Clinical Radiology (1992) 45, 208
Case Report: Duodenal and Jejunal Strictures Treated With Balloon Dilatation Through a Duodenostomy A. J. JOHNSTONE, G. M. A. H E N D R Y * and J. D. ORR
Department of Paediatric Surgery, Western General Hospital, and *Department of Radiology, Royal Hospital for Sick Children, Edinburgh An l 1-year-old girl with duodenal and jejunal strictures considered to be inaccessible for surgery was successfully treated using balloon dilatation under fluoroscopic control via a duodenostomy. This is the first reported paediatric case of small bowel stricture dilatation using a balloon catheter, and it is also the first report of the small bowel being approached fur balloon dilatation through a duodenostomy. This case demonstrates another use for balloon dilatation which appears to be a relatively safe and effective form of treatment for short, subacute strictures involving the gastro-intestinal tract. Johnstone, A.J., Hendry, G.M.A. & Orr, J.D.
(1992). Clinical Radiology 45, 208. Case Report: Duodenal and Jejunal Strictures Treated With Balloon Dilatation Through a Duodenostomy
CASE REPORT An 11-year-old girl was admitted as an emergency with a short history of severe abdominal pain. In the neonatal period she had undergone surgery to correct an oesophageal atresia with an associated tracheooesophageal fistula, and duodenal atresia. At 3 years of age she underwent a Nissen fundoplication to treat persistent gastro-oesophageal reflux, and was well from that time until her emergency admission 8 years later, On examination she had massive abdominal distension, and plain films revealed marked dilatation of her stomach and proximal duodenum. The serum amylase was markedly elevated at 5000 U/litre (normal range 60 180 U/litre), At laparotomy a perforation through an infarcted portion of the posterior wall of the second part of the d u o d e n u m was identified, the pancreas was inflamed, and areas of patchy ischaemia were noted throughout the small bowel without evidence of vascular insufficiency. A duodenostomy was performed and a retroduodenal drain inserted. She had a complicated post-operative course and for the first m o n t h was fed intravenously. During this period, contrast studies demonstrated remodelling of the duodenal loop with the exception of a 6 cm stricture extending from the third part of the d u o d e n u m into the proximal jejunum. Balloon dilatation of this stricture was performed via the duodenostomy, and once a suitable lumen had been established, the duodenostomy was used for enteral feeding. Unfortunately this was not successful and further contrast studies revealed multiple small bowel strictures distally. A second laparotomy was performed and an accessible segment of strictured small bowel was resected. Due to the presence of dense adhesions, it was not possible to approach the d u o d e n u m and proximal jejunum. Enteral feeding was again attempted without success and a persistent 2 cm long stricture in the proximal jejunum was demonstrated radiologically. This was treated with balloon dilatation and the diameter of the stricture was increased to 1.6 cm. Enteral feeding via the duodenostomy was reestablished and she improved steadily. She was discharged 3 months after admission on a combination of oral and enteral feeding, and required two further short admissions for dilatation of the stricture, increasing the diameter to 2.2 cm. Following this, the duodenostomy closed spontaneously and no further imaging has been necessary as she remains well 30 months later. Dilatation of the stricture was performed using a Cooks 10 m m arterial balloon in the first instance, and thereafter Cooks oesophageal balloons graded up to 2.2 cm in diameter.
DISCUSSION Balloon dilatation has been used successfully in recent years to treat children with oesophageal and colonic
strictures (Ball et al., 1983,
1985; Towbin,
1989).
Correspondence to: Mr A. J. Johnstone, Department of Paediatric Surgery, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU.
