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Newborn vomiting: Bilious

Newborn vomiting: Bilious. Joseph A. Iocono, M.D. University of Kentucky. Baby boy Ralph Upchurch. A 3 week-old boy is seen in the ED with a 4 hour history of emesis and dehydration. The baby was vibrant on arrival and placed in room V. What is your differential diagnosis?. Gastroenteritis

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Newborn vomiting: Bilious

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  1. Newborn vomiting:Bilious Joseph A. Iocono, M.D. University of Kentucky

  2. Baby boy Ralph Upchurch A 3 week-old boy is seen in the ED with a 4 hour history of emesis and dehydration. The baby was vibrant on arrival and placed in room V.

  3. What is your differential diagnosis?

  4. Gastroenteritis GERD Pyloric Stenosis Duodenal Atresia Malrotation/Volvulus NEC Formula Intolerance Annular Pancreas Esophageal Atresia Differential Diagnosis

  5. History What other points of the history do you want to know?

  6. Characterization of symptoms Temporal sequence Alleviating / Exacerbating factors: Pertinent PMH, ROS, birth history Relevant family hx. Associated signs and symptoms Consider the Following

  7. Baby boy Ralph Upchurch It’s now midnight, 6 hours later, and you are consulted STAT and told his initial abdominal exam was benign but over the last 4 hours he has become listless and his heart rate is now 190 bpm. The vomiting has not stopped and you notice that mom’s shirt has a greenish stain.

  8. Physical Exam What are you looking for on Physical Exam? Discuss NORMAL RANGE Vital Signs for a newborn

  9. Physical ExamWhat to look for • Vital signs: instability, respiratory distress, • Overall appearance: signs of dehydration, poor perfusion • Abdominal exam: peritonitis • Rectal exam: heme positive?

  10. Physical Exam, Ralph Upchurch • Vital signs: Temp. 99.8, Pulse 190, BP 75/30 Resp 45 • Appearance: Baby is sleepy, does not respond to blood draw • Resp: Shallow breath sounds • Abdomen: flat, hear groaning with exam

  11. What labs do you need?

  12. Would you like to revise your initial differential diagnosis?

  13. Laboratory studies • Type and Cross • CBC: • BMP: evaluate for acidosis • Blood gas: acidosis? • In infants venous and even capillary blood gases allow for determination of acid-base status

  14. Laboratory Values 16 19 132 98 20 359 92 48.2 0.9 3.8 12

  15. What do you think about the labs?

  16. What would you do now?

  17. Laboratory Values Discussion • Profound dehydration with metabolic acidosis. • Elevated WBC

  18. Interventions to Consider • ABCs • Start resuscitation • Fluid bolus • Proper bolus in newborn (20 ml/kg) • Other tests • X-ray? • Ultrasound? • Treatment now?

  19. Malrotation Testing • Upper GI - best test for malrotation. • Duodeno-jejunal junction is normally: • To the left of midline • Level with or superior to the pylorus • Located well posterior • Barium enemasuggestive, but not diagnostic • Ultrasoundmay show SMV/SMA reversal

  20. What would you do now?

  21. Ralph Upchurch • Operate or get more tests?

  22. Operative intervention • Indications • Unstable baby with peritonitis • Positive UGI • Treatment – Ladd’s procedure • Immediate counterclockwise rotation (usually 270 degrees or more) –then wait!! • Division of Ladd’s bands • Mesenteric widening • appendectomy

  23. Malrotation with Midgut Volvulus • A true surgical emergency ! • Due to abnormal rotation and fixation. • 50% of children with symptoms present within the 1st month. • Initial physical findings may be nonspecific. Initial radiographs are nondiagnostic, but may show gastric and proximal duodenal distention with minimal distal bowel gas. • Symptoms are due to either duodenal compression from Ladd’s bands or midgut volvulus. • Distention develops with midgut ischemia, ileus, acidosis, and shock.

  24. Malrotation with Midgut Volvulus “Bilious vomiting in a newborn is malrotation with midgut volvulus until proven otherwise”

  25. Anatomy of malrotation Normal Malrotation

  26. UGI Malrotation

  27. Mid-Gut Volvulus

  28. Summary

  29. QUESTIONS?

  30. Acknowledgment The preceding educational materials were made available through theASSOCIATION FOR SURGICAL EDUCATION In order to improve our educational materials wewelcome your comments/ suggestions at: feedbackPPTM@surgicaleducation.com

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