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.
Gastroenteritis GERD Pyloric Stenosis Duodenal Atresia Malrotation/Volvulus NEC Formula Intolerance Annular Pancreas Esophageal Atresia Differential Diagnosis
History What other points of the history do you want to know?
Characterization of symptoms Temporal sequence Alleviating / Exacerbating factors: Pertinent PMH, ROS, birth history Relevant family hx. Associated signs and symptoms Consider the Following
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.
Physical Exam What are you looking for on Physical Exam? Discuss NORMAL RANGE Vital Signs for a newborn
Physical ExamWhat 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
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
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 enemasuggestive, but not diagnostic • Ultrasoundmay show SMV/SMA reversal
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
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