Intestinal Obstruction from Congenital Bands at the Proximal Jejunum: A Case Report and Literature Review
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 []. No large solid or cystic masses were seen.\nA 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 []. Delayed images were obtained while the patient was supine with contrast never extending beyond the third portion of the duodenum [].\nPatient was subsequently placed prone for several minutes with eventual slight transit of contrast []. Thirty minute delayed prone images demonstrated contrast in the proximal small bowel, however proximal duodenum remained markedly dilated and contrast/debris filled []. Additionally delayed overhead images demonstrated contrast extending to the distal small bowel after patient had been upright for greater than 30 minutes []. 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.\nA subsequent computed tomography (CT) of the abdomen and pelvis was performed with oral and intravenous contrast. The duodenum was distended with the third part of the duodenum tented downward []. The duodenal/jejunal junction was severely narrowed and coursed distally anterior to the right common femoral artery below the bifurcation [].\nThe patient was taken for an exploratory laparotomy and found to have dense vascularized bands without intestinal malrotation. Upon entering the abdomen, the cecum was noted to be in normal anatomical position. 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.