1. A MCPIPA Clinical Pearl
Charles W. Breaux, Jr., MD, FACS
Pediatric Surgery
St. Mary’s Hospital
Grand Junction, CO

2. Intended Audience Pediatricians Family medicine physicians
Emergency physicians
Urgent care physicians
PAs and NPs working with above physicians

3. Clinical Pearl
Bilious vomiting in an infant is an urgent surgical problem until proven otherwise.

4. Discussion Spit-ups are quite common in healthy young infants.
In addition, significant emesis of breast milk or formula is occasionally seen in normal babies.
However, bilious emesis in an infant is mechanical obstruction of the GI tract until proven otherwise.
Immediate consultation should be sought with a pediatric surgeon or neonatologist.

5. Possible Significant Diagnoses
Duodenal atresia or stenosis
Intestinal malrotation +/- midgut volvulus
Jejunal or ileal atresia or stenosis
Meconium ileus (with cystic fibrosis)
Meconium plug syndrome
Hirschsprung’s disease
Imperforate anus.

6. Workup Complete physical examination Plain abdominal x-ray film
(UGI series)
(Contrast enema)
Other anomalies should be looked for, especially with known associated conditions (e.g., association of duodenal atresia with trisomy-21 and congenital heart disease)

7. References
Moss RL, et al. Case Studies in Pediatric Surgery (McGraw-Hill, 2000). 8-11,
Kimura K, Loening-Baucke V. Bilious vomiting in the newborn: rapid diagnosis of intestinal obstruction. American Family Physician May 1; 61(9):
Glass JG. Intestinal obstruction in the newborn: clinical presentation. Medscape.com
Jones J, et al. Neonatal bilious vomiting. Radiopaedia.org

8. Illustrative Cases WH JB

9. WH – Presentation Born @ VVH on 6/3/2014 @ 0824 hrs GA 39-2/7 wk
BW 3228 g
Bilious emeses 6/4/2016
Transferred to SMH, 2300 hrs

10. Complete obstruction of mid duodenum
WH – UGI Series (6/5/2014)
Complete obstruction of mid duodenum

11. WH – Contrast Enema (6/5/2014)
Normal distribution of hepatic flexure & transverse, descending, & sigmoid colon
Ascending colon rotated back on itself w/ cecum + appendix in midabdomen

12. WH – Operation #1 (6/5/2016)
Entire SB involved in midgut volvulus around very narrow mesentery
SB torsed 720 deg & all black
Ladd procedure – SB detorsion, lysis of Ladd’s bands, widening or mesentery, indicated appendectomy
Proximal ½ of SB remained black, distal ½ dark red-purple

13. WH – Operation #2 (6/6/2016) 2nd-look operation 1½ days later
Proximal 85 cm (55%) SB clearly necrotic, distal 69 cm (45%) SB viable although not perfect
Dead SB resected
Primary end-to-end jejuno-ileostomy anastomsis

14. WH – Postop Course TPN until 6/20/2014 Home 6/29/2014
D/C diet = Pregestimil
1 yr postop, wt 30th %’tile
Persistently elevated liver transaminases
NLB 6/23/2015 = mild inflammation + mild fibrosis of portal/periportal areas

15. JB – Presentation Born @ SMH on 8/18/2016 @ 1528 hrs GA 40 wk
BW 3958 g (8 lb 11.6 oz)
Poor feedings + bilious emesis 8/19/2016 late afternoon

16. Air-distended loops of SB
JB – Initial KUB (8/19/2016)
Air-distended loops of SB

17. JB – Contrast Enema (8/19/2016)
Entire colon filled
Unable to reflux thru ICV
Meconium plugs evacuated

18. Normal duodenal C-loop
JB – UGI Series (8/19/2016)
Normal duodenal C-loop

19. Persistently dilated SB loops
JB – KUB (8/20/2016)
Persistently dilated SB loops

20. JB – Contrast Enema (8/20/2016)
No residual meconium plugs
Contrast able to be refluxed thru ICV into nondilated distal ileum
Air-dilated SB loops above

21. JB – Operation (8/21/2016)
Tight stenosis over 2-3 cm of ileum 17 cm proximal to ICV
Resection of stenotic ileal segment
End-to-end anastomosis

22. JB – Operation (8/21/2016)

23. JB – Postop course Home 9/6/2016 (POD #16)
Wt 3615 g (7 lb 15.5 oz)
Office visit 9/19/2016 (POD #29)
Breast-feeding avidly w/o emesis
Lots of flatus + BMs
Wt 4050 g (8 lb 14.9 oz)