Dr_Mohamed Salama MRCPCH

Bilious Vomiting In The Newborn

Rapid Diagnosis Of Intestinal Obstruction

B ilious Vomiting In Newborns Is An Urgent Condition That Requires

The Immediate Involvement Of A Team Of Pediatric Surgeons And
Neonatologists For Perioperative Management.

However, Initial Detection, Evaluation And Treatment Are Often

Performed By Nurses, Family Physicians And General Pediatricians.

Bilious Vomiting, With Or Without Abdominal Distention, Is An Initial

Sign Of Intestinal Obstruction In Newborns.

A Naso- Or Orogastric Tube Should Be Placed Immediately To

Decompress The Stomach.

Physical Examination Should Be Followed By Plain Abdominal Films.

Dilated Bowel Loops And Air-Fluid Levels Suggest Surgical Obstruction.

Contrast Radiography May Be Required.

The Most Common Causes Of Neonatal Intestinal Obstruction Are.

Duodenal Atresia,
Midgut Malrotation And Volvulus,
Jejunoileal Atresia,
Meconium Ileus
Necrotizing Enterocolitis

When A Neonate Develops Bilious Vomiting, One Should Suspect A

Surgical Condition.

After A Focused Physical Examination, A Nasogastric Or Orogastric

Catheter Should Be Placed For Gastric Decompression To Prevent
Further Vomiting And Aspiration.

This Should Be Done Before Any Diagnostic Or Therapeutic Maneuvers

Are Performed.
 Dr_Mohamed Salama MRCPCH

Establishment Of An Intravenous Line Should Follow For Administration

Of Fluid,Electrolytes And Nutrition.

When The Patient Is Hemodynamically Stabilized, Appropriate Imaging

Studies Of The Abdomen Should Be Performed.

These Would Include Plain Abdominal Films And/Or Contrast Studies.

When Dilated Bowel Loops And Air-Fluid Levels Are Demonstrated, The
Diagnosis Of A Surgical Abdomen Is Suggested, And Urgent
Consultation With A Pediatric Surgeon Is Indicated, Preferably In A
Pediatric Surgical Center.

Gastric Decompression, Hydration And Secured Airway Must Be

Completed Before Initiating Transport Of The Patient

TABLE 1 Causes Of Intestinal Obstruction With Bilious

Vomiting In Neonates

Causes Of Intestinal Obstruction With Bilious Vomiting In

Neonates

Preoperati
Diagnosti ve
Age Of c Manageme Postopera
Type Of Cause Onset And Procedur nt Interval tive
Obstruct And Presentati e And Before Managem Prognos
ion Incidence ons Findings Surgery Treatment ent is

Duodenal Embryoge Few Hours Abdominal Nasogastric Diamond-Shaped No Oral Good

Atresia nic; Occurs After Birth; Film, Suction, IV Duodenoduodenost Intake, Unless
In 1 Per Bilious Double- Fluids; 24 To omy Nasogastric Associat
5,000 Live Vomiting, Bubble 48 Hours Suction; ed With
Births; No Sign Feeding At Serious
25% Have Distention 2 To 3 Days Anomali
Down After es
Syndrome Surgery

Malrotatio Incomplete At 3 To 7 Upper GI Nasogastric Ladd's Procedure; No Oral Good

n With Bowel Days; Spiral Sign Suction, IV May Require A Intake; Without
Volvulus Rotation Bilious On Fluid; STAT Second Laparotomy Nasogastric Bowel
Occurring Vomiting, Ultrasound Surgery For Suction Resectio
During 7th Rapid ; Abnormal Symptomati n,
To 12th Deteriorati Location c Patients, Difficult
Weeks Of on With Of The Within With
Gestation Volvulus Superior Daysfor Short-
 Dr_Mohamed Salama MRCPCH

Preoperati
Diagnosti ve
Age Of c Manageme Postopera
Type Of Cause Onset And Procedur nt Interval tive
Obstruct And Presentati e And Before Managem Prognos
ion Incidence ons Findings Surgery Treatment ent is

Mesenteric Others Gut

Vessels Syndrom
e After
Bowel
Resectio
n

Jejunoileal Mesenteric Within 24 Air-Fluid Nasogastric Resection(S) And No Oral Good

