Neonatal intestinal obstruction (NIO) is one of the most common surgical emergencies in pediatric surgery [1,2]. Recent estimates place the incidence at 1 in 2000 live births. The common causes include congenital malformations such as duodenal atresia or stenosis (DA/DS), annular pancreas (AP), Malrotation, JejunoIleal atresia or stenosis (JIA), simple or complicated meconium Ileus (MI), intestinal obstruction related to necrotizing enterocolitis (NEC), intestinal duplications, obstructive vitellointestinal disorders, colonic atresia or stenosis (CA), Hirschsprung’s disease (HD), Meconium plug syndrome, and small left colon syndrome [2,3]. In newborns with suspected JIA, thumb-sized intestinal loops (‘rule of thumb’) and airfluid levels (AFL) on a plain X-ray of the abdomen are highly suggestive of NIO. JIA are generally a single event (>90%); however, multiple atresias occur in 6-20% of patients mostly the proximal jejunum [4-6]. Multiple atresias, often having the appearance of a string of pearls, are associated with a foreshortened bowel length, prematurity, and a high mortality [4,7]. Herein we report a rare case of multiple jejunal atresia with multiple small bowel diverticuli and partial rotational anomaly of gut.

A 5 days old child presented to our emergency department with complain of abdominal distension, non passage of stool since birth and bilious vomiting. Child was full term, having birth weight of 1.5 kg with patent anal opening. On examination abdomen was grossly distended with visible bowel loops. Patient was managed by intravenous fluid resuscitation and after stabilization subjected to radiological investigation. Erect X ray abdomen shows thumb sized intestinal loops with multiple AFL (Figure 1). On surgical exploration there was multiple jejunal atresia along with multiple small bowel mesenteric diverticuli and partial rotational anomaly of gut (Figure 2). Resection and multiple anastomosis was performed.

Figure 1: X-ray erect abdomen: showing thumb sized intestinal loops with multiple air fluid levels suggestive of jejunoileal Atresia (JIA).

Figure 2: Intra-operative picture showing meconium filled multiple diverticuli on mesenteric border (small arrow) with multiple jejunal atresia (large arrow). Type 4 jejunal atresia with multiple diverticuli.