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Nonobstructive Antral Web: An Unusual Cause of Excessive Crying in an Infant

2000; Lippincott Williams & Wilkins; Volume: 31; Issue: 4 Linguagem: Inglês

10.1097/00005176-200010000-00020

1536-4801

Richard J. Noel, Michael Glock, Thomas Pranikoff, Ivor D. Hill,

Intestinal Malrotation and Obstruction Disorders

Crying is the primary means of communication for newborns and very young infants. Parameters for typical crying have been described, and crying that exceeds these sometimes poses a diagnostic dilemma for the physician. The differential diagnosis is extensive and includes potentially fatal conditions (1). We describe an additional cause for excessive crying in an infant who was found to have a nonobstructive antral web. Surgical resection of the web resulted in complete resolution of the symptoms. CASE REPORT A 2-month-old infant was referred for evaluation of excessive crying thought possibly to result from colic. The infant was the product of a full-term gestation and uncomplicated vaginal delivery with a birth weight of 3.4 kg. He began to have periods of inconsolable crying shortly after birth. He cried when he appeared to be hungry and would initially be placated on beginning a feed. After ingesting approximately 1 oz of formula, he would begin crying again, often with increased intensity, and would stop feeding. In an effort to get him to take in adequate nutrition, his parents developed a pattern of feeding him small amounts of formula at approximately hourly intervals whenever he was awake. Before referral, he had been seen on numerous occasions for his symptoms by more than one doctor with no abnormal physical findings noted. Changing his feeds from cow milk to soy-based formula and subsequently a semielemental formula, and treatment with diphenhydramine, simethicone, and finally paregoric had been to no avail. Although there was no history of overt emesis, he was treated empirically with ranitidine for presumed gastroesophageal reflux and peptic esophagitis without improvement. On examination, he cried constantly and could not be consoled. He was afebrile with normal vital signs. His weight and length were 4.5 kg (25th percentile) and 55 cm (10th percentile), respectively. He had normal morphologic features without jaundice or anemia. His anterior fontanel was large but flat. Auscultation of his chest was clear, and he had normal heart sounds. Results of the abdominal examination were normal, without organomegaly or palpable masses. Examination of his extremities showed no evidence of trauma or swelling. In an effort to determine the cause of his apparent discomfort, he underwent several investigations, including a urinalysis with microscopy and culture, a hemogram, an electrocardiogram, and a head magnetic resonance imaging scan; all the results were normal. A 24-hour pH probe study was negative for pathologic acid reflux. An upper gastrointestinal barium series was requested to exclude possible anatomic abnormalities such as paraesophageal or diaphragmatic hernias or intestinal malrotation. This demonstrated only a linear antral lucency consistent with a web (Fig. 1). The radiologist reported the infant was comfortable without crying just before administering the barium. However, after ingesting approximately 1 oz of barium, the infant started crying and continued to do so throughout the study. The contrast material passed easily through the antrum and pylorus to the duodenum, and there was no evidence of malrotation.FIG. 1.: Upper gastrointestinal series view of stomach demonstrating a linear lucency consistent with an antral web. Barium flows distally without evidence of significant obstruction. The study demonstrated otherwise normal anatomy.An upper gastrointestinal endoscopy was performed to confirm the presence of the web. An Olympus GIF N30 endoscope (Roswell, GA, U.S.A.) with a 5.3-mm outer diameter was used and confirmed the presence of an antral mucosal diaphragm with a central fenestration. The endoscope was passed without difficulty through the fenestration and advanced to the third part of the duodenum. All mucosal surfaces appeared normal, without evidence of inflammation. The parents and nursing staff subsequently reported that during the period the infant was kept nil per os (NPO) before the upper gastrointestinal barium study, and again before the upper gastrointestinal endoscopy, there was a noticeable reduction in crying. Because of this, it was decided to fast the infant and provide intravenous maintenance fluids overnight to observe the effect of not feeding. Once again, both the parents and nursing staff reported a decrease in the frequency and intensity of crying by the infant. On resuming feeds the next day, he reverted to his usual pattern of inconsolable crying. The strong temporal relationship between feeding and crying, plus the fact that the antral web was the only abnormality identified, led us to consider a causal relationship between the two. Although no such relationship had been described in an infant, there are several reports of older children experiencing early satiety and pain without vomiting secondary to nonobstructive antral webs. Because of this, and after considerable deliberation between the physicians and the infant's parents, it was