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

Its 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 moms shirt has a greenish stain.

Physical Exam

What are you looking for on

Physical Exam?

Discuss NORMAL RANGE Vital Signs for a newborn

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?

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
16
20

359
48.
2

132

98

19

3.8

12

0.9

92

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 Ladds procedure

Immediate counterclockwise
rotation
(usually 270 degrees or more)
then wait!!
Division of Ladds 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 Ladds
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?

Acknowledgment
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