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

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 It’s 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 mom’s shirt has a greenish stain.

What are you looking for on 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 19 132 98 20 359 92 48.2 0.9 3.8 12

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 – Ladd’s procedure Immediate counterclockwise rotation (usually 270 degrees or more) –then wait!! Division of Ladd’s 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 Ladd’s 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?

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