Recently, two cases have been reported where jejunal (Nealon et al., 1989) and duodenal (Williams and Palmer, 1991) strictures have been dilatated using enteral balloon catheters in adult patients with marked intra-abdominal adhesions, and Crohn's disease respectively. Endoscopy, fluoroscopy or occasionally a combination of both techniques are used to control the balloon catheter's position. Balloon dilatation is particularly useful in the treatment of short, subacute strictures before a significant degree of scarring has occurred. It is important to obtain good quality contrast films of the strictured region of bowel so that the correct size of balloon catheter can be chosen. Normally an inflation pressure of 303-606 kPa, using water-soluble contrast material, held for approximately 30 s is sufficient to dilatate the stricture. This manoeuvre may be repeated several times at each session provided that the bowel's diameter is steadily increasing and that there is no frank bleeding (Towbin, 1989). Further sessions are frequently required to achieve the desired luminal diameter. We believe that this case is unique for two reasons. First, balloon dilatation of the duodenum and jejunum was performed via duodenostomy, and second, duodenal and jejunal strictures have not, to our knowledge, been managed by balloon dilatation in children previously. Interventional radiology successfully treated a patient where surgery would have been technically difficult and would have carried a significant risk for the patient. REFERENCES Ball, WS, Kosloske, A M , Jewell, PF, Seigel, RS & Bartow, SA (1985). Balloon catheter dilatation of focal intestinal strictures following necrotising enterocolitis. Journal of Pediatric Surgery, 20, 637 639. Ball, WS, Seigel, RS, Goldthorn, JF & Kosloske, A M (1983). Colonic strictures in infants following intestinal ischaemia: treatment by balloon catheter dilatation. Radiology, 149, 469 472. Nealon, WH, Beauchamp, RD, Halpert, R & Thompson, JC (1989). Combined endoscopic and fluoroscopic balloon dilatation of a complex proximal jejunal stricture. Surgery, 105, I 13-I 16. Towbin, RB (1989). Pediatric interventional procedures in the 1980s: a period of development, growth, and acceptance. Radiology, 170, 1081 1090. Williams, A J K & Palmer, K R (1991). Endoscopic balloon dilatation as a therapeutic option in the management of intestinal strictures due to Crohn's disease. British Journal of Surgery, 78, 453 454,
Case Report: Duodenal and Jejunal Strictures Treated With Balloon Dilatation Through a Duodenostomy A. J. JOHNSTONE, G. M. A. H E N D R Y * and J. D. ORR
Department of Paediatric Surgery, Western General Hospital, and *Department of Radiology, Royal Hospital for Sick Children, Edinburgh An l 1-year-old girl with duodenal and jejunal strictures considered to be inaccessible for surgery was successfully treated using balloon dilatation under fluoroscopic control via a duodenostomy. This is the first reported paediatric case of small bowel stricture dilatation using a balloon catheter, and it is also the first report of the small bowel being approached fur balloon dilatation through a duodenostomy. This case demonstrates another use for balloon dilatation which appears to be a relatively safe and effective form of treatment for short, subacute strictures involving the gastro-intestinal tract. Johnstone, A.J., Hendry, G.M.A. & Orr, J.D.
