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X-ray showing pneumoperitoneum with positive Rigler's sign (arrows).
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Intraoperative picture showing omental bubble and cheesy deposits on the omentum.
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Intraoperative findings were of a grossly distended abdomen, significant pneumoperitoneum with the air trapped inside the omentum similar to a helium balloon (Fig. 2a), cheesy deposits between the leaves of the omentum, the anterior abdominal wall, lesser sac, anterior to and behind the mobilized second part of the duodenum, in the peripancreatic region and on the rest of the bowel loops (Fig. 2b).
(a) and (b) showing normal epiglottis and a laryngeal spur adjacent to it.
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Autopsy findings were of central and peripheral cyanosis, low set ears, a well formed tongue with a spur or valve like structure extending from the larynx but no choanal atresia or tracheoesophageal fistula (Fig. 3).
Autopsy picture showing cheesy deposits in the peri-splenic area.
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There was cerebral oedema and she had a large membranous VSD (1 cm in diameter), subtotal lung collapse with bronchopneumonia, annular pancreas, duodenal stenosis in D2, patent anastomosis of D1 to jejunum, cheesy infiltrates within the peritoneum and in the splenic area at the tail of the pancreas (Fig. 4).
Micrographs (a) (x400) and (b), (c) (x40). Cheesy granules showing necrotic pancreatic tissue with fat necrosis and inflammatory cell infiltrate consisting of histiocytes, polymorphonuclear cells and areas of fibrosis.
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Histology of the cheesy deposits was reported as necrotic tissue with fat necrosis and mixed inflammatory cells comprised of neutrophilic and histiocytic infiltrate (Fig. 5).
(a) Dilated pancreatic acini with inspissated secretions, oedema of the interstitial tissue and congested bloody vessels; (b) Section of the peritoneal deposit (globule) showing fat necrosis with inflammatory cell infiltrate consisting mainly of neutrophils.
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The body of the pancreas was otherwise normal with some areas of autolytic changes and vascular congestion (Fig. 6, Fig. 7).
(a) (b) and (c) Micrographs (x40) Pancreatic tissue surrounding the duodendum (annular pancreas) with fibrosis of the intestinal wall and occlusion of its lumen.
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There were cystic spaces in the liver and hypertrophy of the muscularis propria at the stenotic duodenum (Fig. 8).