Case presentation A 2600 g infant was born at 36-week gestation to an 18-year-old gravida 2, para 2 mother after an uncomplicated pregnancy. The amniotic fluid was meconium stained. Apgars were 8 at 1 min and 9 at 5 min. The child had vomiting with initial feeds, which worsened over the first 18 h and the abdomen became progressively distended. An upper gastrointestinal series ( Figure 1) and contrast enema ( Figure 2) were performed.
Denouement and discussionThe upper gastrointestinal series demonstrated atresia of the proximal bowel at the duodenojejunal junction. The enema demonstrated a malrotated microcolon in the anterior, lower mid abdomen. The presence of a microcolon with a proximal duodenal or jejunal atresia suggested at least a second more distal atresia or a more complex malformation. Attempts to reflux contrast into the terminal ileum beyond the ileocecal valve were unsuccessful. The patient was then taken to the operating room where a laparotomy disclosed a jejunal atresia just beyond the duodenojejunal junction and the absence of the dorsal mesentery except at the terminal ileum as it inserted into the cecum. The short segment of distal bowel was 'twisted' or spiraled just proximal to the cecum. Only 6 cm of distal small bowel were present. The terminal ileum was obstructed by a web-preventing passage of a catheter. This web was incised at enterotomy and the bowel was reanastomosed.Apple peel small bowel (APSB) is a disorder characterized by proximal jejunal or distal duodenal atresia, agenesis of the dorsal mesentery and variable parts of the distal small bowel, agenesis of the distal superior mesenteric artery and a malrotated microcolon. 1 The syndrome was named, however, after the appearance of the small bowel distal to the obstruction, which spirals in the abdomen like a continuous segment of cut apple peel. This spiral or helical appearance of the distal bowel can be seen on preoperative contrast