Monday, May 21, 2012

Double Bubble Sign

[On antenatal ultrasound  a case with Double Bubble sign  turned out to be  midgut malrotation postnatally]

Appearance-  Two well defined echofree cystic areas seen  in fetal upper abdomen due to fluid distended stomach and proximal duodenum.  Abdominal radiograph of these cases also usually reveals two gaseous/ lucent areas [double bubble] representing air in stomach & duodenum , with gasless rest of the abdomen.

Dr.Subhash Tailor M.D.[ Radiology]
Dr.Gaurav Bahety M Ch [Ped.Surgery ]
Bhilwara [Rajasthan] , INDIA

Possible D/Ds
Intrinsic duodenal obstructions like- duodenal atresia,stenosis and web
Extrinsic causes like – Annular pancreas & Ladd’s band with midgut malrotation

Case details
A 19 yr primi gravida was asked  for antenatal ultrasound in last trimester for fetal well being. She also complained of pain abdomen & slight leaking PV.
At US- Fetal abdomen revealed a Double Bubble Sign [fig. 1 ] . Mild oligohydramnios was also present [due to recent leaking pv]. Fetal gestation was about 35 weeks. No any other abnormality was seen. In keeping  with antenatal sonography findings, a probable diagnosis of Duodenal atresia was made. The patient then delivered  a female child same day.
 Neonatal abdominal radiograph showed  a large single gaseous shadow due to distended stomach , with relatively gasless abdomen [fig. 2 ] . The second bubble was absent , likely the duodenal air was deflated with NG tube or passed distally,which  raised the suspecian of some other pathology or cause .
Again postnatal abdominal ultrasound was asked which  revealed upper abdominal  epigastric whirlpool sign on B-mode  & color Doppler due to mesenteric twist .  There was transposition of superior mesenteric artery & vein with clockwise 360degree rotation of SMV over SMA [fig.3 ] . Rest of abdomen was normal except mildly promiment & fluid filled small bowel loops .So ,on the basis of mesenteric whirlpool sign a possibility of midgut malrotation with volvulus was  suggested.
The neonate was operated in emergency to avoid impending mesenteric ischemia due to suspected volvulus , & the diagnosis of midgut malrotation with volvulus was confirmed  [ fig.4 & 5].

Fig.1 – Fetal upper abdomen shows Double Bubble sign due to fluid distended stomach & prox.duodenum

Fig. 2- Neonatal abdominal radiograph reveals single lucent shadow of stomach with NG tube in situ , & gasless rest of the abdomen

Fig. 3 – Upper abdominal B-mode & color Doppler TS images shows classical Whirlpool sign due to mesenteric twist

Fig.4 – Peroperative photograph of mesenteric twist & midgut malrotation

Fig.5 – Peroperative photograph of mesenteric twist & midgut malrotation after complete exploration


Anonymous said...

Dont we want to publish these good case reports also in The Internet Journal of Radiology and link them?

Sumer Sethi said...

yes Oli sure, i have already encouraged the submitter for IJRA.

MGK Murthy said...

fantastic efforts and congratulation to both of you

hareshwar said...

congratulation a beautiful case

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