congenital duodenal obstruction is one of the most common congenital anomalies , accounting for almost half of cases of neonatal intestinal obstruction , its cause is either an intrinsic defect in the wall ( atresia , stenosis , or diaphragm ) or extrinsic compression due to malrotation , annular pancreas or preduodenal portal vein 1 
 2 
 3 . among all causes of congenital duodenal obstruction , congenital duodenal web ( cdw ) or diaphragm is uncommon and the second part of the duodenum is the most common location ( 85  %    90  % of cases ) , followed by the third and fourth parts of the duodenum 4 . complete or intact diaphragm is basically a duodenal atresia and perforated or fenestrated diaphragm is a subtype of duodenal stenosis 5 . before the mid-1980  s , surgery was the treatment of choice for congenital duodenal obstruction . however , with advances in therapeutic endoscopy , endoscopic procedures have become the preferred mode of treatment because of their simplicity , safety and reduced recovery time . to date , there has been a paucity of data on endoscopic treatment of cdw in pediatric patients . endoscopic balloon dilatation of cdw has been reported in just eight pediatric cases so - far 6 
 7 
 8 . here we report our experience with successful endoscopic balloon dilatation in three children with congenital duodenal web . in 2014 we diagnosed three cases of cdw on the basis of characteristics barium meal follow - through pictures and findings from upper gastrointestinal ( ugi ) endoscopy . the standard ugi scope ( outer diameter 8.8  mm , gif - q 180 , olympus , japan ) was used in all cases . all three patients were subjected to endoscopic balloon dilatation under conscious sedation with midazolam and ketamine . a through - the - scope ( tts ) controlled radial expansion balloon ( cre : microvasive , boston scientific corporation , natick , ma , usa ) was used and the starting size of the balloon was 8  mm for patients aged <  3 years and 10  mm for patients aged >  3 years . a balloon up to after inflation with saline , the balloon was kept in position across the diaphragm for 3 minutes and the procedure was repeated every 3 weeks until a patient became asymptomatic . the initial dilatation session was performed on an inpatient basis and subsequent dilatations were done as outpatient procedures . all three children presented late ( median age 8 years [ range , 2    9 ] ) with bilious vomiting , upper abdominal distension , and failure to thrive . stale food and bilious vomiting upper abdominal distension with visible peristalsis and borborygmi upper abdominal distension , borborygmi and pain abdomen upper abdominal distension ( post - prandial with visible peristalsis ) a 9-year - old boy presented with vomiting , abdominal distension , and failure to thrive that began at age of 3 months . he had a history of large - volume , projectile , bilious vomiting that occurred three to four times a week . he was born to a mother of advanced reproductive age . on examination , the child was emaciated ( table  1 ) and had phenotypic features of down syndrome . an abdominal ( erect ) x - ray showed a double bubble sign and barium meal follow - through ( fig .  1  a ) revealed narrowing in the second part of the duodenum with dilated proximal duodenum and stomach . ugi endoscopy showed a passable narrowing at the lower end of the esophagus with circumferential ulcers ( la - d gerd ) and hiatal hernia . there was a narrowing in the second part of the duodenum just distal to the ampulla , with a tiny hole at the center with proximal duodenal dilatation (  fig.1  b ) . endoscopic dilatation of duodenal web was done with a 10-mm cre balloon under fluoroscopic guidance ( fig . the distal duodenum was normal and narrowing was appreciated as a membrane ( suggestive of duodenal web ) . two more sessions of dilatation were done ( table  2 ) . at the same time , the child was started on a proton pump inhibitor for reflux esophagitis and peptic stricture . on follow up , the child s vomiting and distension had subsided , he began gaining weight and his esophageal ulcer healed . a barium meal follow - through in a 9-year - old boy showed grossly dilation of the first and proximal second parts of the duodenum due to a membrane . an 8-year - old girl presented with complaints of vomiting and failure to thrive since birth . she was having bilious vomiting two to three times per week with increased frequency of vomiting over the last 3 years . she also complained of pain and upper abdominal distension , which used to decrease after vomiting . on examination she had significant failure to thrive ( table  1 ) and her abdominal examination revealed epigastric distension . her abdominal x - ray ( erect ) showed a double bubble sign and barium meal follow - through (  fig . 2  a ) revealed narrowing in the second part of the duodenum with a dilated proximal duodenum . ugi endoscopy showed dilation of the first and proximal second part of duodenum and narrowing with a tiny lumen in the second part of duodenum just distal to the papilla ( fig . endoscopic dilatation of duodenal web was done with a 10-mm cre balloon dilator ( fig .  