bilious vomiting

Bilious Vomiting in the Newborn

Dr. Ali M AhmadMBBCh, MS, MD, MRCS-Ed, EBPS

Associate Consultant Pediatric Surgery; KAAUH_ PNU

Bilious vomiting in newborns- an urgent condition that requires the immediate involvement of a team of pediatric surgeons and neonatologists

Bilious vomiting, with or without abdominal distention, is an initial sign of intestinal obstruction in newborns.

Sequelae of a missed diagnosis can be fatal

INTRODUCTION

Neonatal bilious emesis is a surgical emergency

until proven otherwise

INTRODUCTION

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

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

INTRODUCTION

Abdominal plain film evaluation may show evidence of upper GI tract obstruction with dilatation of the stomach or small bowel to a point of obstruction

Sometimes Plain films that show bowel obstruction may obviate the need for further imaging.

Negative plain films suggest the need for further evaluation

Abdominal Plain Film

Many authors prefer the contrast upper GI series

A few authors have discussed the use of low-osmolarity contrast agents for extremely ill or very premature infants or those with bilious vomiting

These contrast agents are used to evaluate the stomach, the egress of its contents through the pylorus and into the duodenum, and the course of the duodenum to the ligament of Treitz

Contrast Upper Gastrointestinal Series

Other authors have pointed out that US, with water used as a contrast agent, can be highly successful in imaging gastric emptying, GER, and duodenal abnormalities, including midgut volvulus

The major difficulty for some radiologists with regard to the use of US is that its success depends on the skill of the operator.

Both the contrast UGI series and the fluid-aided US examination can reveal the dilated small bowel proximal to an atresia or stenosis and the beaked or twisted point of obstruction of the proximal small bowel in cases of midgut volvulus.

Contrast Upper Gastrointestinal Series

Abnormalities of the lower GI tract that may be causes of bilious vomiting may be demonstrated by barium enema.

The use of barium enema for the analysis of malrotation is less direct than analysis by UGI series

Contrast Enema

Despite the fact that: Only 20% had midgut volvulus. 69% of cases having an idiopathic or transient cause 11% having a lower gastrointestinal cause.

The requirement to treat bilious vomiting as an emergency is valid

Malrotation of bowel Volvulus Intestinal atresia Intestinal stenosis Meconium ileus Meconium plug Hirschsprung disease Imperforate anus Incarcerated hernia

Causes Of Bilious Vomiting In Newborns

1 -Obstruction Causes

Necrotizing enterocolitis Paralytic ileus Peritonitis Milk allergy

2-Gastrointestinal disorders

Other Causes Of Bilious Vomiting In Newborns

Sepsis Meningitis

3-Infectious disorders (nongastrointestinal)

Kernicterus Subdural hematoma Cerebral edema Hydrocephalus

4-Neurological disorders

Inborn errors of metabolism: Urea cycle defects, galactosemia,

Congenital adrenal hyperplasia Neonatal tetany

4-Metabolic and endocrine disorders

Obstructive uropathy Renal insufficiency 5-Renal disorders

Bilious Vomiting In Newborns Common Surgical Causes

Duodenal atresia

Midgut malrotation and volvulus

Jejunoileal atresia

Meconium ileus

Necrotizing enterocolitis

Duodenal atresia

Duodenal atresia is a congenital obstruction of the second portion of the duodenum.

Its etiology is believed to be failure of recanalization of this bowel segment during the early gestational stage.

The pregnancy is associated with polyhydramnios

Duodenal atresia

Occurs in 1 per 5,000 to 10,000 live births Involving male more commonly than female Down syndrome occurs in about 25% Congenital heart disease occurs in about 20%

In 80 %, the papilla of vater opens into the proximal duodenum, accounting for the Bilious Nature of the vomiting.

Types of Duodenal atresia

Type 1: a membrane traverses the internal diameter of the duodenum. Type 2: the atretic ends of the duodenum are connected by a fibrous cord. Type 3: the atretic segments are completely separated

Plain X-Ray for Duodenal atresia

"double-bubble" sign, demonstrating the bubbles in the stomach and the dilated proximal duodenum; this confirms the diagnosis

Surgery is required but is not urgent.

A 24- to 48-hour delay may be allowed before operation for , further evaluation and fluid resuscitation

Surgery for Duodenal atresia

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 transanastomotic tube placement is required. The midpoint of the proximal incision is approximated

to the end of the distal incision.

The prognosis is excellent unless the patient has associated serious congenital anomalies.

Midgut Malrotation And Volvulus

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.

Normally, the third portion of the duodenum passes behind the superior mesenteric vessels along the lower margin of the pancreas


During embryonic life, the colon and small bowel grow rapidly and extrude from the abdominal cavity.

During the 7th wks. of gestation, the Midgut starts being reduced back into the abdominal cavity

The bowel then settles into the abdominal cavity and rotates in a counterclockwise direction, with the cecum coming to rest in the right lower quadrant of the abdomen. This process is completed by the 12th week of gestation.


The malrotated bowel itself does not cause any significant problem.

However, because of the narrow axis, the Midgut can at any time twist around the axis, perhaps triggered by peristaltic action.

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.

Unless it is treated in a Timely Manner, bowel strangulation results in an ischemic loss of extensive bowel, causing the short-gut syndrome


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.

