Start with a free account for 3 free CME credits. Already a subscriber? Sign in.

Bilious Emesis in Neonates

Jason Woods, MD and Solomon Behar, MD
00:00
24:56

No me gusta!

The flash player was unable to start. If you have a flash blocker then try unblocking the flash content - it should be visible below.

Drs. Sol Behar and Jason Woods discuss the evaluation and management of bilious emesis in a neonate. 

 
  • Bilious emesis  in an infant should be treated as an emergency because this is often a symptom of obstruction due to intestinal atresia or midgut volvulus.

  • Causes of intestinal obstruction that present during the neonatal period include:

    • Malrotation with or without volvulus

    • Intestinal atresia

    • Hirschsprung disease

    • Intussusception (rare in the neonatal period)

    • Necrotizing enterocolitis 

  • Malrotation with volvulus. In this condition, the cecum is abnormally positioned in the right upper quadrant and this abnormal positioning predisposes the intestine to twist on its mesentery resulting in volvulus. This causes acute small bowel obstruction and ischemia. 

    • An upper GI, the gold standard for diagnosing or evaluating malrotation, classically shows a duodenum with a "corkscrew" appearance.

  • Intestinal atresia. This is a term used to describe a complete blockage or obstruction anywhere in the intestine. Approximately 30% of infants with duodenal atresia have a chromosomal anomaly, most typically Down syndrome.

    • The "double bubble" sign is caused by dilation of the stomach and proximal duodenum and strongly suggests duodenal atresia

  • Hirschsprung disease. This is a disorder of the motor innervation of the distal intestine that leads to a functional obstruction. In Hirschsprung, the nerves that allow the relaxation of the smooth muscle within the intestine wall are missing, so the area that is affected is constricted.

Dilated large bowel seen with Hirschsprung’s disease in a 4 month old presenting with vomiting and obstipation and abdominal distension

  • A contrast enema can support the diagnosis of Hirschsprung disease. It will often show the presence of a “transition zone” which represents the change from the normal caliber rectum to the dilated colon proximal to the aganglionic region.

 

Arrow is pointing to the “transition zone” in Hirschsprung’s disease

  • For younger kids who have not had time to develop the “transition zone”, the rectosigmoid index, the ratio between the diameter of the rectum and the sigmoid colon, is typically >1 in normal children

Abnormal rectum to sigmoid ratio of <1. Note the narrowness of the rectal diameter (blue line) when compared with the more plump sigmoid diameter (black line)

  • Necrotizing enterocolitis. This is a condition characterized by bowel necrosis with associated severe inflammation, bacterial invasion, and dissection of gas into the bowel wall.

    • Pneumatosis intestinalis, a hallmark of NEC, appears as bubbles of gas in the bowel wall.

Meconium ileus is caused by the obstruction of the small intestines with inspissated meconium. Approximately 10% of patients with CF present with meconium ileus.

To join the conversation, you need to subscribe.

Sign up today for full access to all episodes and to join the conversation.

To download files, you need to subscribe.

Sign up today for full access to all episodes.
Hippo Peds RAP July 2020 Written Summary 974 KB - PDF

To earn CME for this chapter, you need to subscribe.

Sign up today for full access to all episodes and earn CME.

0.25 Free AMA PRA Category 1 Credits™ certified by Hippo Education or 0.25 Free AAP credits certified by AAP (2020)

  1. Complete Quiz
  2. Complete Evaluation
  3. Print Certificate

3.25 AMA PRA Category 1 Credits™ certified by Hippo Education or 3.25 AAP credits certified by AAP (2020)

  1. Complete Quiz
  2. Complete Evaluation
  3. Print Certificate