Qazi, Bilious vomiting and Volvulus

L ETTER T O T HE E D ITOR OPEN ACCESS

Bilious Vomiting and Volvulus: The Eyes Cannot See What the Mind Does Not Know

Abid Qazi

Dear Sir,

Neonates referred from various sources with single or

more episodes of bilious vomiting undergo radiological
investigation and ultrasound examination to exclude
malrotation and volvulus. Although many of these will
have a normal study and feed well afterwards or may
have other diagnoses, nevertheless, approximately 6 to
8% will need corrective surgery for malrotation [1,2].
Rarely an older child may present with similar symptoms.

A study suggested that even in developed world bilious

vomiting might go unrecognized by medical professionals
and parents. Green colour vomiting is single most
important symptom, which should lead to further
investigations [3]. It is expected that in Pakistan where
health care facilities are not well organized and
awareness about paediatric surgical diseases is lacking,
a significant hidden morbidity and mortality may be
associated with this condition.
The consequences of missed or delayed diagnosis can
be catastrophic, leading to long-term morbidity or
mortality. A typical newborn with malrotation and volvulus
present with bright green vomiting (fig. 1). It may be the
only symptom in early phase. At this stage bowel may be
completely viable. Later symptoms can be abdominal
distention, sudden collapse due to haemodynamic
instability or bleeding per rectum. A plain x-ray may be
suggestive due to unequal distribution of bowel gas.
However a normal x-ray does not rule out presence of
volvulus. An upper GI contrast with real time imaging by
an expert radiologist is quite diagnostic. Elements of
radiological diagnosis are position of duodenojejunal
junction in relation to spine. An obstructed or corkscrew
duodenum is suggestive of the presence of volvulus. A
contrast enema has been used in the past to assess
caecal position. If caecum is high and fixed towards the
midline, an indirect inference can be deducted about the
presence of malrotation. However a normal caecal
position cannot exclude malrotation. If in doubt ultrasound
imaging is usually complemented with contrast study to
assess the orientation of mesenteric vessels. Superior
mesenteric artery to the right of vein or a whirl pool
appearance is suggestive of malrotation and volvulus,
respectively.
APSP J Case Rep 2011; 2: 8
Figure 1: Typical dark green vomit often referred to as bilious
vomiting.
An unstable child with bilious vomiting and obvious
abdominal signs should not undergo any further
investigations as prompt surgical intervention is crucial to
save ischemic bowel. There is an apparent cost of
performing contrast study in majority of normal neonates
but comparing it to the cost of catastrophic loss of bowel,
long term requirement of parenteral nutrition, ongoing
surgical care, prolonged hospital stay and loss of life is
much more. Some of these late diagnosed children may
even require bowel and liver transplantation.
It is extremely important for all clinicians, nurses and
midwives to recognize bilious vomiting and understand
that green vomiting means mechanical obstruction unless
proved otherwise. It is our responsibility as paediatric
surgeons to spread the message to paediatricians,
obstetricians, midwives and general practitioners to
identify the bilious vomiting and significance of delay in
diagnosing volvulus.
REFERENCES
1. Godbole P, Stringer MD. Bilious vomiting in the newborn:
How often is it pathologic? J Pediatr Surg 2002;37:909-11.
2. Walker GM, Raine PA. "Bilious vomiting in the newborn:
how often is further investigation undertaken?" J Pediatr Surg
2007; 42:714-6.
3. Walker GM, Neilson A, Young D, Raine PA. Colour of bile
1
 Qazi, Bilious vomiting and Volvulus

vomiting in intestinal obstruction in the newborn: Corresponding author: ABID QAZI

questionnaire study. BMJ 2006;332:1363.
Address:

Department of Paediatric Surgery,

Leeds General Infirmary

UK, LS1 3EX

Email: abidqazi@me.com
Received on: 17-12-2010 Accepted on: 27-12-2010
http://www.apspjcaserep.com © 2011 Qazi,
This work is licensed under a Creative Commons Attribution 3.0
UnportedLicense

How to cite

Qazi A. Bilious vomiting and volvulus: the eyes cannot see what the mind does not know. APSP J Case Rep 2011;2:8

APSP J Case Rep 2011; 2: 8 2