The first case is an 11-month-old girl who presented with non-bloody, non-bilious emesis upon introduction of solid food. Her initial presentation was in the emergency department, where she was admitted for management of dehydration. During her admission, she had an upper GI performed, which demonstrated a duodenal web with near-complete obstruction of the proximal duodenum. She was brought to the operating room for upper endoscopy under general anesthesia. The web was visualized, and biopsy forceps were inserted into the opening prior to undergoing balloon dilation up to 6 mm. Subsequently, hot biopsy forceps were used to excise the web, then the opening was dilated to 12 mm with the balloon, as shown here. Six weeks post-initial operation, repeat upper endoscopy was performed. Hot biopsy forceps and balloon dilation were again used to dilate to a final diameter of 16 mm. A repeat upper GI study was completed three months later, without signs of obstruction. The second case is a nine-month-old male who presented to the GI clinic with difficulty tolerating introduction of solid food into his diet, with associated emesis of undigested food. No prior history of difficulty feeding with breast milk. An upper GI study showed abrupt narrowing of the second portion of the duodenum, representing a web or stenosis. He was admitted for upper endoscopy under general anesthesia in the operating room. The web was visualized just proximal to the second portion. Forceps were introduced into the opening of the web. Balloon dilation was then performed using a TTC dilator with mucosal disruption up to 8 mm, as shown here. A 5.8 millimeter scope was able to be passed through the cross-structured area after dilation. About one month later, the patient continued to have symptoms. He returned to the operating room for repeat upper endoscopy. The web was re-dilated with the balloon up to eight millimeters as shown here. Hot biopsy forceps were then used to excise the edges of the web opening prior to reinserting the balloon dilator with an opening up to 10 millimeters. Three weeks after excision, the patient returned again to the operating room where he underwent repeat upper endoscopy and further excision of the web with a triangle knife tip. The patient had resolution of his symptoms, and on re-visualization, the endoscope was successfully advanced to the third part of the duodenum. The third case is a girl who first presented at 4 weeks age with feeding intolerance and dehydration to the emergency room. There, she had an ultrasound pylorus performed without muscular thickening and had an abdominal x-ray that demonstrated gaseous distension of the stomach. After admission, an upper GI study was performed, which demonstrated findings consistent with gastric outlet obstruction. The patient was taken to the operating room for upper endoscopy under general anesthesia. On endoscopy, there was found a duodenal web in the first part of the duodenum with a one millimeter opening. Biopsy forceps were placed in the opening and used to dilate to two to three millimeters. The patient continued to be followed for weight gain and any signs of feeding intolerance. He continued to do well, and at nine months age, with sufficient growth, it was decided to perform web resection to aid in advancement of diet beyond purees. The patient was brought to the operating room for upper endoscopy under general anesthesia. Using a TTC balloon dilator, the aperture was dilated to nine millimeters. with evidence of mucosal disruption. A 5.8 mm scope was passed through to visualize the second part of the duodenum. Hot biopsy forceps were used to resect a portion of the edges of the duodenal web. All three patients are currently asymptomatic. They did require multiple procedures under general anesthesia, but had overall lower invasiveness of operation and shorter recovery times than with surgical repair. These cases add to the body of literature, demonstrating that endoscopic techniques are effective for repairing duodenal web. The second case further adds an example of additional endoscopic equipment used to help in cases with more challenging anatomy.

duodenal web

infants

obstruction

endoscopic techniques

asymptomatic