Neonatal Bilious Emesis

1. Neonatal Bilious Emesis David Kuykendall, MD UNSOM 2013

2. Bilious Vomiting in the Newborn • An urgent condition that should be recognized early • Usually requires: pediatric surgeons and neonatalogists • Key is early detection and evaluation • Specific Differential: • likely caused by gastrointestinal obstruction • obstruction must come distal to the Ampulla of Vater

3. History and Physical • Take a good history • OLDCARTS, nutritional/hydration status, course of disease, etc. • Physical examination • Distention • Pain (poor feeding, fussiness, etc.) • Hypotension and Fever • Palpable or visual bowel loops • Erythema and tenderness of abdominal skin (perforation) • Verify Bilious Emesis • Nursing staff, parental staff, output from NG Tube, etc.

4. Initial Steps of Management • Nasogastric/Orogastric tube should be placed immediately to decompress stomach • Establish IV access for fluid, electrolytes, and/or nutrition • Acute Abdominal Series (plain films): Including upright and supine views • Dilated loops of bowel and air-fluid levels suggest “surgical abdomen” and immediate pediatric surgery consultation should be obtained • Free air in abdomen or free fluid in pelvis suggest need for EMERGENT SURGERY • Contrast Radiography may be needed for diagnosis

5. Radiography • In all abdominal films must write to include pelvis in ALL abdominal views • Helps visualize transition points • Portions of GI involvement

6. Bilious Emesis in Newborn • Duodenal Atresia • MidgutMalrotation • JejunoilealAtresia • Volvulus • Meconium Plug/Ileus • Necrotizing Enterocolitis • Other unlikely conditions to present in Newborn but worth consideration: • Hirschprung’s Disease • Annular Pancreas • Organomegaly (various causes: parasites, rheumatologic, etc.)

7. Duodenal Atresia • Congenital absence or complete closure of the lumen of the duodenum • Epidemiology: 1 in every 5,000-10,000 Births • 20-40% of cases are associated with Down Syndrome • Causes polyhydramnios during pregnancy and bilious emesis in newborns • “Double Bubble Sign”: Visualized air lumen of distended stomach and distended duodenum separated by pyloric sphincter • Often presents in first 24 hours of life • Treatment: Surgery (Duodenoduodenostomy) • Can be performed open or laprascopically • Prognosis is good • Few long term complications (mortality 6%)

8. MidgutMalrotation/Volvulus • Congenital Anomaly involving malrotation of Midgut • Rotation in a clockwise (normally counterclockwise) fashion around the superior mesenteric vessels • Obstruction in midgut and possible infarction • MUST BE CORRECTED IMMEDIATELY • Infarction common: May necessitate bowel resection • Manifests commonly as volvulus within first week of life • Abdominal Distention usually absent • Metabolic Acidosis, hypotension, free air suggest ischemia • Diagnosis: Malposition of mesenteric vessels on abdominal ultrasound • Upper GI contrast study usually needed to make diagnosis • Once diagnosis is made urgent surgery should be performed • Treatment: Surgery (Exploratory Laparotomy) • Usually involves release of Ladd’s Band to release fibrous bands causing obstruction (fibrous bands extending from duodenum to retroperitoneum) • Prognosis is excellent if performed in timely manner • Usually requires a “second look” surgery 24 hours following initial operation for small bowel follow through to detect any necrotic/ischemic bowel • Shown to maximize length of viable bowel and improved prognosis

9. JejunoilealAtresia • Caused by mesenteric vascular accident during fetal life • Volvulus, intussusecption, or intestinal herniation may cause infarction of a segment of small bowel during fetal life • Four anatomical Classifications: Membranous, Interrupted, Apple-peel, Multiple • All present identically • Abdominal distention with bilious vomiting in first 24 hours of life • Complication: Meconium Peritonitis • Caused by spillage of Meconium into abdominal cavity • Constant pain/fussiness, fever, hypotension, guarding, firm abdomen • Diagnosis: plain abdominal radiography • Dilated small bowel and air-fluid levels proximal to obstruction • Treatment: Surgery • Surgical approach varies by each case • bowel resection with primary anastamosis usually involved • Prognosis is poor: increasingly poor with length of bowel resected.