(1992). Clinical Radiology 45, 208. Case Report: Duodenal and Jejunal Strictures Treated With Balloon Dilatation Through a Duodenostomy
CASE REPORT An 11-year-old girl was admitted as an emergency with a short history of severe abdominal pain. In the neonatal period she had undergone surgery to correct an oesophageal atresia with an associated tracheooesophageal fistula, and duodenal atresia. At 3 years of age she underwent a Nissen fundoplication to treat persistent gastro-oesophageal reflux, and was well from that time until her emergency admission 8 years later, On examination she had massive abdominal distension, and plain films revealed marked dilatation of her stomach and proximal duodenum. The serum amylase was markedly elevated at 5000 U/litre (normal range 60 180 U/litre), At laparotomy a perforation through an infarcted portion of the posterior wall of the second part of the d u o d e n u m was identified, the pancreas was inflamed, and areas of patchy ischaemia were noted throughout the small bowel without evidence of vascular insufficiency. A duodenostomy was performed and a retroduodenal drain inserted. She had a complicated post-operative course and for the first m o n t h was fed intravenously. During this period, contrast studies demonstrated remodelling of the duodenal loop with the exception of a 6 cm stricture extending from the third part of the d u o d e n u m into the proximal jejunum. Balloon dilatation of this stricture was performed via the duodenostomy, and once a suitable lumen had been established, the duodenostomy was used for enteral feeding. Unfortunately this was not successful and further contrast studies revealed multiple small bowel strictures distally. A second laparotomy was performed and an accessible segment of strictured small bowel was resected. Due to the presence of dense adhesions, it was not possible to approach the d u o d e n u m and proximal jejunum. Enteral feeding was again attempted without success and a persistent 2 cm long stricture in the proximal jejunum was demonstrated radiologically. This was treated with balloon dilatation and the diameter of the stricture was increased to 1.6 cm. Enteral feeding via the duodenostomy was reestablished and she improved steadily. She was discharged 3 months after admission on a combination of oral and enteral feeding, and required two further short admissions for dilatation of the stricture, increasing the diameter to 2.2 cm. Following this, the duodenostomy closed spontaneously and no further imaging has been necessary as she remains well 30 months later. Dilatation of the stricture was performed using a Cooks 10 m m arterial balloon in the first instance, and thereafter Cooks oesophageal balloons graded up to 2.2 cm in diameter.
DISCUSSION Balloon dilatation has been used successfully in recent years to treat children with oesophageal and colonic
strictures (Ball et al., 1983,
1985; Towbin,
1989).
Correspondence to: Mr A. J. Johnstone, Department of Paediatric Surgery, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU.
Recently, two cases have been reported where jejunal (Nealon et al., 1989) and duodenal (Williams and Palmer, 1991) strictures have been dilatated using enteral balloon catheters in adult patients with marked intra-abdominal adhesions, and Crohn's disease respectively. Endoscopy, fluoroscopy or occasionally a combination of both techniques are used to control the balloon catheter's position. Balloon dilatation is particularly useful in the treatment of short, subacute strictures before a significant degree of scarring has occurred. It is important to obtain good quality contrast films of the strictured region of bowel so that the correct size of balloon catheter can be chosen. Normally an inflation pressure of 303-606 kPa, using water-soluble contrast material, held for approximately 30 s is sufficient to dilatate the stricture. This manoeuvre may be repeated several times at each session provided that the bowel's diameter is steadily increasing and that there is no frank bleeding (Towbin, 1989). Further sessions are frequently required to achieve the desired luminal diameter. We believe that this case is unique for two reasons. First, balloon dilatation of the duodenum and jejunum was performed via duodenostomy, and second, duodenal and jejunal strictures have not, to our knowledge, been managed by balloon dilatation in children previously. Interventional radiology successfully treated a patient where surgery would have been technically difficult and would have carried a significant risk for the patient. REFERENCES Ball, WS, Kosloske, A M , Jewell, PF, Seigel, RS & Bartow, SA (1985). Balloon catheter dilatation of focal intestinal strictures following necrotising enterocolitis. Journal of Pediatric Surgery, 20, 637 639. Ball, WS, Seigel, RS, Goldthorn, JF & Kosloske, A M (1983). Colonic strictures in infants following intestinal ischaemia: treatment by balloon catheter dilatation. Radiology, 149, 469 472. Nealon, WH, Beauchamp, RD, Halpert, R & Thompson, JC (1989). Combined endoscopic and fluoroscopic balloon dilatation of a complex proximal jejunal stricture. Surgery, 105, I 13-I 16. Towbin, RB (1989). Pediatric interventional procedures in the 1980s: a period of development, growth, and acceptance. Radiology, 170, 1081 1090. Williams, A J K & Palmer, K R (1991). Endoscopic balloon dilatation as a therapeutic option in the management of intestinal strictures due to Crohn's disease. British Journal of Surgery, 78, 453 454,
