Anomalies of duodenal development: causes, symptoms, diagnosis, treatment

Anomalies in the development of the duodenum are rare.

[1], [2], [3], [4]

Atresia and congenital stenosis of the duodenum

Atresia, congenital stenosis and membranous membrane fusion of the duodenum are detected on the first day after birth: abundant vomiting, frequent regurgitation and other symptoms, high intestinal obstruction. No chair. When X-ray examination (the contrast is injected into the stomach through a thin probe), the expansion of the stomach and the absence of a contrast agent in the stomach are noted. If surgical treatment is not possible in the next 24 hours, newborns die from dehydration and exhaustion.

With partial narrowing of the lumen of the duodenum, the nutrition of the child can be disturbed insignificantly or not at all. In the second case, the complaints of patients are of little character and the narrowing of the lumen of the duodenum can be detected accidentally by an x-ray examination already in an adult.

In X-ray examination, congenital internal membranes and duodenum lobes usually create a pattern of symmetrical narrowing of a very small extent (1-2 to 5 mm), depending on the thickness of the membrane. The relief of the intestinal mucosa is not altered or extended folds are defined over the narrowing. With external scars, strands or additional ligaments (lig. Cystoduodenocolicum), the narrowing regions have smooth, distinct contours, their length does not exceed 0.5-1 cm.

The gastroduodenoscopic examination also significantly facilitates the diagnosis: either a circular narrowing of the duodenal region, usually with unchanged mucous membrane, or membrane membranes, the innate character of which is easily determined for the experienced endoscopist, is revealed.

Symptoms

The clinical picture depends on the degree of compression. In adults, this sensation is a rapid overfilling of the stomach during meals, belching, nausea, and sometimes vomiting. With complete compression of the intestine, the symptoms are similar to those with its atresia and are detected from the first days after the birth of the child.

Congenital compression of the duodenum should be distinguished from compression due to the adhesive process in the abdominal cavity (periduodenitis, consequences of surgical interventions), etc.

Treatment is surgical.

[5], [6], [7], [8]

Arteriomeenteric obstruction

The greatest clinical importance is the anomaly of the superior mesenteric artery and other congenital and constitutional disorders, which can lead to a violation of the passage of the contents of the duodenum along its lower-horizontal branch (the so-called arteriomesenteric obstruction). As is known, normally the superior mesenteric artery departs from the aorta, crosses the anterior surface of the lower horizontal branch of the duodenum, passing behind the pancreas, and then enters the mesentery of the small intestine. However, with some of its location anomalies, the presence of additional branches, as well as with pronounced lumbar lordosis, a congenital short mesentery of the small intestine or its significant downward sloping (pronounced enteroptosis, severe weight loss), it can squeeze the duodenum, disrupting its patency. Perhaps, in those cases when the symptoms of chronic arterio-mesenteric obstruction (we prefer the term "duodenal arteriomisenteric compression") arise in old age, the compaction of this artery due to atherosclerotic lesion is important.

Acute duodenal arterio-mesenteric obstruction arises suddenly due to a sharp expansion of the stomach or a significant overflow of its food, as a result of which the intestine is pushed down, the mesentery of the small intestine is stretched and the superior mesenteric artery contracts the lower horizontal branch of the duodenum. The clinical picture as with acute emerging intestinal obstruction (sharp pain in the epigastric region).

Symptoms

Clinical picture of chronic duodenal arteriomesenteral compression: a feeling of heaviness and dull or strong pain and a feeling of "overflow" of the stomach (sometimes after taking even a small amount of food), arising soon after eating, belching, less often vomiting of food eaten.

Often, these symptoms subsided in a forced position (knee-elbow, sometimes on the side), in standing position - strengthened. In most cases, the disease occurs at a young age, and gradually its symptoms intensify. In severe cases, attention is drawn to the appearance of patients: these are asthenics with a flabby abdominal wall and a sagging stomach.

Diagnostics

Diagnosis of arteriomesentral obstruction (in our opinion, it is preferable to use the term "arteriomesentral compression of the duodenum") is most easily confirmed by contrast X-ray examination, in which at the intersection of the lower-horizontal branch of the duodenum (during the transition to the jejunum), a short segment of constriction is revealed-squeezing the mesentery with a thin gut, in which the upper aboral artery passes. It is the compression of the artery and creates the difficulty of the passage of the contents along the lower-horizontal branch of the duodenum.

