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Endoscopic Treatment of Duodenal Web in Association With Annular Pancreas in an Infant.

CASE REPORT An 8-month-old, nonsyndromic girl presented with delayed symptoms of partial upper gastrointestinal (GI) obstruction. These included persistent and forceful nonbilious vomiting since birth and history of failure to thrive. The infant had been treated with acid-suppressive therapy for gastro-oesophageal reflux without improvement. History of polyhydramnios was noted on antenatal screening. The patient was unwell at presentation with continued nonbilious vomiting, signs of acute dehydration, nil hematemesis and biochemical changes of hypochloremic alkalosis, consistent with gastric outlet obstruction (venous pH 7.5, CO2 43 mmHg, base excess 9.2 mmol/L), and hypokalaemia (2.7 mmol/L). Complete blood count, C-reactive protein, serum lipase, and liver function tests were normal. Abdominal ultrasound performed in the emergency department showed pneumobilia and a subsequent abdominal X-ray depicted gastroduodenal pneumatosis (Fig. 1). A nasogastric tube was successfully placed, with no reported difficulty or excessive trauma, to decompress the bowel. A contrast CT scan of the abdomen was suggestive of duodenal stenosis, an annular pancreas without signs of malrotation (Fig. 2). Given the history of nonbilious vomiting and nil hematemesis, in conjunction with the finding of pneumatosis on imaging before the endoscopy, we believe that the pneumatosis was because of severe emesis with upper gastrointestinal obstruction. After patient stabilization, endoscopy was performed initially with an Olympus XP-180N (Olympus Medical Systems Corp, Tokyo, Japan) to visualize the duodenum. The gastric antrum and first part of the duodenum were grossly dilated. A membranous obstruction to the second part of the duodenum proximal to the ampulla was present with a 2–3 mm luminal opening with no