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

UPPER GI SERIES in Midgut Malrotation And Volvulus

Malrotation without volvulus

Note the small bowel in the right abdomen

UPPER GI SERIES in Midgut Malrotation And Volvulus

Malrotation with volvulus

US in Midgut Malrotation And Volvulus

Ultrasound with color Doppler shows malrotation with midgut volvulus demonstrating the "whirlpool sign.

" The superior mesenteric vein wraps around the superior mesenteric artery

CT SCAN in Midgut Malrotation And Volvulus

CT shows the abnormal relationship of the SMV to the SMA.

The SMV should lie to the right of the SMA in this adolescent with undiagnosed malrotation without volvulus

Surgical Rx for Midgut Malrotation And Volvulus

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

Surgical Rx

"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

This band is divided to release the duodenal obstruction

Surgical Rx

The fused intestinal mesentery must be dissected to widen its axis and prevent recurrence of volvulus

During this dissection, the superior mesenteric vessels are clearly exposed and must not be injured

Surgical Rx

When the operation is performed in a timely manner, the prognosis is excellent.

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.

24 H 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


Very occasionally, malrotation of the bowel can be identified in older patients who have had multiple episodes of abdominal pain of undetermined origin.

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

Jejunoileal Atresia

• Caused by intrauterine mesenteric vascular accident

FOUR TYPES:1. Membranous2. Interrupted3. Apple-peel4. Multiple

Jejunoileal Atresia

The symptoms and signs are identical regardless of the type of lesion.

Abdominal distention with bilious vomiting is observed within the first 24 hours after birth.

The more proximal the lesion, the earlier and more serious is the bile-stained vomiting

Jejunoileal Atresia

Upright abdominal film showing distention of the bowel

with multiple air-fluid levels suggesting

lower intestinal atresia

Jejunoileal Atresia

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

MECONIUM ILEUS

Retention of thick tenacious meconium in the bowel (ileum, jejunum or colon), which results in bowel obstruction.

In one half of patients with meconium ileus, the bowel is intact, and its continuity is preserved.

The other patients have associated volvulus, jejunoileal atresia, bowel perforation and/or meconium peritonitis.

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

MECONIUM ILEUS

The involved bowel is distended by meconium retention during fetal life.

After a few hours of postnatal life, bowel distention becomes remarkable because of swallowed air and causes bilious vomiting.

On physical examination, the thickened bowel loops are often visible and palpable through the abdominal wall.

Remarkable abdominal distention, tenderness and/or erythema of the abdominal skin indicates perforation, which requires immediate surgery

MECONIUM ILEUS

The plain abdominal films show distended loops of intestine with thickened bowel walls.

A large amount of meconium mixed with swallowed air produces the so-called "ground-glass" sign, which is typical of meconium ileus

MECONIUM ILEUS

Calcification, free air or very large air-fluid levels suggest bowel perforation, which requires urgent surgery

MECONIUM ILEUS

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

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.

When a Gastrografin enema is unsuccessful, laparotomy is indicated to evacuate the obstructing meconium by enterotomy irrigation

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

Meconium Peritonitis

Aseptic peritonitis caused by spillage of meconium into the abdominal cavity during the development of jejunoileal atresia

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

NECROTIZING ENTEROCOLITIS (NEC)

NEC is a rapidly progressing catastrophic disease producing extensive bowel necrosis, infection and perforation in newborns.

The etiology is unknown, although several likely causes have been reported.

Prematurity and pulmonary disorders are common predisposing factors.

The usual onset is 10 to 12 days of age, with presenting symptoms of gastric retention, bilious vomiting, ileus, abdominal distention and bloody stools.

Bradycardia, hypothermia, apneic spells and hypotension are later signs of progressive deterioration. Abnormal hemorrhage, hyperbilirubinemia and oliguria are late finding


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


• 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 intestinalis, air in the portal vein and/or free air are the radiographic findings


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• Clinical deterioration develop• Intractable metabolic acidosis and

thrombocytopenia are also critical signs of bowel ischemia, indicating surgical treatment

Diagnostic Age and presentations incidence Diagnosis"double-bubble" •Few hours after birth

•no distention•1 per 5,000 L.B•25% have Down.

Duodenal atresia

abnormal location of the SM vessels

•At 3 to 7 days•rapid deterioration

•Incomplete bowel rotation

Malrotation& volvulus

Air-fluid levels •Within 24 hours of birth•abdominal distention

•1 per 3,000 L.B•M.V. accident

Jejunoileal atresia

•air-fluid levels,•sweat test

•Immediately after birth•abdominal distention

•1 per 5,000 L.B•15% of with CF

Meconium ileus

Pneumatosis •10 to 12 days after birth•distention, bloody stools

•2.4 per 1,000 L.B•Cause unknown

NEC

Neonatal intestinal obstruction With bilious vomiting

Prognosis Treatment DiagnosisGood unless associated with serious anomalies duodenoduodenostomy Duodenal atresia

Good without bowel resection, Difficult with short-gut syndrome

Ladd's procedure Volvulus

Good unless excessive loss of bowel Resection (s) and anastomosis (es) Jejunoileal atresia

Depends on the systemic problems 1. Gastrografin enema2. Enterostomy

Meconium ileus

25% need surgery (65% survival rate)75% can be treated medically (95% survival rate)

Resection of necrotic bowel and enterostomy

NEC

Neonatal intestinal obstruction With bilious vomiting

Bilious Vomiting in the Newborn

Dr. Ali M AhmadMBBCh, MS, MD, MRCS-Ed, EBPS

Associate Consultant Pediatric Surgery; KAAUH_ PNU

Thank You

bilious vomiting

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