article · International Journal of Surgery Case Reports
Intestinal atresia is a frequent cause of bowel obstruction in newborn infants. Type IIIb, known as Christmas tree or apple peel atresia, is an uncommon and severe form where the mesentery is absent and the distal bowel coils around a single artery. Intestinal malrotation is another developmental anomaly that risks bowel twisting and obstruction, and finding both conditions together is extraordinarily rare. A fifteen-day-old male infant presented with abdominal swelling, bilious vomiting, and high potassium levels. After imaging confirmed obstruction, surgery revealed the coiled ileal atresia alongside incomplete gut rotation. Surgeons removed the affected bowel sections and formed an ileostomy and colostomy. The infant recovered smoothly with working stomas, showing that prompt diagnosis and surgical care can achieve good outcomes.
Congenital bowel defects can rapidly become life-threatening in newborns due to severe obstruction or reduced blood supply. Because symptoms can mask multiple coexisting abnormalities, documented clinical management of rare dual anomalies helps paediatric surgeons recognise complex presentations early, guiding timely surgical decisions that prevent fatal complications such as volvulus or extensive bowel loss.
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BACKGROUND: Intestinal atresia is a common cause of neonatal intestinal obstruction. Type IIIb, also known as "Christmas Tree" or "Apple Peel" atresia, is a rare and severe variant characterized by the absence of the mesentery and a distal small bowel coiled around a single arterial vessel. Its incidence is low, accounting for 5-10 % of small bowel atresias. Intestinal malrotation, occurs due to failure of normal embryological gut rotation, is also rare and can predispose to volvulus and duodenal obstruction. The coexistence of both anomalies is extremely uncommon. CASE PRESENTATION: We report a 15-day-old-male neonate with progressive abdominal distension, bilious vomiting, and hyperkalemia. Abdominal radiographs showed features of small bowel obstruction, while ultrasound was inconclusive. Exploratory laparotomy revealed type IIIb ileal atresia with the classical "Christmas Tree" configuration and collapsed distal bowels. Additionally, incomplete intestinal rotation was identified with a free-floating cecum and right-sided duodenojejunal junction. Surgical resection of the distal collapsed ileum, cecum, and part of the ascending colon was performed, followed by creation of a double stoma (ileostomy and colostomy). The postoperative period was uneventful with good stoma function. DISCUSSION: This case highlights the diagnostic and surgical challenges posed by a rare dual congenital anomaly. The Christmas Tree pattern increases the risk of short bowel syndrome, while malrotation adds potential for volvulus. Early operative intervention is essential, especially in resource-limited settings. CONCLUSION: Clinicians must consider coexisting anomalies when evaluating neonatal intestinal obstruction. Prompt surgery and individualized management can lead to favorable outcomes even in complex cases.
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DOI: 10.1016/j.ijscr.2025.111948
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