decided that the web should be surgically excised. Surgical exploration revealed normal anatomy and no hernias. Passage of a nasoenteric tube failed to demonstrate any obstruction. A gastrotomy was made and the antral web was clearly visualized proximal to the pylorus. The web was excised submucosally and a pyloroplasty was performed before closure of the abdomen. The patient was initially kept NPO and received intravenous nutrition. An upper gastrointestinal series on the fourth postoperative day revealed no obstructions or extravasation of contrast. Small-volume clear liquids by mouth were started and progressively advanced. The infant initially cried again, but with markedly decreased intensity and frequency. On the fifth postoperative day, the infant was started on a hydrolyzed infant formula, which he tolerated without problems. The amount of crying observed and reported by the parents and nursing staff was markedly diminished. After discharge from hospital, the parents reported continued improvement, with minimal crying and a progressive increase in the volume of formula the infant could ingest with each feed. Three months after surgery, the infant no longer had any abnormal crying episodes, was tolerating at least 5 oz of formula per feed, and was demonstrating satisfactory growth. DISCUSSION Antral webs are thin, fenestrated diaphragms with bilateral mucosal surfaces lacking a supporting muscular layer; they are typically located 1 to 2 cm from the pylorus (2). Depending on the size of the fenestration, they have been associated with varying degrees of gastric outlet obstruction. First described in children in 1942 (3), the entity typically presents with persistent nonbilious vomiting in the newborn and very young infant. In the pediatric age group, the onset of symptoms is more common during infancy, and of 65 cases reviewed from the pediatric literature (2,4–16), 46 (70%) were newborns or infants at the time of diagnosis. In this young age group, vomiting, often projectile, is the primary symptom and resembles hypertrophic pyloric stenosis. In the older child, abdominal pain and early satiety are reported; vomiting may not be a feature. To our knowledge, excessive crying suggesting pain or discomfort has not previously been described as an initial symptom in infancy. The striking feature on presentation of this infant was the repetitive nature and intensity of the crying, for which no identifiable cause was found on physical examination. This prompted the series of investigations looking for other occult causes of pain, such as acid reflux with peptic esophagitis, intracranial lesions, and cardiac anomalies. The request for an upper gastrointestinal barium series was to exclude anatomic abnormalities, but the identification of an antral web was unexpected. Even with this knowledge, we were initially reluctant to attribute the crying to the antral web, because it did not appear to be causing any obstruction to gastric emptying, based on the free flow of barium into the duodenum. Endoscopy also revealed a fenestration large enough for a tube with a 5.3-mm outer diameter to traverse and allow clear visualization of the distal antrum, pylorus, and duodenum. With time, however, the strong temporal relationship between feeding and crying, plus the lack of any other abnormality, led us to consider the possibility that the web was the cause of discomfort. This possibility was supported by reports of early satiety and pain in older children resulting from nonobstructive antral webs. The mechanism for such pain is uncertain. The web may impair adaptive relaxation of the stomach, but this is speculative (17). Most patients with symptomatic antral webs have been treated with surgical excision. Endoscopic resection of webs with direct instrumentation has been described as an alternative to surgery in children (6). There are reports in which patients with antral webs causing primarily emesis have been treated nonsurgically with small, thickened feeds, with eventual resolution of symptoms (15). In contrast, others have found this form of therapy less satisfactory and have subsequently resorted to surgical excision (5). An additional consideration prompting some to recommend excision of the web is the documented persistence of symptoms over a period of time. In one report, an 11-year-old child who first had emesis in infancy later had persistent abdominal discomfort and early satiety that resolved with web resection (7). There is also the potential that the web may trap a foreign body, as occurred in a 6-year-old child with multiple episodes of apnea, apparently related to ingestion of a marble 1 month before he appeared for treatment (13). The decision to perform surgery in this infant was made only after considerable debate between all the parties concerned. In retrospect, it was the correct decision: the symptomatic response confirmed that the web was the cause of this infant's discomfort. After surgery, there was an immediate reduction in the frequency and intensity of crying, and thereafter the infant could tolerate larger volumes of feeds with no obvious discomfort. Although an antral web is probably an extremely unusual cause of pain in infants, it should be considered in the differential diagnosis of unexplained excessive crying in this age group.