Ch. 32 Infant with Bilious Emesis Flashcards
A 7-mo male infant presents with 2 episodes of green emesis, decreased stool and urine output, and lethargy. The mother states he was full-term baby with no prior illnesses or surgery. He fed normally for months until the day prior to presentation. He had a normal, nonbloody bowel movement 24 hrs ago. His HR is slightly elevated and he is normotensive and afebrile. He is lethargic but otherwise has a normal physical exam. His abdomen is soft, nontender and nondistended.
Malrotation with midgut volvulus
(always suspect in infant with bilious vomiting or any child with bilious vomiting and abdominal pain)
What is malrotation?
How does age affect differential dx of bilious emesis?
Of note:
Intussception: seen in 6- to 12-m/o chubby, healthy-looking kids who have episodes of colicky abdominal pain that makes them double up and squat
- Pain lasts for about 1 min… kid looks perfectly happy and normal until he gets another colic
- PE findings: “empty” RLQ and “currant jelly” stools
- Barium/air enema = both dx and therapeutic… if reduction not achieved radiologically, surgery is done
- U/S = method of choice 100% specificity/sensitivity: “target sign”
Why is it important to distinguish between bilious and nonbilious vomiting in an infant?
Bilious emesis most likely due to surgically correctable lesion until proven otherwise
Obstructive processes proximal to pylorus always cause nonbilious emesis
Bilious emesis implies patient pylorus + obstruction distal to ampulla of Vater
Distinguishing b/w proximal and distal causes of obstruction will determine what type of dx study to perform
Workup:
What is the first imaging study to obtain?
If pt is hemodynamically stable, plain abdominal radiograph to exclude gross performation (would reveal free air under diaphragm)
If no free air, then UGI contrast series to visualize duodenum and proximal small intestine
What is the etiology of malrotation?
Failure of midgut (supplied by SMA) to rotate and fix properly, typically during its return into the abdominal cavity (10-12 weeks)
Strangulation, closed loop obstruction, intestine becomes ischemic
Does malrotation always result in midgut volvulus? Is it always acute?
No. Dx of malrotation is not itself a surgical emergency. However, it predisposes infant to midgut volvulus.
Not always acute… if acute volvulus is incomplete or intermittent, infant may appear well between episodes of vomiting
What is the most important immediate management issue?
Acute midgut volvulus = surgical emergency
Any delay in operating –> loss of intestine
Patient should be rapidly fluid resuscitated and taken to the OR for urgent laparotomy
Orogastric or NGT should be placed to decompress stomach + broad-spectrum ABX given while preparing for OR
What operation is required?
Ladd’s procedure –> relieve any intestinal obstruction and prevent risk of recurrent volvulus
1) Gently rotate gut counterclockwise…
2) Divide Ladd’s bands (peritoneal attachments from RUQ quadrant to ascending colon)
3) Straighten duodenum and examine for intrinsic obstruction
