1. Newborn vomiting: Bilious
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?

4. Differential Diagnosis
Gastroenteritis
GERD
Pyloric Stenosis
Duodenal Atresia
Malrotation/Volvulus
NEC
Formula Intolerance
Annular Pancreas
Esophageal Atresia

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

6. 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
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.

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

9. 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?

10. 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

11. What labs do you need?

12. Would you like to revise your initial differential diagnosis?

13. 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

14. Laboratory Values 16 19
132 98 20
359 92
48.2
0.9
3.8 12

15. What do you think about the labs?

16. What would you do now?

17. Laboratory Values Discussion
Profound dehydration with metabolic acidosis.
Elevated WBC

18. Interventions to Consider
ABCs
Start resuscitation
Fluid bolus
Proper bolus in newborn (20 ml/kg)
Other tests
X-ray?
Ultrasound?
Treatment now?

19. 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

20. What would you do now?

21. Ralph Upchurch
Operate or get more tests?

22. 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

23. 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.

24. Malrotation with Midgut Volvulus
“Bilious vomiting in a newborn is malrotation with midgut volvulus until proven otherwise”

25. Anatomy of malrotation
Normal Malrotation

26. UGI Malrotation

27. Mid-Gut Volvulus

28. Summary

29. QUESTIONS?

30. Acknowledgment
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