Bilious Vomiting in the Newborn: Rapid Diagnosis of Intestinal Obstruction

TABLE 1
Causes of Intestinal Obstruction with Bilious Vomiting in Neonates
TYPE OF
OBSTRUCTION
CAUSE AND
INCIDENCE
AGE OF ONSET
AND
PRESENTATIONS
DIAGNOSTIC
PROCEDURE
AND
FINDINGS
PREOPERATIVE
MANAGEMENT
INTERVAL
BEFORE
SURGERY
TREATMENT
POSTOPERATIVE
MANAGEMENT
PROGNOSIS
Duodenal
atresia
Embryogenic;
occurs in 1
per 5,000 live
births; 25%
have Down
syndrome
Few hours after
birth; bilious
vomiting, no
distention
Abdominal
film, double-
bubble sign
Nasogastric
suction, IV fluids;
24 to 48 hours
Diamond-shaped
duodenoduodenostomy
No oral intake,
nasogastric
suction; feeding at
2 to 3 days after
surgery
Good unless
associated
with serious
anomalies
Malrotation with
volvulus
Incomplete
bowel
rotation
occurring
during 7th to
12th weeks
of gestation
At 3 to 7 days;
bilious vomiting,
rapid deterioration
with volvulus
Upper GI
spiral sign on
ultrasound;
abnormal
location of the
superior
mesenteric
vessels
Nasogastric
suction, IV fluid;
STAT surgery for
symptomatic
patients, within
daysfor others
Ladd's procedure; may
require a second
laparotomy
No oral intake;
nasogastric suction
Good without
bowel
resection,
difficult with
short-gut
syndrome
after bowel
resection
Jejunoileal
atresia
Mesenteric
vascular
accident
during fetal
life in 1 per
3,000 live
births
Within 24 hours of
birth; vomiting,
abdominal
distention
Air-fluid levels
on abdominal
film
Nasogastric
suction, IV fluids;
12 to 24 hours
Resection(s) and
anastomosis(es)
No oral intake,
nasogastric
suction; feeding at
2 to 4 days after
surgery
Good unless
excessive
loss of bowel
Meconium ileus Genetic,
occurs in
15% of
newborns
with cystic
fibrosis, and
in 1 per 5,000
to 10,000 live
births
Immediately after
birth; abdominal
distention, bilious
vomiting
Abdominal
film;
distention, air-
fluid levels,
sweat test,
ground-
glass sign
Decompression Enterostomy if
complicated;
Gastrografin enema
plus IV fluids
Acetylcysteine
(Mucomyst),
pancreatic
enzymes
Depends on
the systemic
problems
Necrotizing ileus Cause
unknown in
2.4 per 1,000
live births
10 to 12 days after
birth; distention,
vomiting, bloody
stools
Abdominal
film;
distention,
pneumatosis,
air in the
aortal vein
Nasogastric
suction, IV fluids,
nutrition,
antibiotics for 10
days. When
perforated,
immediate
surgery
Resection of necrotic
bowel and enterostomy
Same as
preoperative
management
25% need
surgery (65%
survival rate)
75% can be
treated
medically
(95% survival
rate)
IV = intravenous; GI = gastrointestinal.
FIGURE 1.
Upright abdominal film showing the characteristic double-bubble sign that confirms the diagnosis of duodenal atresia. Note the dilated stomach (thin arrow) and dilated proximal
duodenum (thick arrow).
FIGURE 2.
Upper gastrointestinal contrast study demonstrating a typical spiral configuration of jejunum in a patient with volvulus of the bowel.
FIGURE 3.
Interrupted-type bowel atresia. Continuity of the bowel is interrupted between the enlarged proximal bowel (right side of photo) and the atrophic distal bowel (left side of photo).
FIGURE 4.
Upright abdominal film showing distention of the bowel with multiple air-fluid levels suggesting lower intestinal atresia.
FIGURE 5.
Meconium ileus. Contrast enema demonstrates a microcolon.
FIGURE 6.
Abdominal film showing pneumatosis cystoides intestinalis in the right lower quadrant in a neonate with necrotizing enterocolitis.
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