1.  This is to state that the authors or the institution has not received any payment or services
of whatsoever nature from any third party whether government or private in relation to this
work.
 This is to state that there are no patents whether planned issued or pending that are
broadly relevant to this work.

2.  An atresia is defined as ‘a congenital absence of a body opening or body passage[1].
 Intestinal Atresia is a common cause of neonatal intestinal obstruction.[5]
 Lack of revacuolization is probable cause for most cases of duodenal atresia. [5]
 Jejunoileal atresias occur as a result of intestinal volvulus, intussusception, internal
hernia or strangulation in a tight gastroschisis or omphalocoele defect. [5]
 In a Retrospective study by Laura K Dalla Vecchia Karen W West et al. wherein a
population based sample of 277 neonates with intestinal atresia & stenosis treated from
July 1 1972 to April 30 1997, jejunoileal atresia was found in 128 out of 277 neonates
which included 61 females (48%) & 67 males (52%). [5]
 In this study additional atresias were noted in 3 patients in the colon & in 5 patients in
the duodenum. [5]
 However, no study has till date found triple atresias with imperforate anus in a female
newborm with Down’s syndrome.[5] This rarity and mode of presentation make it an
interesting case to be reported.

3.  G2P1L1 WITH 39 WEEKS GESTATION BY DATE WITH PREVIOUS LSCS BY USG 1- 37 WK 4 DAY; USG 2 37 WK 4 DAY; USH 3 36 WK 6
DAYS BLOOD GROUP B POSITIVE DELIVERED BY FULL TERM LSCS ON 3RD JUNE 2015 AT 11.15 AM WEIGHING 2.75 KGS AT BIRTH.
 BABY CRIED IMMEDIATELY AFTER BIRTH. RECEIVED IN CLEAN WARM LINEN CLOTHES AFTER WHICH ORONASAL SUCTIONING
DONE.
 UMBILICAL CORD CLAMPED AND CUT UNDER ASEPTIC PRECAUTION WHEREIN 2 ARTERIES AND 1 VEIN WAS FOUND.
 APGAR AT 1 MIN: 7 & AT 5 MIN: 8
 NGT WAS PASSED TILL STOMACH AND TRACHEO OESOPHAGEAL FISTULA WAS RULED OUT.
 HOWEVER, BABY WAS FOUND TO HAVE IMPERFORATE ANUS AT BIRTH
 BABY WAS EUTHERMIC AND EUHYDRATED
 VITALS: HR- 142/MIN RR 42/MIN PPWF PRESENT; CAPILLARY REFILL TIME LESS THAN 3 SEC.
 S/E- CVS- S1S2 NORMAL RS- AEBE; B/L CLEAR.; P/A TENSE NO T/G/R. ABDOMINAL DISTENSION PRESENT. CNS- TONE, REFLEX
(PALMAR GRASP, SUCKLING) ACCORDING TO GESTATIONAL AGE.
 ANTENATAL USG STOMACH, DUODENUM & PROXIMAL SMALL BOWEL LOOPS WERE DILATED WITH MAX. DIAMETER 2CM.
 POST NATAL USG RT. KIDNEY MEASURED 3.6CMX1.6 CM WITH E/O EXTRA RENAL PELVIS WITH ANTERO POSTERIOR DIAMETER 7
MM WITH MILD HYDRONEPHROSIS. LEFT KIDNEY 3.3 CMX 1.5CM IN DIAMETER. FLUID FILLED TRANSVERSE COLON 2.8 CM CALIBRE.
 2 D ECHO- SMALL PDA WITH LEFT TO RIGHT SHUNT 2 MM IN DIAMETER. SMALL ASD WITH LT. TO RT. SHUNT 2MM IN DIAMETER.
GOOD LV & RV FUNCTION.
 KARYOTYPING REVEALED TRISOMY OF CHROMOSOME 21.
 INTRA OP FINDINGS: A VERY RARE COMBINATION OF ANOMALIES WAS NOTICED. PATIENT HAD JEJUNAL WITH COLONIC WITH
RECTAL ATRESIA. THIS IS A RARE COMBINATION OF ANOMALIES IN A PATIENT WITH DOWNS SYNDROME WITH ANORECTAL
MALFORMATION.URETHRAL AND VAGINAL OPENING WERE DISTINCTLY PRESENT. AN ABNORMAL FISTULOUS RACT COULD NOT BE
DEMONSTRATED IN THE PERINEUM.
 INTRA OP APPENDIX WAS FOUND TO BE INFLAMMED AND HENCE APPENDICECTOMY WAS DONE.
 HPE REPORT OF ATRETIC SEGMENT OF COLON JEJUNUM & DUODENUM SHOWED NO SPECIFIC CELLULAR PATHOLOGY.
 Post operatively patient recovered well from general anaesthesia and was administered Inj ceftriaxone; Inj. Ranitidine & Inj. Paracetamol along
with IV fluids 0.45% NS & Isolyte P.
 Check dressing of wound as well as colostomy wound was done after 24 hours.
 RT aspirate was done 2 hourly and CVP was maintained
 Patient was transfused 2 points of FFP and 1 point of platelet post operatively.
 AG charting was maintained every 2 hourly.
 Input output charting was done every 12 hourly.
 However, patient did not survive and died on post operative day 2 as a result of cardio respiratory arrest due to pulmonary haemorrhage.

