A 4-year-old emaciated male child presented to us with history of intermittent episodes of bilious vomiting (once/twice in 7-10 days), abdominal pain and failure to thrive. Past history was not significant. He was immunized till date. Physical examination revealed the child to be pale and weighing only 8.5 Kgs. There were no signs of dehydration and hypoproteinemia.

Abdominal examination revealed mildly distended abdomen with visible peristalsis seen mainly above the umbilicus. No definite abdominal lump was palpable. There was no organomegaly. Rest of the systemic examination was unremarkable. Investiga-tions revealed hemoglobin to be 9 g/dL. All serum investigations were within normal limits. Upright abdominal X-ray showed some dilated bowel loops. Barium meal follow-through showed dilatation of the duodenum and proximal jejunum with a distal cut off (Fig. 1). Delayed films showed most of the barium retained in the stomach and duodenum. A fair amount of barium had passed distally. On exploratory laparotomy dilated proximal jejunum with collapsed distal loops were seen at the level of mid-jejunum. The point of attachment of diaphragm was indicated by applying pressure on the Ryles tube which produced an indentation in the jejunal wall. The Ryles tube could not be negotiated through the central perforation. Enterotomy was done across this area of obstruction and the web with central perforation situated 8 cm from the duodeno-jejunal junction was excised. Intestine was closed in two layers. Post -operative period was uneventful.

Fig.1. Barium meal showing severely dilated bowel proximal to obstruction in jejunam.

Partial intra-luminal occlusion due to stenosis resulting in incomplete intestinal obstruction accounts for about 5% of cases of jejuno-ileal obstruction. Out of these 5% cases of stenosis, 75% occur in the duodenum, 20% in the ileum and only 5% in the jejunum(2). Jejuno-ileal atresia has been classified into 4 types(3). Our case can be included into type 1 in which there is a membrane or diaphragm with the bowel wall in continuity. Type 1 has proximal dilated bowel, intact mesentery and the total bowel length is normal. This type of jejuno-ileal lesion occurs due to fetal ischemic necrosis, which is explained by the vascular theory(4). The onset of clinical symptoms is variable and is reportedly proportionate to the diameter of the central perforation in the web. The treatment for jejunal web remains surgical excision even though variable approaches may be used. Endoscopic laser therapy has been successfully tried for duodenal web. Simultaneous laparotomy with endoscopy has also proved useful(5). Inspite of low incidence of jejunal diaphragm as a cause of intestinal obstruction in older children, it should be considered in the differential diagnosis of long-standing sub-acute intestinal obstruction.

Paras R. Kothari,
Namrata P. Kothari,
From the Department of Pediatric Surgery,
LTMM College and General Hospital,
Sion, Mumbai 400 022, India.
E-mail: drparaskothari@rediffmail.com

1. Grostelf JL. Jejuno-ileal atresia and stenosis. In: Welch KJ, Randolph JG, Ravitch MM, O’Neill JA Jr, Rowe MI, editors. Pediatric Surgery, vol 2, 4th edition. Chicago: Yearbook Medical Publishers Inc. 1986; 838-848.

2. Trler JS, Winter HS. Anatomy, embryology and developmental abnormalities of the small intestine and colon. In: Seleisenger MH, Fordtran JS, eds. Gastrointestinal disease, 4th edition. Philadelphia: WB Saunders Company; 1989, p. 991-1021.

3. Martin L W, Zerella JT. Jejuno-ileal atresia: Proposed classification. Pediatr Surg 1976, 11: 399-403.

4. Louw JH. Congenital intestinal atresias and stenosis in the newborn: observations on its pathogenesis and treatment. Ann R Coll Surg Engl 1959; 25: 209.

5. De Backer T, Voet V, Vandenplas Y, Deconinck P. Simulataneous laparotomy and intraoperative endoscopy for the treatment of high jejunal membranous stenosis in a 1-year-old boy. Surg Laparosc Endosc 1993; 3: 333-336.