Bilious Vomiting in Neonates

Question 1

Duodenal atresia

Answer 1

1 in 5000 (higher in Downs syndrome)
Few hours after birth
AXR shows “double bubble sign, contrast study may confirm
Duodenoduodenostomy

Question 2

Malrotation with volvulus

Answer 2

Usually cause by incomplete rotation during embryogenesis
Usually 3-7 days after birth, volvulus with compromised circulation may result in peritoneal signs and haemodynamic instability
Upper GI contrast study may show DJ flexure is more medially placed, USS may show abnormal orientation of SMA and SMV
Ladd’s procedure - counterclockwise detorsion of the bowel + surgical division of Ladd’s bands + widening of the small intestine’s mesentery + performing an appendectomy + reorientation of the small bowel on the right and the cecum and colon on the left (the appendicectomy is performed so as not to be confused by atypical presentation of appendicitis at a later date)

Question 3

Jejunal/ ileal atresia

Answer 3

Usually caused by vascular insufficiency in utero, usually 1 in 3000
Usually within 24 hours of birth
AXR will show air-fluid levels
Laparotomy with primary resection and anastomosis

Question 4

Meconium ileus

Answer 4

Occurs in between 15 and 20% of those babies with cystic fibrosis, otherwise 1 in 5000
Typically in first 24-48 hours of life with abdominal distension and bilious vomiting
Air - fluid levels on AXR, sweat test to confirm cystic fibrosis
Surgical decompression, serosal damage may require segmental resection

Question 5

Necrotising enterocolitis

Answer 5

Up to 2.4 per 1000 births, risks increased in prematurity and inter-current illness
Usually second week of life
Dilated bowel loops on AXR, pneumatosis and portal venous air
Conservative and supportive for non perforated cases, laparotomy and resection in cases of perforation of ongoing clinical deterioration