The double bubble sign

The double bubble sign in neonates is seen on plain abdominal radiographs in a variety of conditions. It represents gas distended dilated stomach and proximal duodenum, and implies congenital proximal bowel obstruction. A newborn with a double bubble and no distal bowel gas can be presumed to have duodenal atresia and in most cases no further imaging is required. If double bubble is present with distal bowel gas the differential diagnosis includes duodenal stenosis, duodenal web, annular pancreas and midgut volvulus. In these cases usually an upper GI contrast study is performed to distinguish between midgut volvulus which requires emergent surgery, and other causes which can be repaired electively.