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A MCPIPA Clinical Pearl

Bilious vomiting in infants is a sign of mechanical obstruction of the gastrointestinal tract until proven otherwise. Immediate consultation with a pediatric surgeon or neonatologist is advised. This clinical pearl provides information on possible diagnoses, workup, and management.

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A MCPIPA Clinical Pearl

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  1. A MCPIPA Clinical Pearl Charles W. Breaux, Jr., MD, FACS Pediatric Surgery St. Mary’s Hospital Grand Junction, CO

  2. Intended Audience Pediatricians Family medicine physicians Emergency physicians Urgent care physicians PAs and NPs working with above physicians

  3. Clinical Pearl Bilious vomiting in an infant is an urgent surgical problem until proven otherwise.

  4. Discussion Spit-ups are quite common in healthy young infants. In addition, significant emesis of breast milk or formula is occasionally seen in normal babies. However, bilious emesis in an infant is mechanical obstruction of the GI tract until proven otherwise. Immediate consultation should be sought with a pediatric surgeon or neonatologist.

  5. Possible Significant Diagnoses Duodenal atresia or stenosis Intestinal malrotation +/- midgutvolvulus Jejunalor ileal atresia or stenosis Meconium ileus (with cystic fibrosis) Meconium plug syndrome Hirschsprung’s disease Imperforate anus.

  6. Workup Complete physical examination Plain abdominal x-ray film (UGI series) (Contrast enema) Other anomalies should be looked for, especially with known associated conditions (e.g., association of duodenal atresia with trisomy-21 and congenital heart disease)

  7. References • Moss RL, et al. Case Studies in Pediatric Surgery (McGraw-Hill, 2000). 8-11, 218-224 • Kimura K, Loening-Baucke V. Bilious vomiting in the newborn: rapid diagnosis of intestinal obstruction. American Family Physician. 2000 May 1; 61(9):2791-2798 • http://www.aafp.org/afp/2000/0501/p2791.html • Glass JG. Intestinal obstruction in the newborn: clinical presentation. Medscape.com • http://emedicine.medscape.com/article/2066380-clinical • Jones J, et al. Neonatal bilious vomiting. Radiopaedia.org • http://radiopaedia.org/articles/neonatal-bilious-vomiting

  8. Illustrative Cases WH JB

  9. WH – Presentation Born @ VVH on 6/3/2014 @ 0824 hrs GA 39-2/7 wk BW 3228 g Bilious emeses 6/4/2016 Transferred to SMH, arriving @ 2300 hrs

  10. WH – UGI Series (6/5/2014) Complete obstruction of mid duodenum

  11. WH – Contrast Enema (6/5/2014) • Normal distribution of hepatic flexure & transverse, descending, & sigmoid colon • Ascending colon rotated back on itself w/ cecum + appendix in midabdomen

  12. WH – Operation #1 (6/5/2016) Entire SB involved in midgut volvulus around very narrow mesentery SB torsed 720 deg & all black Ladd procedure – SB detorsion, lysis of Ladd’s bands, widening or mesentery, indicated appendectomy Proximal ½ of SB remained black, distal ½ dark red-purple

  13. WH – Operation #2 (6/6/2016) 2nd-look operation 1½ days later Proximal 85 cm (55%) SB clearly necrotic, distal 69 cm (45%) SB viable although not perfect Dead SB resected Primary end-to-end jejuno-ileostomy anastomsis

  14. WH – Postop Course TPN until 6/20/2014 Home 6/29/2014 D/C diet = Pregestimil 1 yr postop, wt 30th %’tile Persistently elevated liver transaminases NLB 6/23/2015 = mild inflammation + mild fibrosis of portal/periportal areas

  15. JB – Presentation Born @ SMH on 8/18/2016 @ 1528 hrs GA 40 wk BW 3958 g (8 lb 11.6 oz) Poor feedings + bilious emesis 8/19/2016 late afternoon

  16. JB – Initial KUB (8/19/2016) Air-distended loops of SB

  17. JB – Contrast Enema (8/19/2016) • Entire colon filled • Unable to reflux thru ICV • Meconium plugs evacuated

  18. JB – UGI Series (8/19/2016) Normal duodenal C-loop

  19. JB – KUB (8/20/2016) Persistently dilated SB loops

  20. JB – Contrast Enema (8/20/2016) • No residual meconium plugs • Contrast able to be refluxed thru ICV into nondilated distal ileum • Air-dilated SB loops above

  21. JB – Operation (8/21/2016) Tight stenosis over 2-3 cm of ileum 17 cm proximal to ICV Resection of stenoticileal segment End-to-end anastomosis

  22. JB – Operation (8/21/2016)

  23. JB – Postop course • Home 9/6/2016 (POD #16) • Wt 3615 g (7 lb 15.5 oz) • Office visit 9/19/2016 (POD #29) • Breast-feeding avidly w/o emesis • Lots of flatus + BMs • Wt 4050 g (8 lb 14.9 oz)

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