Newborn vomiting: Bilious

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Newborn vomitingBilious

• Joseph A. Iocono, M.D.
• University of Kentucky

2
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.

3
What is your differential diagnosis?
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Differential Diagnosis

• Gastroenteritis
• GERD
• Pyloric Stenosis
• Duodenal Atresia
• Malrotation/Volvulus

• NEC
• Formula Intolerance
• Annular Pancreas
• Esophageal Atresia

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History

• What other points of the history do you want to
  know?

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Consider the Following

• Characterization of symptoms
• Temporal sequence
• Alleviating / Exacerbating factors

• Pertinent PMH, ROS, birth history
• Relevant family hx.
• Associated signs and symptoms

7
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.

8
Physical Exam

• What are you looking for on
• Physical Exam?
• Discuss NORMAL RANGE Vital Signs
  for a newborn

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Physical ExamWhat to look for

• Vital signs instability, respiratory distress,
• Overall appearance signs of dehydration, poor
  perfusion
• Abdominal exam peritonitis
• Rectal exam heme positive?

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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

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What labs do you need?
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Would you like to revise your initial
differential diagnosis?
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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

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Laboratory Values
16
19
132
98
359
20
92
48.2
0.9
3.8
12
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What do you think about the labs?
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What would you do now?
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Laboratory Values Discussion

• Profound dehydration with metabolic acidosis.
• Elevated WBC

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Interventions to Consider

• ABCs
• Start resuscitation
• Fluid bolus
• Proper bolus in newborn (20 ml/kg)
• Other tests
• X-ray?
• Ultrasound?
• Treatment now?

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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

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What would you do now?
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Ralph Upchurch

• Operate or get more tests?

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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

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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.

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Malrotation with Midgut Volvulus

• Bilious vomiting in a newborn is malrotation
  with midgut volvulus until proven otherwise

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Anatomy of malrotation

• Normal Malrotation

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UGI Malrotation
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Mid-Gut Volvulus
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Summary
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QUESTIONS?
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