Atresia Vascular Hours Of Levels On Suction, IV Anastomosis(Es) Intake, Unless
Accident Birth; Abdominal Fluids; 12 To Nasogastric Excessiv
During Vomiting, Film 24 Hours Suction; e Loss Of
Fetal Life Abdominal Feeding At Bowel
In 1 Per Distention 2 To 4 Days
3,000 Live After
Births Surgery

Meconium Genetic, Immediatel Abdominal Decompress Enterostomy If Acetylcyste Depends

Ileus Occurs In y After Film; ion Complicated; ine On The
15% Of Birth; Distention, Gastrografin Enema (Mucomyst) Systemic
Newborns Abdominal Air-Fluid Plus IV Fluids , Pancreatic Problems
With Cystic Distention, Levels, Enzymes
Fibrosis, Bilious Sweat
And In 1 Vomiting Test,
Per 5,000 Ground-
To 10,000 Glass
Live Births Sign

Necrotizin Cause 10 To 12 Abdominal Nasogastric Resection Of Same As 25%

g Ileus Unknown Days After Film; Suction, IV Necrotic Bowel And Preoperativ Need
In 2.4 Per Birth; Distention, Fluids, Enterostomy e Surgery
1,000 Live Distention, Pneumatos Nutrition, Manageme (65%
Births Vomiting, is, Air In Antibiotics nt Survival
Bloody The Aortal For 10 Days. Rate)
Stools Vein When 75% Can
Perforated, Be
Immediate Treated
Surgery Medicall
y (95%
Survival
 Dr_Mohamed Salama MRCPCH

Preoperati
Diagnosti ve
Age Of c Manageme Postopera
Type Of Cause Onset And Procedur nt Interval tive
Obstruct And Presentati e And Before Managem Prognos
ion Incidence ons Findings Surgery Treatment ent is

Rate)

A) Duodenal Atresia:

1. Duodenal Atresia Is A Congenital Obstruction Of The Second

Portion Of The Duodenum.
2. Its Etiology Is Believed To Be Failure Of Recanalization Of This
Bowel Segment During The Early Gestational Stage.
3. The Pregnancy Is Associated With Polyhydramnios, As It Is In
Many Cases Where The Infant Is Subsequently Discovered To
Have An Intestinal Obstruction.
4. Duodenal Atresia Occurs In 1 Per 5,000 To 10,000 Live Births,
Involving Male Infants More Commonly Than Female Infants.
5. Down Syndrome Occurs In About One-Quarter Of These Patients;
Congenital Heart Disease Occurs In About 20 Percent Of Them.
6. Duodenal Atresia May Result In Either A Membranous Or
Interrupted-Type Lesion That Is Located At The Level Of The
Papilla Of Vater.
7. In 80 Percent Of These Patients, The Papilla Of Vater Opens Into
The Proximal Duodenum, Accounting For The Bilious Nature Of
The Vomiting.
8. Abdominal Plain Film Shows A Characteristic Double-Bubble
Sign, Demonstrating The Bubbles In The Stomach And The
Dilated Proximal Duodenum; This Confirms The Diagnosis
9. A Nasogastric Tube Should Be Placed For Continuous Suction Of
Gastric Contents, And Intravenous Fluid Administration Should Be
Started.
10. Surgery Is Required But Is Not Urgent. A 24- To 48-Hour
Delay May Be Allowed Before Operation For Transport, Further
Evaluation And Fluid Resuscitation.

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).
Dr_Mohamed Salama MRCPCH

A Diamond-Shaped
Duodenoduodenostomy Is The
Standard Procedure For The
Interrupted-Type Lesion. The
Membranous-Type Lesion Is
Treated Simply By Excision Of
The Obstructing Membrane. No
Gastrostomy Or
Transanastomotic Tube
Placement Is Required. The
Prognosis Is Excellent Unless
The Patient Has Associated
Serious Congenital Anomalies.

B) Midgut Malrotation
And Volvulus
1) Malrotation Of The Midgut Is An Anatomic Abnormality That
Allows The Midgut To Twist In A Clockwise Direction Around The
Superior Mesenteric Vessels To Obstruct And, Perhaps, Infarct The
Bulk Of The Small And Large Intestines.

2) Normally, The Third Portion Of The Duodenum Passes Behind The

Superior Mesenteric Vessels Along The Lower Margin Of The
Pancreas.

