Congenital Duodenal Obstruction Presenting as an Olive-Shaped Abdominal Mass: Case Study

A 3-month-old male infant, born to healthy consanguineous parents, presented with a 20-day history of bilious and forceful vomiting, substantial weight loss, and lethargy. 

The child had been hospitalized twice before – to different hospitals for fluid therapy – being suspected to have hypertrophic pyloric stenosis. However, the parents delayed pyloromyotomy until a second medical opinion. 

Upon examination, the infant exhibited signs of severe dehydration, had cautery marks from a traditional healer, and showed the classic features of congenital duodenal obstruction rather than pyloric stenosis. 

The investigations included ultrasound and barium meal. Hypertrophic pyloric stenosis was excluded by abdominal ultrasound (USG). The USG overruled pyloric stenosis, and the barium meal test disclosed a massively distended stomach, absence of distal gas, and triple bubble sign. Exploratory laparotomy, web incision, and hernia repair were performed, with postoperative care and monitoring in the PICU. The laparotomy rendered a congenital duodenal web (CDW). 

The case underscores the importance of considering proximal bowel obstruction in infants with a palpable olive mass, highlighting the need for thorough history-taking, physical examination, and prompt diagnostic measures such as point-of-care ultrasound. Clinicians should maintain an open diagnostic mindset when evaluating persistent vomiting in newborns, as it may indicate more serious conditions beyond common diseases like hypertrophic pyloric stenosis.

Source: Abdulaziz GM, Mohamed KM, Zilai AH, Attieh AI, Alhammad EA, Akkam AY. Case Reports in Pediatrics. 2023; 2023.