Neonate with bilious vomiting and suspected volvulus
A 5-week-old boy is brought by his parents with a 12-hour history of bilious vomiting and poor feeding. He was born at term, weighs 4.2 kg, and had been thriving until today. He is lethargic but arousable. Temperature 37.8°C, heart rate 168/min, respiratory rate 48/min, blood pressure 72/44 mmHg, capillary refill 3 seconds. Abdomen is distended and tender, with no palpable mass; there is no blood per rectum. He has passed urine once in the last 8 hours. Blood gas shows pH 7.28, base excess -8, sodium 132 mmol/L, potassium 3.2 mmol/L, chloride 98 mmol/L, glucose 3.1 mmol/L. The surgical registrar suspects malrotation with volvulus and requests an upper gastrointestinal contrast study, but the radiology suite is busy and the paediatric anaesthetist is available only in 2 hours.
1. What is the immediate priority and how would you resuscitate this infant?
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The immediate priority is resuscitation and urgent surgical exploration for suspected midgut volvulus, not investigation for its own sake. Bilious vomiting in a neonate is a surgical emergency until proved otherwise. This infant is lethargic, tachycardic, hypotensive for age, acidotic, hypoglycaemic, and oliguric, so he is shocked.
I would:
- Give oxygen and secure IV access; consider intraosseous access if IV access is difficult.
- Give a 20 mL/kg bolus of 0.9% sodium chloride and reassess; repeat if perfusion remains poor, watching for fluid overload.
- Correct hypoglycaemia with 10% dextrose 2 mL/kg, then maintain a glucose infusion.
- Pass a nasogastric tube to decompress the stomach and reduce aspiration risk.
- Give IV broad-spectrum antibiotics after blood cultures.
- Keep him warm, crossmatch blood, and correct potassium and acidosis cautiously once perfusion is restored.
- Call the paediatric surgeon and anaesthetist immediately and prepare theatre.
The 2-hour anaesthetic delay should be used for resuscitation and transfer, not for waiting on radiology. If he stabilises, a rapid contrast study may be considered, but it must not delay surgery.
2. Should the upper gastrointestinal contrast study be performed before theatre? Justify your answer.
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The contrast study should be performed only if the infant is stable and it can be completed without delaying surgery. A normal study does not reliably exclude malrotation, and an abnormal study in a shocked infant does not change the need for urgent laparotomy. In this baby, the combination of bilious vomiting, abdominal tenderness, lethargy, acidosis, and poor perfusion makes volvulus with possible bowel necrosis the working diagnosis. The priority is to detorse the volvulus before further bowel infarction occurs.
If the radiology suite is busy and the anaesthetist is available in 2 hours, I would not wait for imaging. I would resuscitate and take him to theatre as soon as the anaesthetist is ready. If he were haemodynamically stable, less tender, and the diagnosis were unclear, a limited upper gastrointestinal contrast study could be justified, looking for a malpositioned duodenojejunal flexure or a corkscrew duodenum. Even then, the study must be done immediately and the theatre kept ready. The registrar’s request is reasonable in a stable patient but unsafe if it becomes a bottleneck.
3. Describe the operative steps and key postoperative concerns.
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At laparotomy I would deliver the bowel and inspect for malrotation. If a volvulus is present, I would detorse it counterclockwise and assess bowel viability after releasing the twist. Non-viable bowel would be resected; doubtful bowel may be left and re-explored at a second look. I would then perform a Ladd procedure: divide the Ladd bands, widen the mesenteric base, place the small bowel on the right and the colon on the left, and remove the appendix so that future appendicitis is not confusing. I would not attempt to fix the bowel with sutures.
Postoperatively the infant needs nasogastric decompression, IV fluids, analgesia, and antibiotics. I would monitor for sepsis, ongoing ischaemia, anastomotic leak if resection was needed, and short bowel syndrome if a large resection was required. Feeding is introduced gradually once bowel function returns. Parents should be warned about wound infection, adhesional obstruction, and the small risk of recurrent volvulus. Prognosis is good if the bowel is viable at surgery; delay increases the risk of massive resection and long-term parenteral nutrition.