3) During Embryonic Life, The Colon And Small Bowel Grow Rapidly
And Extrude From The Abdominal Cavity.

4) During The Seventh Week Of Gestation, The Midgut Starts Being

Reduced Back Into The Abdominal Cavity.

5) The Bowel Then Settles Into The Abdominal Cavity And Rotates In
A Counterclockwise Direction (As Viewed From The Front), With
The Cecum Coming To Rest In The Right Lower Quadrant Of The
Abdomen.

6) This Process Is Completed By The 12th Week Of Gestation.

Dr_Mohamed Salama MRCPCH

7) For Unknown Reasons, However, In Patients With Midgut

Malrotation, The Rotation Ceases After The First 90 Degrees, And
The Duodenum And Ascending Colon Are Juxtaposed Around The
Superior Mesenteric Vessels, With The Entire Midgut Suspended
From This Narrow Axis.

8) The Malrotated Bowel Itself Does Not Cause Any Significant

Problem.

9) However, Because Of The Narrow Axis, The Midgut Can At Any

Time Twist Around The Axis, Perhaps Triggered By Peristaltic
Action.

10) The Tighter The Twist, The More The Midgut Suffers From
Obstruction Of The Lumen, Obstruction Of Venous And Lymphatic
Return From The Midgut, And Obstruction Of Arterial Inflow, Thus
Threatening Midgut Viability.

11) Unless It Is Treated In A Timely Manner, Bowel

Strangulation Results In An Ischemic Loss Of Extensive Bowel,
Causing The Short-Gut Syndrome.

12) Most Patients With Midgut Malrotation Develop Volvulus

Within The First Week Of Life. Bilious Vomiting Is The Initial
Symptom, But Abdominal Distention Is Not Remarkable.

13) The Bowel Can Be Involved In Strangulation At Any Time

And At Any Age. Once Midgut Ischemia Occurs, Unstable
Hemodynamics, Intractable Metabolic Acidosis And Necrosis With
Perforation Develop, Putting The Patient At Critical Risk.

14) A Malposition Of The Superior Mesenteric Vessels

Demonstrated By Ultrasound Examination Is Diagnostic. An
Upper Gastrointestinal (GI) Contrast Study May Show An
Obstruction At The Second Portion Of The Duodenum.

15) The Jejunum May Show A Spiral Configuration Lesser

Degrees Of Obstruction May Show As A Duodenojejunum That
Occupies The Right Hemi-Abdomen.
Dr_Mohamed Salama MRCPCH

16) Urgent Surgical Treatment Should Be Considered Once The

Diagnosis Is Established. Midgut Volvulus Is Associated With A
Mortality Rate Of 28 Percent. Elective Surgery Is Allowed In
Patients Who Were Incidentally Diagnosed By A Contrast Study
Performed For Some Other Reason.

Upper Gastrointestinal Contrast Study Demonstrating A Typical Spiral

Configuration Of Jejunum In A Patient With Volvulus Of The Bowel.

MANAGEMENT :

1) At Surgery, A Fibrous Band,

Called Ladd's Band, Is
Found To Extend From The
Retroperitoneum To The
Malpositioned Cecum, Across
The Anterior Aspect Of The
Second Portion Of The
Duodenum.

2) This Band Is Divided To Release The Duodenal Obstruction. The

Fused Intestinal Mesentery Must Be Dissected To Widen Its Axis
And Prevent Recurrence Of Volvulus.

3) During This Dissection, The Superior Mesenteric Vessels Are

Clearly Exposed And Must Not Be Injured.

4) When The Operation Is Performed In A Timely Manner, The

Prognosis Is Excellent.

5) If Extensive Bowel Is Ischemic Because Of The Volvulus, The

Bowel Is Untwisted And Simply Reduced Into The Abdominal
Cavity, And The Abdominal Wound Is Closed.

6) Twenty-Four Hours Later, The Abdomen Is Reentered For A

Second Look. At This Time, A Demarcation Is Visible Between
Necrotic And Viable Bowel, Which Allows The Surgeon To Resect
The Necrotic Bowel And Create An Enterostomy At The Distal End
Of The Normal Bowel. Bowel Reconstruction Is Performed In A
Later Operation.
Dr_Mohamed Salama MRCPCH

7) This Approach Can Salvage The Maximal Length Of Bowel And

Avoid Development Of The Short-Gut Syndrome.

