Slide 1

Newborn vomiting:
Bilious

Joseph A. Iocono, M.D.
University of Kentucky


Slide 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.


Slide 3

What is your differential
diagnosis?


Slide 4

Differential Diagnosis






Gastroenteritis
GERD
Pyloric Stenosis
Duodenal Atresia
Malrotation/Volvulus






NEC
Formula Intolerance
Annular Pancreas
Esophageal Atresia


Slide 5

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


Slide 6

Consider the Following
 Characterization of
symptoms
 Temporal sequence
 Alleviating /
Exacerbating factors:

 Pertinent PMH, ROS,
birth history
 Relevant family hx.
 Associated signs and
symptoms


Slide 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.


Slide 8

Physical Exam

What are you looking for on
Physical Exam?

Discuss NORMAL RANGE Vital Signs for a newborn


Slide 9

Physical Exam
What to look for
 Vital signs: instability, respiratory distress,
 Overall appearance: signs of dehydration, poor
perfusion
 Abdominal exam: peritonitis
 Rectal exam: heme positive?


Slide 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


Slide 11

What labs do you need?


Slide 12

Would you like to revise your
initial differential diagnosis?


Slide 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


Slide 14

Laboratory Values
16
20

359
48.2

132

98

19

3.8

12

0.9

92


Slide 15

What do you think about the
labs?


Slide 16

What would you do now?


Slide 17

Laboratory Values Discussion

 Profound dehydration with metabolic acidosis.
 Elevated WBC


Slide 18

Interventions to Consider
 ABCs
• Start resuscitation
• Fluid bolus
• Proper bolus in newborn (20 ml/kg)

 Other tests
• X-ray?
• Ultrasound?

 Treatment now?


Slide 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 enema suggestive, but not
diagnostic
 Ultrasound may show SMV/SMA
reversal


Slide 20

What would you do now?


Slide 21

Ralph Upchurch
 Operate or get more tests?


Slide 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


Slide 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.


Slide 24

Malrotation with Midgut Volvulus

“Bilious vomiting in a newborn is
malrotation with midgut volvulus
until proven otherwise”


Slide 25

Anatomy of malrotation
Normal

Malrotation


Slide 26

UGI Malrotation


Slide 27

Mid-Gut Volvulus


Slide 28

Summary


Slide 29

QUESTIONS?


Slide 30

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION
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