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Neonatal intestinal atresias (duodenum, jejunum and ileum)
Duodenal atresia comes from failed recanalisation and presents with a "double bubble" and a strong link to Down syndrome; jejunoileal atresia comes from an intra-uterine vascular accident and presents with many dilated loops — the lower the obstruction, the more distended the abdomen and the later the vomiting.
Why it matters in the exam
The exam shows a newborn with green vomiting on day one, sometimes after polyhydramnios in pregnancy. Questions cover the X-ray finding, associated anomalies, the next step and the principles of surgery. In duodenal atresia the obstruction is usually below the papilla, so the vomiting is green; about a third of the children have Down syndrome, and there are links with annular pancreas, malrotation, heart defects and anorectal malformations. The X-ray shows a "double bubble" (dilated stomach and duodenum) with no distal gas. If there is some distal gas, stenosis or an incomplete web is possible — and volvulus must be excluded.
Treatment of duodenal atresia is a diamond-shaped duodenoduodenostomy after stabilisation, a cardiac check and fluid correction; it is not an emergency operation as long as volvulus is not suspected. With a duodenal web beware the "windsock" — a stretched web that makes the obstruction appear lower — and remember that the papilla lies close to the web. An annular pancreas is not divided; it is bypassed.
Jejunoileal atresia is classified into types: I — a web with an intact wall; II — a fibrous cord between the ends; IIIa — a gap with a mesenteric defect; IIIb — "apple peel", in which the distal bowel spirals around a single vessel; IV — multiple atresias. At surgery the patency of the distal bowel is checked (injecting saline along it) because further atresias may exist, and the dilated proximal segment, which contracts poorly, is resected or tapered. Some newborns with ileal atresia have cystic fibrosis, so this is tested. Pyloric atresia is rare and linked with epidermolysis bullosa.
Key points
- Double bubble — duodenal atresia; look for Down syndrome.
- Distal gas — exclude volvulus.
- Jejunoileal atresia — intra-uterine vascular accident.
- Type IIIb — apple peel; type IV — multiple.
- Check distal patency and exclude cystic fibrosis.
Summary table
| Feature | Duodenal atresia | Jejunoileal atresia |
|---|---|---|
| Mechanism | Failed recanalisation | Intra-uterine vascular accident |
| X-ray | Double bubble, no distal gas | Many dilated loops with fluid levels |
| Associated anomalies | Down syndrome (about a third), annular pancreas, heart, malrotation | Few; cystic fibrosis in a minority |
| Surgery | Diamond-shaped duodenoduodenostomy | Resection or tapering of the dilated segment and anastomosis; distal patency check |
| Trap | Distal gas — exclude volvulus | Multiple atresias are possible |
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Sources
- Holcomb and Ashcraft's Pediatric Surgery, 7th edition (2019) — Duodenal Atresia and Stenosis; Jejunoileal Atresia and Stenosis
- ACR Appropriateness Criteria: Vomiting in Infants, 2019 — Neonatal bilious vomiting
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.