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Arab Board Surgery Clinical study materials
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A 3-day-old with bilious vomiting and a normal abdominal X-ray

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A 3-day-old with bilious vomiting and a normal abdominal X-ray

A 3-day-old term boy, birth weight 3.4 kg, is brought in with bilious vomiting since this morning and poor feeding. He passed meconium on day 1. Temperature 37.9 °C, HR 168/min, RR 60, capillary refill 4 seconds. Abdomen is soft but distended; there is no guarding. Abdominal X-ray shows a few dilated loops but no pneumoperitoneum and no classic 'double bubble'. WCC 16 ×10^9/L, platelets 180 ×10^9/L, glucose 2.9 mmol/L, lactate 2.8 mmol/L, and a capillary blood gas shows pH 7.28, base deficit −7. He has not passed stool since admission. The paediatric surgical registrar is 30 minutes away; the neonatal unit has incubator space.

1. What is your differential diagnosis, and what is the immediate management before the registrar arrives?

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Differential

  • Malrotation with midgut volvulus - the classic 'can't-miss' cause of bilious vomiting in a neonate; the X-ray may be normal or non-specific. Time-critical because of bowel infarction.
  • Duodenal atresia/web - usually presents earlier with a double bubble, but a web can present at day 3.
  • Jejunoileal atresia - usually more distal distension.
  • Meconium ileus / meconium plug - consider cystic fibrosis; meconium passed on day 1 makes complete obstruction less likely but does not exclude it.
  • Hirschsprung disease - usually delayed meconium passage; can present with enterocolitis.
  • Necrotising enterocolitis - usually in preterm or unwell babies; term baby with bilious vomiting and shock should still be considered.
  • Sepsis - always on the list in a neonate with vomiting and poor perfusion.

Immediate management

  • Nil by mouth, insert a nasogastric tube and aspirate (bilious aspirate supports proximal obstruction).
  • Resuscitation: IV access, 10–20 mL/kg crystalloid bolus for poor perfusion, correct glucose (10% dextrose bolus), monitor urine output and weight.
  • Broad-spectrum antibiotics (e.g., ampicillin + gentamicin + metronidazole) after blood cultures - neonatal sepsis cannot be excluded.
  • Urgent contrast study: upper GI contrast is the investigation of choice for suspected malrotation; if the baby is too unstable, proceed to theatre.
  • Call the paediatric surgical registrar and neonatal transport - this baby may need transfer to a surgical NICU.
  • Keep the baby warm, monitor glucose and electrolytes, and document aspirates.

2. The upper GI contrast study shows a corkscrew duodenum with the duodenojejunal flexure on the right. What is the diagnosis, and what are the operative principles? What would you do if the bowel is frankly necrotic at laparotomy?

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Diagnosis

  • Malrotation with midgut volvulus - the corkscrew appearance and right-sided duodenojejunal flexure are diagnostic. This is a surgical emergency; delay risks extensive small bowel infarction.

Operative principles (Ladd procedure)

  1. Detorse the volvulus - counter-clockwise (usually) until the mesentery is untwisted; assess bowel viability.
  2. Divide Ladd bands - divide the peritoneal bands crossing the duodenum to the right colon, mobilising the duodenum.
  3. Widen the mesenteric base - separate the duodenojejunal and ileocaecal junctions to prevent recurrence.
  4. Place the bowel in a non-rotated position - small bowel on the right, colon on the left.
  5. Appendicectomy - because the appendix will lie in an abnormal position and future appendicitis could be misdiagnosed.
  6. Do not attempt to restore normal rotation.

If bowel is necrotic

  • Resect clearly non-viable bowel and consider second-look laparotomy at 24–48 h after detorsion - some bowel may recover. Avoid massive resection in a neonate if borderline.
  • If extensive necrosis (e.g., near-total small bowel), discuss with neonatology and parents about prognosis; consider damage control and a planned relook rather than immediate massive resection.
  • Post-operatively: parenteral nutrition, careful fluid/electrolyte management, and monitoring for short bowel syndrome.

Key point

  • Bilious vomiting in a neonate is a surgical emergency until malrotation is excluded; a normal X-ray does not exclude it.