of the duodenum .
there was an abrupt cutoff with no contrast extending beyond approximately the mid abdomen [ figure 2 ] .
delayed images were obtained while the patient was supine with contrast never extending beyond the third portion of the duodenum [ figure 3 ] .
single contrast upper gastrointestinal series shows on a single view plain radiograph the contrast abruptly cutting off approximately at the mid abdomen ( arrow ) .
single contrast upper gastrointestinal series shows on delayed images with patient laying supine , contrast never extending beyond third portion of duodenum with persistent cutoff ( arrow ) .
contrast is seen in antrum of stomach ( star ) , proximal duodenum , and descending duodenum .
patient was subsequently placed prone for several minutes with eventual slight transit of contrast [ figure 4 ] .
thirty minute delayed prone images demonstrated contrast in the proximal small bowel , however proximal duodenum remained markedly dilated and contrast / debris filled [ figure 5 ] . additionally delayed overhead images demonstrated contrast extending to the distal small bowel after patient had been upright for greater than 30 minutes [ figure 6 ] .
markedly dilated proximal duodenum with abrupt cutoff in the third portion of the duodenum raised concern for a questionable mass like positionally dependent extrinsic compression of the third portion of the duodenum .
delayed prone images demonstrated contrast in the proximal small bowel with persistent dilatation of the proximal duodenum .
additional delayed image following several minutes of prone position demonstrates a small amount of contrast progressing to the jejunum ( arrow ) .
delayed abdominal radiograph following the upper gastrointestinal series after patient had been upright for greater than 30mins demonstrates further progression of contrast into the jejunum and ileum ( star ) .
distal most extent of contrast near the cecum ( arrow ) . a subsequent computed tomography ( ct ) of the abdomen and pelvis
the duodenum was distended with the third part of the duodenum tented downward [ figure 7 ] .
the duodenal / jejunal junction was severely narrowed and coursed distally anterior to the right common femoral artery below the bifurcation [ figure 7 ] . computed tomography ( ct ) of the abdomen and pelvis shows dilated fluid filled duodenum ( asterisk , a ) .
duodenum tented medially ( black arrow , b ) and downward ( white arrow , c , black arrow , e ) .
duodenum severely narrowed as it crosses anterior to right femoral vein below the bifurcation ( white arrow , d ) .
the patient was taken for an exploratory laparotomy and found to have dense vascularized bands without intestinal malrotation . upon entering the abdomen ,
. further exploration in the abdomen revealed the proximal jejunum tethered by dense vascularized bands running from approximately five inches distal to the ligament of treitz down into the pelvis .
the cecum was incidentally noted to be folded back on itself and adherent to this tented portion of the jejunum .
after these adhesions were ligated , the bowel was examined and no other anatomical abnormalities were discovered .
the patient experienced a normal post - operative course with subsequent complete resolution of symptoms .
the congenital causes of intestinal obstruction in infants and children are intestinal atresia and stenosis , congenital bands , remnants of embryologic structures such as vitelline arteries or veins , omphalomesenteric ducts or a mesourachus . in addition
intestinal obstructions caused by other anomalous congenital bands have only been described sporadically in the literature and are otherwise rare.[57 ] an example of anomalous congenital bands is ladd bands .
they arise from the cecum and extend to the sub - hepatic region , posterior peritoneum or abdominal wall .
ladd bands result in compression of the 2 or 3 duodenal portions , which lead to intestinal obstruction .
however , the location of these bands is different from embryonic remnants such as vitelline vessels or omphalomesenteric ducts .
akgur et al . , cited a few series of cases to suggest that these bands are the result of a mesenteric developmental anomaly .
mesenteric anomalies have not been well documented aside from cases of malrotation and anomalous intestinal fixation . in our patient ,
upper gastrointestinal ( ugi ) barium examination showed a dilated duodenum near the ligament of treitz with sharp obstruction .
most duodenal obstructions by external compression are caused by abnormal duodenal rotation with internal herniation or ladd bands . in our patient
our case is particularly rare as abnormal dense vascularized bands were seen distal to the ligament of treitz , which is not characteristic of ladd bands .
this resulted in dilatation of the proximal jejunum which was not readily identified on the ugi barium examination .
though imaging demonstrated a high grade obstruction , the patient 's symptoms were chronic and mild . furthermore prone
positioning partially alleviated the degree of obstruction presumably by altering the position of the anomalous bands and relieving the obstruction .
finding an anomalous band tethering the proximal jejunum to the pelvis and adhering the jejunum and cecum is unique and unlike previously described congenital peritoneal bands .
as no previous operation had been performed on this patient and operative findings did not show any other abnormal post inflammatory adhesions between the small and large intestines , the etiology of these bands was determined to be congenital .
, discovered a band running from the antimesenteric wall of the proximal jejunum just distal to the treitz 's ligament to the root of the mesentery . the anomalous congenital band in that case was considered to be the remnant of ventral mesentery that failed to resorb completely . in both our case and the case described by liu et al .
external compression of the proximal jejunum by an anomalous band should be included in the differential diagnosis of obstruction of the distal duodenum or duodeno - jejunal junction for patients without previous history of surgery , especially when ugi barium examination shows normal duodenal rotation and duodeno - jejunal fixation .
 congenital anomalous bands at the proximal jejunum resulting in obstruction have been described sporadically in the literature and are otherwise rare . 
 we present a case of an 8 year - old girl with a nine - month history of intermittent vomiting and no history of prior surgery . 
 the imaging workup includes an abdominal ultrasound , a single contrast upper gastrointestinal series , and a dual contrast computed tomography of the abdomen and pelvis . 
 surgical intervention revealed the presence of dense bands at the proximal jejunum without evidence of malrotation . 
 our report reviews the embryology and radiologic findings of this entity using different imaging modalities . 