At the same time, the proximal part of it is enlarged, peristalsis is intensified, spastic and antiperistaltic contractions are observed, in some cases - even the expansion of the stomach. The method of duodenography is more evident, in which a narrow transverse band of 1.5 cm width or slightly more with smooth contours is revealed at the left edge of the lumbar vertebrae in the lower-horizontal part of the duodenum. The relief of the mucosa in this area is not changed. Sometimes the passage of the contrast suspension through the narrowed region is restored by examining the patient in the knee-elbow position, which is convincingly enough to confirm the diagnosis. The characteristic localization of the narrowing zone of the duodenum with unchanged mucosa is also observed with gastroduodenoscopy (with a sufficiently "deep" advance of the duodenoscope - to the final part of the lower-horizontal branch of the duodenum).

[9], [10], [11], [12], [13], [14], [15]

Treatment

Basically conservative. Recommended high-calorie fractional nutrition (5-6 times a day) - in order to increase the body weight of patients and reduce gastroenteroptosis (reduce the tension of the mesentery of the small intestine and compression of the superior mesenteric artery of the duodenum). Means that improve appetite are shown: the collection is appetizing (in the form of infusion), insulin injections at 4-6 units a day before meals, methandrostenolone, retabolil. To eliminate motor disorders of the duodenum, antispasmodic agents are prescribed, metoclopramide (cerucal). In especially severe cases, at the beginning of treatment, which is expedient to be performed in the gastroenterological department of the therapeutic hospital, after a meal it is recommended to take a knee-elbow position for 30-60 minutes, at which the tension of the mesentery of the small intestine and compression of the lower-horizontal branch of the duodenum decrease. In severe cases, when conservative measures do not help, surgical treatment is indicated.

Duplication of the duodenum

Duplication of the duodenum is an extremely rare anomaly. In this case there is an additional intestinal tube 1-4 cm in diameter, located parallel to the main tube and having a common wall with it. Clinical symptoms are either absent or pain in the epigagic area after eating, vomiting (with delay in duodenal duplication of food masses). Diagnosis is determined by X-ray examination.

Treatment for severe clinical symptoms is surgical.

Enterogenic cysts of the duodenum are single and multiple. With a large size, there are clinical symptoms of impaired patency of the duodenum. Diagnosis is established by X-ray examination and duodenofibroscopy. Treatment is surgical.

[16], [17], [18], [19]

Digestion of the duodenum

In rare cases, due to incomplete obliteration of the ventral mesentery, fibrous cords are formed, which cause external constrictions of the duodenum; most often there is compression of the upper half of the descending part of the duodenum with a ligament going from the gallbladder to the hepatic bend of the large intestine.

For stenoses caused by an annular, i.e., "annular" pancreas, their location in the upper or middle third of the descending part of the duodenum is characteristic, most often directly above the large papilla of the duodenum. Obstruction of the lumen is usually eccentric, since the extra pancreas is rarely a closed ring, but more often contains a patch of connective tissue. The length of the constriction is 2-3 cm, the contours are clear, smooth. The intestinal mucosa in this area is unchanged, represented by delicate, delicate folds, and above and below the narrowing of the fold are thickened or normal. The length of the narrowed section and its diameter do not change with compression, changing the position of the patient's body and with additional studies. To facilitate the diagnosis can gastroduodenoskopiya (draws attention to unchanged mucous membrane in the constriction) and computed tomography. Given that squeezing of the duodenum is more common in adults on the background of densification of the gland tissue due to chronic pancreatitis, these data can be obtained with the help of ultrasound.

Treatment is surgical. With a slight narrowing of the lumen of the duodenum and the absence of intestinal symptoms it is sufficient to recommend a fractional diet, a mechanically sparing diet.

[20], [21]

Anomalies of the location of the duodenum

Anomalies of the location of the duodenum are relatively common. Thus, when the turn of the intestine unfinished during embryogenesis, the descending part of the duodenum does not turn to the left, passing to the lower horizontal part of it, but descends, without a sharp topographic-anatomical boundary, passing into the jejunum. This anomaly is not clinically significant and is detected accidentally by X-ray examination.

In the presence of a mesentery of the duodenum, it can form additional bends and kinks that prevent the food from moving along it and in some cases are the cause of painful attacks accompanied by vomiting.

Sometimes the pain occurs when the contents of the stomach in the intestine overeat and enter in large portions. Often, the pain calms down in a certain position of the patient, which helps to straighten the excesses (lying on his back, on his side, in the knee-elbow position, etc.). The diagnosis is established by roentgenological examination.

Treatment for severe clinical symptoms is surgical (fixation of the duodenum to the back wall of the abdominal cavity).

[22], [23], [24]

Congenital diverticula of the duodenum

Congenital diverticula of the duodenum have the same clinical picture as the acquired ones. Before surgery, a differential diagnosis with acquired diverticula is possible if the diverticulum is detected already in childhood.

[25], [26], [27], [28], [29], [30], [31], [32],