2  c ) under fluoroscopic guidance and the post - dilation appearance was the same as in patient 1 . after 3 weeks , dilatation was repeated with a 12-mm cre balloon , after that child s vomiting subsided , her abdominal distension decreased , and she started gaining weight . a barium meal follow - through of an 8-year - old girl showing duodenal obstruction with grossly dilation of the first and second parts of duodenum . b endoscopic image showing narrowing just distal to the ampulla with bulging ( bellowing ) of the membrane and a tiny lumen . c a balloon catheter passing through the lumen of diaphragm . a 2-year - old girl presented with a history of vomiting , failure to thrive , and upper abdominal distension for 6 months . the patient had wasting , stunting (  table  1 ) , and her abdominal examination revealed epigastric distension . 3  a ) showed narrowing in the second part of the duodenum with a dilated proximal duodenum . ugi endoscopy showed a membrane - like obstruction with a tiny opening in the second part just distal to the papilla ( the membrane was bellowing into the proximal dilated duodenum [ wind - sock ] due to reverse peristalsis , a characteristic picture of duodenal diaphragm ) (  fig . endoscopic dilatation of duodenal web was started with an 8-mm cre balloon ( fig . three more dilatation were performed at 3-week intervals ( table  2 ) , using progressively larger balloons , after which the child s vomiting subsided , her abdominal distension decreased , she started gaining weight . a barium meal follow - through of a girl aged 2 years and 3 months demonstrating duodenal obstruction with grossly dilation of the first and proximal second parts of the duodenum . b endoscopic image showing the duodenal diaphragm with a tiny central lumen . c endoscopic image showing roomy duodenal lumen proximal to the obstruction and the balloon catheter in situ . a 9-year - old boy presented with vomiting , abdominal distension , and failure to thrive that began at age of 3 months . he had a history of large - volume , projectile , bilious vomiting that occurred three to four times a week . he was born to a mother of advanced reproductive age . on examination , the child was emaciated ( table  1 ) and had phenotypic features of down syndrome . an abdominal ( erect ) x - ray showed a double bubble sign and barium meal follow - through ( fig .  1  a ) revealed narrowing in the second part of the duodenum with dilated proximal duodenum and stomach . ugi endoscopy showed a passable narrowing at the lower end of the esophagus with circumferential ulcers ( la - d gerd ) and hiatal hernia . there was a narrowing in the second part of the duodenum just distal to the ampulla , with a tiny hole at the center with proximal duodenal dilatation (  fig.1  b ) . endoscopic dilatation of duodenal web was done with a 10-mm cre balloon under fluoroscopic guidance ( fig . the distal duodenum was normal and narrowing was appreciated as a membrane ( suggestive of duodenal web ) . two more sessions of dilatation were done ( table  2 ) . at the same time , the child was started on a proton pump inhibitor for reflux esophagitis and peptic stricture . on follow up , the child s vomiting and distension had subsided , he began gaining weight and his esophageal ulcer healed . a barium meal follow - through in a 9-year - old boy showed grossly dilation of the first and proximal second parts of the duodenum due to a membrane . an 8-year - old girl presented with complaints of vomiting and failure to thrive since birth . she was having bilious vomiting two to three times per week with increased frequency of vomiting over the last 3 years . she also complained of pain and upper abdominal distension , which used to decrease after vomiting . on examination she had significant failure to thrive ( table  1 ) and her abdominal examination revealed epigastric distension . her abdominal x - ray ( erect ) showed a double bubble sign and barium meal follow - through (  fig .  2  a ) revealed narrowing in the second part of the duodenum with a dilated proximal duodenum . ugi endoscopy showed dilation of the first and proximal second part of duodenum and narrowing with a tiny lumen in the second part of duodenum just distal to the papilla ( fig . endoscopic dilatation of duodenal web was done with a 10-mm cre balloon dilator ( fig .  2  c ) under fluoroscopic guidance and after 3 weeks , dilatation was repeated with a 12-mm cre balloon , after that child s vomiting subsided , her abdominal distension decreased , and she started gaining weight . a barium meal follow - through of an 8-year - old girl showing duodenal obstruction with grossly dilation of the first and second parts of duodenum . b endoscopic image showing narrowing just distal to the ampulla with bulging ( bellowing ) of the membrane and a tiny lumen . a 2-year - old girl presented with a history of vomiting , failure to thrive , and upper abdominal distension for 6 months . the patient had wasting , stunting (  table  1 ) , and her abdominal examination revealed epigastric distension . .  