10. Meconium Plug/Ileus • Retention of meconium in bowel which causes obstruction • Associated with: Malrotation, Atresia, Volvulus, Bowel Perforation, and Peritonitis • Occurs in 15% of CF patients • Only 5-10% of patients with meconiumileus don’t involve CF as a primary diagnosis • Presents as abdominal distention and bilious emesis • Can palpate loops of distended bowel through the abdomen • Tenderness and erythema of abdominal skin indicates perforation and peritonitis: Needs emergent surgery • Diagnosis: Abdominal radiography • Ground Glass Sign: meconium mixed with swallowed air • Contrast enema may show Microcolon: reflux of contrast into ileum distal to meconium plug

11. Meconium Plug/Ileus • Treatment: Most patients respond to Gastrograffin Enema • Gastrograffin works by drawing substantial fluid into lumen of colon which helps expel meconium plug • Gastrograffin enema “diagnostic and therapeutic” • Successful in rates 16-50% (various sources) • If unsuccessful: • Surgery indicated for laparotomy • Signs of perforation and peritonitis require immediate surgical evaluation

12. Necrotizing Enterocolitis • Rapidly progressing infection often involving bowel necrosis and perforation • Etiology unknown; decreased blood flow, bacterial in wall of bowel, decreased mucus production • Major risk factors: Prematurity and Pulmonary disorders • Onset typically 10-12 days of age • Presents: abdominal distention, bilious emesis, bloody stools, and +/- Fevers • Bradycardia, hypothermia, apneic spells and hypotension are later signs of progressive deterioration. • Hemorrhage, hyperbilirubinemia and oliguria are late findings • Exam Findings: Erythema and edema of abdominal wall, absence of bowel sounds, palpable/visible loops of bowel, guarding, lethargy (poor tone and activity) • May manifest poorly in premature infants • Diagnosis: Abdominal films done serially every 6-8 hours initially and daily for 7-10 days to measure progression • Distended loops with thickened bowel wall, pneumatosisintestinalis, air in the portal vein and/or free air are common radiographic findings • Daily bowel gas pattern changes are a good prognostic indicator • CBC, arterial pH, blood gas, and electrolytes should be obtained • Intractable metabolic acidosis and thrombocytopenia are also critical signs of bowel ischemia, indicating surgical treatment

13. Necrotizing Enterocolitis • Most cases can be managed medically • gastric decompression and intravenous administration of fluid, nutrition and antibiotics for 10 days • Successful in majority of cases: vary by institution and treatment protocols • Surgery • Enterostomy to divert fecal stream • Rates vary by institution

14. Hirschsprung's disease • Developmental disorder involving failure of migration of neural crest cells to the large intestine • Results in absence of mesenteric plexus which regulate stool motility and activity • Causes condition called congenital aganglionicmegacolon • Occurs in 1 in every 50,000 child births • More common in boys • Presents with megacolon, abdominal distention, constipation: • Not commonly diagnosed in newborns • Common sign in newborns is failure to pass stool • 1% of affected newborns will fail to pass meconium/stool • Diagnosed most commonly in 8-10 year old range • Diagnosis: Biopsy of colon showing absence of mesenteric plexus • Treatment: Colon resection of affected areas of bowel

15. Annular Pancreas • Rare condition where second portion of the duodenum is obstructed by a ring of malformed pancreatic tissue • occur in 1 out of 12,000 to 15,000 newborns • Usually not full obstruction, shows narrowing of lumen • Due to partial obstruction usually diagnosed much later in life • More commonly diagnosed in adulthood than childhood • May present as pancreatitis • Associated with Down Syndrome • Diagnostic imaging: Abdominal radiography, CT, upper and lower GI series • Treatment: Surgical • Bypass obstruction of duodenum with duodenumduodenotomy or laprascopicgastrojejunostomy

16. Organomegaly • Neoplastic • POEMS (plasma cell syndrome) • Metabolic, Storage Diseases • Amyloidosis • Gaucher’s Disease • Hunter’s Mucopolysaccharidosis • Genetic • Beckwith-Wiedemann Syndrome • Lipodystrophy • Endocrine • Gigantism (Acromegaly in adults) • Infectious • Various (parasites, bacterial, viral, etc.)

17. Organomegaly • Increases in organ (bowel, colon, esophagus) disturb its ability to maintain normal motility • This can cause obstruction at the levels of affected organs which can lead to bilious emesis • Diagnosis: Similar workup to previously discussed disease states • Management: Fluid and electrolytes, NGT for decompression of the stomach, pediatric surgeon consultation • Treatment: Treat underlying cause • Surgery for perforation, resection, etc.

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