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A 6 month old boy is brought into the emergency department. He has been crying constantly since early this morning and has had an episode of green vomit. He has no past medical history, is fully immunised and meeting all milestones. The only history of relevance is that there have been episodes of abdominal pain and vomiting over the last month.

On examination, the child looks unwell from the end of the bed. He is quieter now, and minimally interactive, however, when you examine the abdomen, which his mother says looks distended, there is pain. You call the surgeons for review and whilst waiting get IV access and perform an abdominal x-ray.

What are you concerned about in this child? What does the x-ray show? What is the likely diagnosis?

Your Response

The keys to the puzzle here are the recent ‘grumbling’ abdominal symptoms, the inconsolable crying, the bilious vomiting ( remember bilious is BAD), the end of the bed impression of a sick child who is now quiet and the distended abdomen, with pain on palpation.

The Xray shows a “Double Bubble Sign”.

The double bubble sign is basically an obstruction of the duodenum. It represents air in the stomach and duodenum.

In the newborn differentials of significant concern are:

  • Duodenal atresia
    • 1:6,000 newborns
    • Atresia is distal to ampulla of Vater
    • Associated with Down Syndrome in 30% of cases
  • Annular Pancreas
    • Pancreas obstructs the second part of the duodenum
  • Malrotation and Volvulus
    • There is rotation around the superior mesenteric artery. If severe(3 + rotations) it results in bowel necrosis.
  • Ladd’s Bands
    • Peritoneum attaching cecum to abdominal wall obstructs duodenum.

In this case, given the story of previous abdominal symptoms in a child that is progressing normally, a major concern will be Malrotation and Volvulus.

All of the above conditions are surgical emergencies, with 100% mortality unless repaired. The red flag is bilious vomiting.



  1. Correia-Pinto J et al. Congenital Duodenal Obstruction and Double-Bubble Sign. NEJM 2014; 371:e16September 11, 2014
  2. Learningradiology.com
  3. Traubici J. The double bubble sign. Radiology.2001;220:463-464.
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