3  a ) showed narrowing in the second part of the duodenum with a dilated proximal duodenum . ugi endoscopy showed a membrane - like obstruction with a tiny opening in the second part just distal to the papilla ( the membrane was bellowing into the proximal dilated duodenum [ wind - sock ] due to reverse peristalsis , a characteristic picture of duodenal diaphragm ) (  fig . endoscopic dilatation of duodenal web was started with an 8-mm cre balloon ( fig . three more dilatation were performed at 3-week intervals ( table  2 ) , using progressively larger balloons , after which the child s vomiting subsided , her abdominal distension decreased , she started gaining weight . a barium meal follow - through of a girl aged 2 years and 3 months demonstrating duodenal obstruction with grossly dilation of the first and proximal second parts of the duodenum . c endoscopic image showing roomy duodenal lumen proximal to the obstruction and the balloon catheter in situ . patients with complete - type duodenal web present early in the neonatal period with duodenal obstruction whereas the fenestrated type may present late . reports also exist of congenital duodenal web diagnosed in adulthood 5 
 9 . in our case series , all three patients presented late as they had the fenestrated type of web with recurrent bilious vomiting , abdominal distension , and failure to thrive . all three children had a web in the second part of the duodenum ( distal to the ampulla ) , which is the most common site of cdw formation 4 . multiple associated disorders like down syndrome , cardiac anomalies , malrotation of the gut , vertebral defect , renal anomalies etc . have been described with cdw 10 . in our series surgery , in the form of excision and duodenoplasty or bypass procedures like duodeno - duodenostomy and dudeno - jejunostomy used to be the conventional modality for treatment of cdw 2 
 3 . however , with the advent of endoscopic procedures for various gastrointestinal conditions , treatment with procedures such as endoscopic membranotomy with laser 11 , sphincterotome 12,high - frequency - wave snare / cutter 12 , hot biopsy forceps 4 , insulated - tip diathermic knife 13 and needle knife 14 have been reported . endoscopic therapy has become popular because it produces no abdominal incision ( scar ) , is not associated with complications such as adhesion development , involves shorter hospital stay , and the procedures sometimes can be performed without general anaesthesia . more invasive endoscopic procedures such as cutting the web with an electrocautery device or laser carry risks of perforation , excessive bleeding and trauma to the ampulla of vater . endoscopic dilatation , in contrast , is a relatively safe procedure with a reduced risk of the previously mentioned complications . endoscopic balloon dilatation produces tearing in the membrane of the diaphragm , which contains only mucosa and submucosa and lacks a muscular layer . the first endoscopic balloon dilatation of cdw , done with a 12-mm balloon catheter was reported by asabe et al 6 in 2008 in a 9-day - old boy . the dilatation was repeated at 30 and 51 days of life with 13-mm and 13.5-mm balloon catheters . mochizuki et al 7 reported another case of 7-month - old girl and , like us , they used a through - the - scope cre balloons measuring 10  mm , 12  mm , and 15  mm for proximal jejunal web . recently , huang et al 8 reported their experience with endoscopic balloon dilatation in a series of six cases involving children aged 2 to 37 months with cdw . they used 10-mm to 16-mm balloon catheters and with the exception of one child , all were treated only with balloon dilatation . one child required endoscopic electrocauterization of an obstructing membrane following balloon dilatation . in our series , we managed to treat all three patients with endoscopic balloon dilatation only . all of our patients became asymptomatic after two to four sessions of endoscopic dilatation and none developed any complications . in conclusion , duodenal diaphragm should be suspected in cases of abdominal distension with bilious vomiting in children , even those who are relatively older .
background and study aims : congenital duodenal web ( cdw ) is an uncommon cause of duodenal obstruction and endoscopic balloon dilatation has been reported in just eight pediatric cases to date . 
 here we are reporting three cases of cdw managed successfully with balloon dilatation . 
 cases and methods : in 2014 we diagnosed three cases of cdw on the basis of typical radiological and endoscopic findings . 
 endoscopic balloon dilatation was done under conscious sedation with a through - the - scope controlled radial expansion ( cre ) balloon . 
 results : all three children presented late ( median age 8 [ range 2    9 ] years ) with bilious vomiting , upper abdominal distension , and failure to thrive . 
 one of them had associated down syndrome and another had horseshoe kidney . in all cases , cdw was observed in the second part of the duodenum beyond the ampulla , causing partial duodenal obstruction . 
 after repeated endoscopic dilatation ( 2    4 sessions ) , all three patients became asymptomatic . 
 none of the patients experienced complications after balloon dilatation . 
 conclusions : duodenal diaphragm should be suspected in patients with abdominal distension with bilious vomiting , even in relatively older children . 
 endoscopic balloon dilatation is a simple and effective method of treating this condition .