8) Very Occasionally, Malrotation Of The Bowel Can Be Identified In

Older Patients Who Have Had Multiple Episodes Of Abdominal
Pain Of Undetermined Origin.

9) The Upper GI Contrast Study Is Helpful In Making This Diagnosis.

Prophylactic Surgical Treatment Should Be Recommended In This
Situation To Avoid A Potential Catastrophic Strangulation Of
Bowel Later.

C) Jejunoileal Atresia
1) Jejunoileal Atresia Is Caused By A Mesenteric Vascular Accident
During Fetal Life. Volvulus, Intussusception Or Internal Hernia
May Cause Infarction Of A Segment Of Fetal Intestine, As Shown
Experimentally In Animals.

2) Jejunoileal Atresia Is Classified Anatomically Into Four Types: (1)

Membranous, (2) Interrupted (3) Apple-Peel And (4) Multiple.

3) The Symptoms And Signs Are Identical Regardless Of The Type Of

Lesion.

4) Abdominal Distention With Bilious Vomiting Is Observed Within

The First 24 Hours After Birth.

5) The More Proximal The Lesion, The Earlier And More Serious Is
The Bile-Stained Vomiting.

6) Abdominal Films Show Air-Fluid Levels Proximal To The Lesion,

Confirming The Diagnosis Of Bowel Obstruction

7) In The Past, Barium Enema Was The Classic Diagnostic Study For
Jejunoileal Atresia, But It Is Not Necessarily Required Today For
Diagnosis, Because The Results Of The Barium Enema May
Appear Normal In Patients Whose Mesenteric Vascular Accident
Occurred Shortly Before Birth, Thereby Confusing The Diagnosis.
In Our Experience, Only 10 Percent Of Patients Required This
Study For Diagnosis.
Dr_Mohamed Salama MRCPCH

8) Preoperatively, Stomach Decompression, Intravenous Hydration

And Correction Of Any Electrolyte Disturbance Must Be Achieved.

9) An Interval Of 12 To 24 Hours Is Allowed For Pre-Operative

Preparation. At Surgery, A Different Surgical Strategy Is Indicated
For Each Type Of Lesion.

10) In General, Bowel Reconstruction Is Achieved By An End-To-

End (Or End-To-Side) Anastomosis (Or Anastomoses In Multiple
Atresias).The Prognosis Is Usually Good Unless Excessive Bowel
Resection Is Needed.

11) Meconium Peritonitis Is An Aseptic Peritonitis Caused By

Spillage Of Meconium Into The Abdominal Cavity During The
Development Of Jejunoileal Atresia. Extravasation Of Meconium
Causes An Intense Chemical And Foreign Body Reaction With
Characteristic Calcifications, Vascular Fibrous Proliferation And
Cyst Formation. Once The Diagnosis Has Been Established,
Preparation Is Required For Possible Excessive Blood Loss During
The Operation. Meconium Peritonitis Occurs Frequently In
Association With Meconium Ileus.
Dr_Mohamed Salama MRCPCH

D) Meconium Ileus
1. Meconium Ileus Is Characterized By Retention Of Thick Tenacious
Meconium In The Bowel (Ileum, Jejunum Or Colon), Which Results
In Bowel Obstruction.

2. In One Half Of Patients With Meconium Ileus, The Bowel Is Intact,

And Its Continuity Is Preserved.

3. The Other Patients Have Associated Volvulus, Jejunoileal Atresia,

Bowel Perforation And/Or Meconium Peritonitis.

4. Meconium Ileus Occurs In 15 Percent Of Newborns With Cystic

Fibrosis, And Only 5 To 10 Percent Of Patients With Meconium
Ileus Do Not Have Cystic Fibrosis.

5. The Involved Bowel Is Distended By Meconium Retention During

Fetal Life.

6. After A Few Hours Of Postnatal Life, Bowel Distention Becomes

Remarkable Because Of Swallowed Air And Causes Bilious
Vomiting.

7. In Some Cases, Meconium Retention May Cause

Dystociaproducing Abdominal Distention.

8. On Physical Examination, The Thickened Bowel Loops Are Often

Visible And Palpable Through The Abdominal Wall.

9. Remarkable Abdominal Distention, Tenderness And/Or Erythema

Of The Abdominal Skin Indicates Perforation, Which Requires
Immediate Surgery.

