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?

Differential Diagnosis

Gastroenteritis GERD Pyloric Stenosis Duodenal Atresia Malrotation/Volvulus

NEC Formula Intolerance Annular Pancreas Esophageal Atresia

History

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

Consider the Following

Characterization of symptoms

Temporal sequence Alleviating /

Exacerbating factors:

Pertinent PMH, ROS, birth history

Relevant family hx. Associated signs and

symptoms

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.

Physical Exam

What are you looking for on Physical Exam?

Discuss NORMAL RANGE Vital Signs for a newborn

Physical ExamWhat to look for

Vital signs: instability, respiratory distress, Overall appearance: signs of dehydration, poor

perfusion Abdominal exam: peritonitis Rectal exam: heme positive?

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

What labs do you need?

Would you like to revise your initial differential diagnosis?

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

Laboratory Values

132 98

3.8 12

16

48.2

359 9219

0.9

20

What do you think about the labs?

What would you do now?

Laboratory Values Discussion

Profound dehydration with metabolic acidosis.

Elevated WBC

Interventions to Consider

ABCs• Start resuscitation• Fluid bolus

• Proper bolus in newborn (20 ml/kg)

Other tests• X-ray?• Ultrasound?

Treatment now?

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 enema suggestive, but not diagnostic

Ultrasound may show SMV/SMA reversal

What would you do now?

Ralph Upchurch

Operate or get more tests?

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

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.

Malrotation with Midgut Volvulus

“Bilious vomiting in a newborn is malrotation with midgut volvulus

until proven otherwise”

Anatomy of malrotation

Normal Malrotation

UGI Malrotation

Mid-Gut Volvulus

Summary

QUESTIONS?

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