A 6-week-old infant born in rural India presents with intermittent abdominal distension, bilious vomiting, and failure to thrive. Abdominal examination reveals visible peristaltic waves. Abdominal X-ray shows a 'double bubble' sign with air-fluid levels. Upper GI contrast study confirms duodenal atresia with normal position of the ligament of Treitz. What is the most appropriate next step in management?

Explanation

## Management of Confirmed Duodenal Atresia **Key Point:** Once duodenal atresia is confirmed with normal ligament of Treitz position, the diagnosis is definitive and surgical repair is the only curative treatment. Preoperative optimization followed by duodenoduodenostomy is the standard of care. ### Why Surgical Repair? **High-Yield:** Duodenal atresia is a complete intrinsic obstruction with no lumen — it cannot resolve spontaneously. The infant is at risk of: - Severe malnutrition and failure to thrive - Aspiration pneumonia from persistent vomiting - Electrolyte derangements and dehydration - Bowel perforation if obstruction is prolonged ### Preoperative Optimization Steps | Step | Rationale | |------|----------| | NPO (nil per os) | Prevent aspiration; prepare for surgery | | Nasogastric decompression | Relieve gastric distension; reduce vomiting | | IV fluid resuscitation | Correct dehydration and electrolyte abnormalities | | Assess for VACTERL associations | Duodenal atresia is part of VACTERL syndrome in ~30%; screen for cardiac defects, renal anomalies, vertebral defects | | Echocardiography | Rule out congenital heart disease before surgery | | Renal ultrasound | Identify renal anomalies | ### Surgical Approach ```mermaid flowchart TD A[Duodenal atresia confirmed]:::outcome --> B[Preoperative optimization]:::action B --> C[Echocardiography + renal ultrasound]:::action C --> D[Surgical repair: Duodenoduodenostomy]:::action D --> E[Diamond-shaped or gastrojejunal anastomosis]:::action E --> F[Good long-term outcomes]:::outcome ``` **Clinical Pearl:** Duodenal atresia is often associated with Down syndrome (trisomy 21) and VACTERL syndrome. Always screen for these associations before surgery. **Mnemonic:** VACTERL = **V**ertebral, **A**nal, **C**ardiac, **T**racheoesophageal, **R**enal, **L**imb anomalies. Duodenal atresia is part of this spectrum. **Tip:** The timing of surgery is after preoperative stabilization and investigation — usually within 24–48 hours of diagnosis in a healthy neonate without major cardiac defects. [cite:Sabiston Textbook of Surgery Ch 67]