10. Rectal Examination Is Often Difficult, The Small Caliber Of

The Rectum Not Allowing The Examiner's Finger To Enter.

11. Mucus Plugs May Be Evacuated After Withdrawal Of The

Examination Finger.

12. The Plain Abdominal Films Show Distended Loops Of

Intestine With Thickened Bowel Walls. A Large Amount Of
Dr_Mohamed Salama MRCPCH

Meconium Mixed With Swallowed Air Produces The So-Called

Ground-Glass Sign, Which Is Typical Of Meconium Ileus.

13. Calcification, Free Air Or Very Large Air-Fluid Levels

Suggest Bowel Perforation, Which Requires Urgent Surgery.

A Contrast Enema Demonstrates A Microcolon . Reflux Of

Contrast Into The Ileum Demonstrates The Plugs, Which Are
Located In The Distal Small Intestine. The Small Bowel Is Of
Narrow Caliber Distal To The Meconium Plug And Dilated Proximal
To The Meconium Plugs.

Meconium Ileus.
Contrast Enema
Demonstrates A
Microcolon.

14) Patients With

Uncomplicated
Meconium Ileus May
Be Successfully
Treated With A
Diatrizoate Maglumine
(Gastrografin) Enema
Performed While Adequate Intravenous Fluid Is Being Administered.

The Hypertonicity Of The Radiopaque Agent (1,900 Mosm Per L) Draws

Fluid Into The Bowel To Facilitate Passage And Expulsion Of The
Tenacious Meconium.

This Treatment Is Successful In 16 To 50 Percent Of Patients.

15) When A Gastrografin Enema Is Unsuccessful, Laparotomy Is

Indicated To Evacuate The Obstructing Meconium By Enterotomy
Irrigation. I

16) Immediate Surgery Is Indicated In Patients With Complicated

Meconium Ileus. Bowel Resection For Perforation And/Or Obstruction
Related To Kinking Of The Bowel Is Indicated, Usually Requiring A
Temporary Enterostomy
Dr_Mohamed Salama MRCPCH

E) Necrotizing Enterocolitis
1. Necrotizing Enterocolitis Is A Rapidly Progressing Catastrophic
Disease Producing Extensive Bowel Necrosis, Infection And
Perforation In Newborns.

2. The Etiology Is Unknown, Although Several Likely Causes Have

Been Reported. Prematurity And Pulmonary Disorders Are
Common Predisposing Factors

3. The Usual Onset Is 10 To 12 Days Of Age, With Presenting

Symptoms Of Gastric Retention, Bilious Vomiting, Ileus,
Abdominal Distention And Bloody Stools.

4. Bradycardia, Hypothermia, Apneic Spells And Hypotension Are

Later Signs Of Progressive Deterioration.

5. Abnormal Hemorrhage, Hyperbilirubinemia And Oliguria Are Late

Findings.

Physical Findings

Include Erythema And Edema Of The Abdominal Wall,

Absence Of Bowel Sounds, Abdominal Distention,

Visible And/Or Palpable Loops Of The Bowel,

Guarding And Lethargy.

It Should Be Kept In Mind That Physical Findings Do Not Always

Or Accurately Reflect An Intestinal Catastrophe, Especially In A
Weak Premature Infant.

Abdominal Plain Films Taken At An Interval Of Six To Eight Hours

Initially And Daily In The Following Seven To 10 Days Are Helpful
In Diagnosis And Evaluation Of The Clinical Progress.

Distended Loops With Thickened Bowel Wall, Pneumatosis

Cystoides Intestinalis, Air In The Portal Vein And/Or Free Air Are
The Radiographic Findings
Dr_Mohamed Salama MRCPCH

Daily Change In Bowel Gas Pattern Is A Good Prognostic Sign

Because It Excludes Ileus And Bowel Necrosis.

Once The Diagnosis Is Made, Gastric Decompression And

Intravenous Administration Of Fluid And Antibiotics Should Be
Started.

Complete Blood Cell Count, Arterial Ph And Blood Gas

Determination, And Electrolyte Assays Are Mandatory.

Surgery Is Indicated When Free Peritoneal Gas Or Clinical

Deterioration Develop. Intractable Metabolic Acidosis And
Thrombocytopenia Are Also Critical Signs Of Bowel Ischemia,
Indicating Surgical Treatment.