The present case shows congenital duodenal web as a cause of intestinal obstruction in a term neonate. The neonate presented with intermittent bilious emesis and there was no significant abdominal distension at time of admission. Baby also passed meconium regularly. The bilious emesis was negligible while the baby was nil per oral and was more pronounced while baby was on feeds.

Gastrointestinal webs are not a very common cause of intestinal obstruction in neonates. Although it can occur anywhere along the gastrointestinal tract, the small intestine and stomach are the most common site of occurrence. Some authors consider intestinal webs, including duodenal, jejunal, and ileal webs, to be a type of intestinal atresia [3, 4]. The second portion of the duodenum is the most frequent site of intestinal webs (85–90% cases) followed by third and fourth part of duodenum [3, 5, 6]. Congenital duodenal web refers to complete or partial luminal blockage in the duodenum and arises from a membranous web or intraluminal diverticulum. Structurally, the web consists of mucosa and submucosa and lacks muscular layer [7]. Typically, a small opening is present at the centre of the duodenal web, which differentiates it from duodenal atresia. Although there is limited epidemiological information available regarding duodenal webs, they are believed to be less common, with an estimated incidence ranging from 1 in 10,000 to 1 in 40,000 [8].

A study spanning 32 years and examining 138 neonatal cases of duodenal obstruction revealed that vomiting was the most common symptom which was present in 90% of cases, and bilious vomiting in 66% of cases. Abdominal distension (25%), dehydration (24%), and weight loss (17%) were the other reported signs and symptoms [9]. More than half (56%) of the neonates developed symptoms within 24 h of birth. Plain abdominal roentgenograms were diagnostic in 58% of cases [9]. In our case although the baby exhibited repeated instances of bilious vomiting, abdominal radiographs reports were unremarkable. Sarin YK et al. have reported 18 cases of duodenal web and found that the average age of the presentation was around 8 days, with bilious vomiting being the most frequent symptom [7]. But, the classical radiographic signs of small intestinal atresia was not evident in all cases, similar to the index case. In another case series, the authors have discussed 12 cases of congenital duodenal web and noted that the first and second parts of the duodenum were the most frequently affected sites. However, our case presented a rare occurrence of duodenal web at the duodenojejunal flexure [10]. It is clear from the above discussion that congenital duodenal web, though less common, remains a differentials in suspected cases of small intestinal obstruction in neonate. Intermittent bilious vomiting may provide an additional clue and CT abdomen may be of help in such cases.

Gupta et al. have reported congenital duodenal web that were found near duodeno-jejunal flexure with good outcome in 2 out of 3 cases [6]. Webs at duodeno-jejunal flexure are always surgically challenging and at the same time poses a huge challenge to the treating neonatologist due to heightened risk of sepsis during post operative period.

The case we have presented is mostly one of the very few cases who have atypical presentation with the site of obstruction being at the duodenojejunal flexure, which itself is a rare site, There has been no recurrence any symptoms till now. The neonate is healthy during follow-up visit and has been growing well.