Ch. 31 Newborn with Bilious Emesis Flashcards
Bilious Emesis in Newborn
Differential dx in neonatal period (0-1 month): (8)
- Duodenal atresia
- Hirschsprung’s disease
- Imperforate anus
- Incarcerated inguinal hernia
- Jejunoileal/colonic atresia
- Malrotation with midgut volvulus
- Meconium ileus/plug
- Necrotizing enterocolitis
Specific findings:
Duodenal atresia
“Double bubble” on AXR
No distal bowel gas
Specific findings:
Hirschsprung’s disease
Transition zone (caliber change) on contrast enema
Absence of ganglion cells + hypertrophied nerve trunks on rectal biopsy
AGANGLIONIC MEGACOLON
Specific findings:
Imperforate anus
Bowel gas present
No anus on physical exam
Specific findings:
Incarcerated inguinal hernia
Inguinal hernia with evidence of incarceration on physical exam
Specific findings:
Jejunoileal/colonic atresia
Distal obstruction
Microcolon on contrast enema
Specific findings:
Malrotation with midgut volvulus
Corkscrew appearance of duodenum on contrast UGI
Misplaced ligament of Treitz
Specific findings:
Meconium ileus/plug
No passage of meconium
Distended abdomen
Gastrografin enemia = diagnostic and therapeutic (gastrografin draws fluid in, dissolves pellets of meconium in terminal ileum)
Specific findings:
Necrotizing enterocolitis
Seen in premies when they are FIRST FED: (NICU)
- Feeding intolerance
- Abdominal distention
- Rapidly dropping platelet count (in babies, a sign of sepsis)
- Fixed dilated loop
- Pneumatosis intestinalis (gas cysts in bowel wall) on AXR *** REQUIRES SURGICAL INTERVENTION
- Also.. portal venous air
Tx: stop all feedings and give broad-spec abx, IV fluids, IV nutrition
Case:
A term newborn female presents with bilious vomiting 12 hrs after uneventful delivery. Prenatal U/S showed polyhydramnios, but mother was lost to f/u. Infant passed meconium soon after birth. All vital signs are normal, and on physical exam, infant is well appearing. Abdomen is soft and nontender with epigastric distension. She has single palmar crease in both hands. Abdominal radiograph shows a “double-bubble.”
Most likely dx?
Duodenal atresia
What is the significance of bilious vomiting in a newborn?
Implies reflux of enteric content from distal to ampulla of Vater
Indicates:
- Pylorus is patent
- r/o common stomach pathology i.e. pyloric stenosis
What is the significance of polyhydramnios?
Amniotic fluid volume determined by steady state b/w in utero swallowing and fetal urine production
Either:
- Diseases that impair swallowing
- CDH
- Duodenal atresia
- Esophageal atresia
- Gastroschisis
- Neck mass
- Neurologic devastation
- TEF
- Diseases that increase urine production
- Maternal diabetes
- Twin pregnancy
Does the passage of meconium exclude dx of intestinal obstruction?
No.
Still possible to have neonatal bowel obstruction w/ passage of meconium. Meconium = ingested lanugo (fine body hair), amniotic fluid, bile, mucus, shed epithelial cells
Cannot pass with obstruction
Mucus is secreted and epithelium is shed along entire length of intestine (meconium distal to point of obstruction may still be passed)
Pathophysiology:
What is the etiology of duodenal obstruction?
What is the pathophysiology of this condition?
Most common cause of congenital duodenal obstruction = duodenal atresia
Pathophysiology: intrinsic duodenal obstructions arise from embryologic events around 6 weeks of gestation… duodenal atresia results when there is a failure of the gut to recanalize and the lumen remains obliterated
**Differs from pathophysiology of jejunoileal atresias (result of in utero vascular accidents leading to segmental intestinal ischemia –> subsequent resorption)
Most common associated abnormality?
Down-Syndrome (Trisomy 21) - 28% incidence (single palmar crease highly suggestive)
Workup:
First Imaging Study to obtain?
AP abdominal x-ray to r/o pneumoperitoneum (intestinal performation and immediate need for surgery)
If no evidence of free air and bowel gas pattern (duodenal atresia “double bubble” or distal obstruction.. dilated loops) –> UPPER GI SERIES (e.g. barium swallow) –> VOLVULUS
