Purpose or Case Report: Educational goals: Highlight epidemiology, clinical presentation, radiographic findings, and treatment for common neonatal obstructions considered high in the intestinal tract including malrotation with midgut volvulus, duodenal atresia, duodenal web, annular pancreas, and proximal jejunal atresia.

Malrotation with midgut volvulus occurs when abnormally rotated and fixated small bowel twists about the superior mesenteric artery. This often presents with bilious vomiting in the first month of life and requires emergent surgical repair. Abdominal radiographs may be normal or show distention of the stomach and proximal duodenum with some distal bowel gas seen. An upper GI fluoroscopy exam (UGI) demonstrates a spiral/corkscrew sign or abrupt beaking with small bowel malrotation. Duodenal atresia is usually the result of incomplete recanalization of the duodenum. This presents at birth with abdominal distention and bilious or non-bilious vomiting depending on the segment of duodenum affected. Treatment is surgical resection of the atresia and reanastomosis. Classically on radiograph there is a double bubble sign, which may be seen on an antenatal ultrasound. Duodenal web results from an incomplete diaphragm/web within the lumen which causes intermittent complete or partial obstruction. There may be mild symptoms, or it may present similarly to duodenal atresia. It usually presents after the first week of life but may present in any age. Treatment is usually surgical or endoscopic resection. Abdomen radiographs may show mild proximal dilation or a double bubble sign distal bowel gas. UGI classically shows a windsock sign or duodenal dimple sign. Annular pancreas results from incomplete rotation of the ventral pancreatic bud leading to pancreatic tissue encasing the descending duodenum. The presentation and age of onset varies, in neonates and children it causes similar symptoms of duodenal obstruction. Cross-sectional imaging shows the duct draining the pancreatic head encircling the duodenum. Symptomatic cases of annular pancreas are usually treated surgically to alleviate obstructive symptoms. Jejunal atresia results from a vascular injury in utero causing one or more areas of stenosis/atresia. Proximal jejunal atresia presents with abdominal distention and bilious emesis. Abdominal radiographs classically show a triple bubble sign. Treatment is surgical resection of the involved segments of bowel.
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