A 5-day-old with bilious vomiting, 9% weight loss and parents who think it is milk intolerance
A 5-day-old term boy is brought to the emergency department at 03:00 with bilious vomiting that started 6 hours ago and has occurred four times. He was born at term, weighed 3.4 kg, and passed meconium on day 1. He has fed poorly since last evening. He is drowsy, with a sunken fontanelle, pulse 176/min, capillary refill 3 seconds, and a soft, mildly distended abdomen without tenderness or guarding; there is no blood per rectum. Capillary glucose is 2.9 mmol/L. He has lost 9% of birth weight. A nasogastric tube has not yet been passed. The on-call radiology registrar can perform an upper gastrointestinal contrast study within 45 minutes, and the paediatric surgeon is 20 minutes away. There is no paediatric intensive care bed in the hospital; the nearest is 90 minutes by road. The parents ask whether the vomiting could simply be milk intolerance because an aunt's baby had the same problem.
1. Give your differential diagnosis and explain which single diagnosis you must exclude and why.
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Bilious vomiting in a neonate is a surgical emergency until excluded, whatever the milk-intolerance story suggests.
- Malrotation with midgut volvulus is the diagnosis that must be excluded. The whole midgut is supplied by the superior mesenteric artery, which twists on a narrow pedicle; infarction of all small bowel beyond the duodenum can occur within hours. This is why every neonatal bilious vomit demands urgent imaging or laparotomy.
- Duodenal atresia or web usually presents on day 1 with a double bubble and no distal gas; he passed meconium, which makes complete atresia unlikely.
- Jejunoileal atresia, meconium ileus (screen for cystic fibrosis) and meconium plug.
- Hirschsprung disease usually presents with delayed meconium and distension rather than acute bilious vomiting on day 5.
- Necrotising enterocolitis is possible but typically affects preterm or growth-restricted babies with bloody stools, ileus and pneumatosis; his abdomen is soft.
- Sepsis, meningitis, and metabolic causes including congenital adrenal hyperplasia and galactosaemia.
- Incarcerated inguinoscrotal hernia - examine the groins before anything else.
The rate of deterioration (6 hours, four vomits, drowsiness, tachycardia, 9% weight loss) points to ongoing obstruction with a vascular component rather than a benign feeding problem.
2. State your resuscitation and investigation plan for the next hour, including the decision between an upper gastrointestinal contrast study and immediate laparotomy.
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Resuscitation, in parallel with calling the surgeon:
- Nil by mouth; pass a nasogastric tube and decompress, documenting volume and colour, which also reduces aspiration risk at induction.
- Two intravenous cannulae; 20 mL/kg 0.9% sodium chloride bolus for the tachycardia and delayed capillary refill, reassess, and repeat if still shocked; then maintenance fluid with potassium once urine output is established.
- Correct the glucose with 2 mL/kg of 10% dextrose intravenously; hypoglycaemia risks brain injury and contributes to the drowsiness.
- Keep him warm (incubator, warmed fluids); monitor heart rate, capillary refill, urine output, blood gas and lactate, full blood count, electrolytes; group and save.
- Broad-spectrum antibiotics if ischaemia or perforation is suspected; check vitamin K status.
Investigation versus theatre: in a stable child, an urgent upper gastrointestinal contrast study is the right next step, because a corkscrew duodenum or a duodenojejunal flexure lying in the right upper quadrant confirms malrotation and avoids an unnecessary laparotomy. But the study must not delay surgery if there is peritonitis, a rising lactate, persistent shock after 40 mL/kg, or free gas. Given his initial response to fluid and a 45-minute scan, I would pass the nasogastric tube and proceed with contrast while theatre is prepared, with a low threshold to abandon the study. If he remains tachycardic after 40 mL/kg, I would go straight to laparotomy.
3. At operation, 20 cm of midgut is dusky after detorsion. Describe the procedure and your decisions about the bowel and about a second look.
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This is a Ladd procedure.
- Transverse upper abdominal incision; deliver the bowel and inspect the orientation - small bowel on the right, colon on the left.
- Detorsion: untwist counter-clockwise, usually 360–720 degrees, until the mesentery is flat. Document the direction and number of turns.
- Assess viability over 10–15 minutes with warm packs. The bowel is dusky but not frankly necrotic. Do not resect bowel that might recover before you know the total length - his entire midgut is at stake.
- Divide the Ladd bands running from the caecum across the duodenum, widen the mesenteric root by dividing adhesions between duodenum and colon, and leave the small bowel on the right and colon on the left, a non-rotation arrangement that reduces the chance of further volvulus.
- Appendicectomy, because the appendix lies in an abnormal position and future appendicitis would be misdiagnosed.
- Do not attempt to fix the bowel with sutures.
Second look: if any segment is of doubtful viability, or more than 20–30 cm is ischaemic, close with a temporary dressing and return at 24–48 hours. Necrotic bowel declares itself and is resected then; primary resection risks leaving a short bowel. Prognosis depends on residual small bowel length, the presence of the ileocaecal valve (very poor with less than 25 cm and no valve), and long-term parenteral nutrition with its cholestatic complications. He also needs transfer planning: no paediatric intensive care bed here, and a 90-minute road transfer should be arranged once the airway and abdomen are controlled.