4. Figure 3: X-ray abdomen
erect on 3rd day of life after
surgery.
Figure 2: X-ray chest on
2nd day of life
Figure 1: X-ray Chest 1st day of life

5. Figure 4: Jejunal Atresia Figure 5: Colonic Atresia with malrotation
of gut
Figure 6: Colonic atresia with malrotation of gut Figure 7: Ileal atresia

6.  2 major theories regarding etiology of intestinal atresia are Tandler’s concept of
lack of revacuolization of solid cord stage of intestinal development and classic
study of Louw and Barnard suggesting a late intrauterine mesenteric vascular
accident is the cause of most jejunoileal and colonic atresias[3,4]
 Familial instances of jejunoileal and colonic atresias have also been observed
suggesting that genetics plays a part in these cases.[5]
 The first inguinal colostomy was performed in 1783 (2), but most infants died, and
colostomy was considered as a method of last resort.
 In a Retrospective study by Laura K Dalla Vecchia Karen W West et al. wherein a
population based sample of 277 neonates with intestinal atresia & stenosis treated
from July 1 1972 to April 30 1997, operative mortality for neonates with duodenal
atresia was 4% with jejunoileal atresia 0.8% and with colonic atresia 0%. [5]
 In this study 5% cases had imperforate anus associated with duodenal atresia ; 28%
cases malrotation was associated with duodenal atresia..; duodenal obstruction was
observed in prenatal ultrasonogramsi n 16% of neonates with duodenal atresia .
Jejuno ileal atresia with duodenal atresia was found 3.6% of cases.colonic atresia
was found 1.5 % of cases with duodenal atresia. Ladd Procedure with
appendectomy was performed in 28% of cases with malrotation of the gut. [5]
 However, this female newborn did not survive after under going ileal duodenal and
jejunal resection and anastomosis with appendectomy with colostomy inspite of
efforts in line with set protocols. However, the rarity and mode of presentation make
it an interesting case to be reported.

7. 1. Concise Medical Dictionary 8th edition. Oxford University Press, Oxford. 1980.
ISBN-13: 9780199557141:2-3
2. Littre A: Diverses observations anatomiques, histoire de l’acadamemie royale
de Science Paris, 1710.
3. Tandler J. Zur Entwicklungsgeschichte des Menschlichen Duodenum in
Fruhen Embryonalstadien. Morphol Jahrb. 1900;29:187-216
4. Louw JH, Barnard CN. Congenital Intestinal Atresia: Observations on its
origin. Lancet 1955;2:1065-1067
5. Ilaura K Dalla Vecchia Karen W West et al. ntestinal Atresia & Stenosis a 25
year experience with 277 cases Arch Surg. 1998;133:490-497