Duodenal Ulcer Associated With Incomplete Duodenal Diaphragm By D. C. Keramidas
and N. Vayatzis
Athens, Greece Peptic duodenal ulcer associated with congenital incomplete duodenal diaphragm has not been described in children. An etiologic correlation of the ulcer with the diaphragm may be possible. CASE
REPORT
I.K., a 9-yr-old boy, was admitted November 10, 1974, with a long history of poor feedings and frequent nonbilious vomiting as well as colicky periumbilicai and epigastric pain. On examination, the epigastrium was slightly distended, and there was tenderness to the right of the midline. The upper gastrointestinal series demonstrated distension of the stomach, increased peristalsis, narrowing of the pyloric canal and deformity of the duodenal bulb (Fig. 1). Increased gastric juice with hyperacidity was also found. At operation, a healed duodenal ulcer close to the pylorus was discovered. A pylorotomy, extended up to the middle of the first portion of Ihe duodenum, with excision of the ulcer, revealed an incomplete mucosal diaphragm. There was a small eccentric aperture of the diaphragm (Fig. 2). The diaphragm was excised. The pylorotomy was closed transversely in two layers, and the operation was completed by performing a vagotomy. DISCUSSION The symptoms and signs of incomplete duodenal in children, varying with the degree of obstruction.’
diaphragm may appear in infants The location of the diaphragm
as well as is twice as
0 \
2 Fig. 1. Radiograph taken after barium meal administration reveals increased peristalsis of the stomach, narrowing of the pyloric area, and deformity of the duodenal bulb. Fig. 2.
Sectional diagram shows the ulcer (U) and the incomplete diaphragm (D) location.
o 1975 by Grune & Stratton,
Inc.
Journal of Pediatric Surgery, Vol. 10, No. 5 (October), 1975
837
CASE REPORTS
838
common below the papilla of Vater than above it.’ The presence of bile in the vomitus does not definitely indicate the level of obstruction, since bile ducts have bifurcated to empty both above and below the diaphragm.3 In the present case, there were intermittent episodes of nonbilious vomiting. Symptoms of peptic ulcer occurred later. The duodenal ulcer was situated proximal to the incomplete diaphragm. Increased gastric juice, hyperacidity, and ulcer formation may have been secondary to duodenal stenosis leading to chronic stasis and excessive antral stimulation. Hypertonicity of the stomach and hyperacidity have been thought to be causative factors of gastroduodenal ulcer in infants and children.4*5 One case of healed gastric ulcer combined with an incomplete prepyloric diaphragm has been described in a 7-yr-old boy.6 No duodenal ulcer in association with incomplete duodenal diaphragm has been reported previously. REFERENCES 1. Girvan DP, Stephens CA: Congenital intrinsic duodenal obstruction: A twenty-year review of its surgical management and consequences. J Pediatr Surg 9:833, 1974 2. Rowe MI, Buckner D, Clatworthy HW Jr: Windsock web of the duodenum. Am J Surg 116444, 1968 3. Boyden EA, Cope JG, Bill AH Anatomy and embryology of congenital
Jr: in-
trinsic obstruction of the duodenum. Am J Surg 114:190, 1967 4. Kelsey D, Stayman JW Jr, McLaughling ED, et al: Massive bleeding in a newborn infant from a gastric ulcer associated with hypertrophic pyloric stenosis. Surgery 64:979, 1968 5. Haneman B: Duodenal ulcer in children. Gut 9:251, 1968 6. Farman J, Cywes S, Werbelaff L: Pyloric mucosal diaphragms. Clin Radio1 19:95, 1968
and N. Vayatzis
Athens, Greece Peptic duodenal ulcer associated with congenital incomplete duodenal diaphragm has not been described in children. An etiologic correlation of the ulcer with the diaphragm may be possible. CASE
REPORT
I.K., a 9-yr-old boy, was admitted November 10, 1974, with a long history of poor feedings and frequent nonbilious vomiting as well as colicky periumbilicai and epigastric pain. On examination, the epigastrium was slightly distended, and there was tenderness to the right of the midline. The upper gastrointestinal series demonstrated distension of the stomach, increased peristalsis, narrowing of the pyloric canal and deformity of the duodenal bulb (Fig. 1). Increased gastric juice with hyperacidity was also found. At operation, a healed duodenal ulcer close to the pylorus was discovered. A pylorotomy, extended up to the middle of the first portion of Ihe duodenum, with excision of the ulcer, revealed an incomplete mucosal diaphragm. There was a small eccentric aperture of the diaphragm (Fig. 2). The diaphragm was excised. The pylorotomy was closed transversely in two layers, and the operation was completed by performing a vagotomy. DISCUSSION The symptoms and signs of incomplete duodenal in children, varying with the degree of obstruction.’
diaphragm may appear in infants The location of the diaphragm
as well as is twice as
0 \
2 Fig. 1. Radiograph taken after barium meal administration reveals increased peristalsis of the stomach, narrowing of the pyloric area, and deformity of the duodenal bulb. Fig. 2.
Sectional diagram shows the ulcer (U) and the incomplete diaphragm (D) location.
o 1975 by Grune & Stratton,
Inc.
Journal of Pediatric Surgery, Vol. 10, No. 5 (October), 1975
837
CASE REPORTS
838
common below the papilla of Vater than above it.’ The presence of bile in the vomitus does not definitely indicate the level of obstruction, since bile ducts have bifurcated to empty both above and below the diaphragm.3 In the present case, there were intermittent episodes of nonbilious vomiting. Symptoms of peptic ulcer occurred later. The duodenal ulcer was situated proximal to the incomplete diaphragm. Increased gastric juice, hyperacidity, and ulcer formation may have been secondary to duodenal stenosis leading to chronic stasis and excessive antral stimulation. Hypertonicity of the stomach and hyperacidity have been thought to be causative factors of gastroduodenal ulcer in infants and children.4*5 One case of healed gastric ulcer combined with an incomplete prepyloric diaphragm has been described in a 7-yr-old boy.6 No duodenal ulcer in association with incomplete duodenal diaphragm has been reported previously. REFERENCES 1. Girvan DP, Stephens CA: Congenital intrinsic duodenal obstruction: A twenty-year review of its surgical management and consequences. J Pediatr Surg 9:833, 1974 2. Rowe MI, Buckner D, Clatworthy HW Jr: Windsock web of the duodenum. Am J Surg 116444, 1968 3. Boyden EA, Cope JG, Bill AH Anatomy and embryology of congenital
Jr: in-
trinsic obstruction of the duodenum. Am J Surg 114:190, 1967 4. Kelsey D, Stayman JW Jr, McLaughling ED, et al: Massive bleeding in a newborn infant from a gastric ulcer associated with hypertrophic pyloric stenosis. Surgery 64:979, 1968 5. Haneman B: Duodenal ulcer in children. Gut 9:251, 1968 6. Farman J, Cywes S, Werbelaff L: Pyloric mucosal diaphragms. Clin Radio1 19:95, 1968
