Bilious vomiting in a five-week-old at a district general hospital
A 5-week-old term boy is brought to a district general hospital at 21:00 with three episodes of bilious vomiting in six hours. He fed normally until mid-afternoon and passed a normal stool today. He is alert, heart rate 176, respiratory rate 44, capillary refill 3 seconds, temperature 36.9 °C, with a soft but mildly distended abdomen and mild tenderness in the right lower quadrant; there is no guarding. Capillary glucose 3.9 mmol/L, venous lactate 2.1 mmol/L, white cell count 14.2 × 10⁹/L, platelets 320 × 10⁹/L. Abdominal radiograph shows a non-specific gas pattern with no free gas and no pneumatosis. The nearest paediatric surgical centre is two hours away by road; a retrieval ambulance is 45 minutes away. The resident general surgeon on site does not perform neonatal laparotomies, and the consultant paediatric surgeon at the tertiary centre advises transfer after resuscitation.
1. What is your differential diagnosis, and what should happen in the next two hours?
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Bilious vomiting in a neonate is malrotation with midgut volvulus until proven otherwise - the bowel can twist and infarct within hours. The wider differential includes duodenal atresia or web, jejunoileal atresia, meconium ileus, Hirschsprung disease, an incarcerated hernia and sepsis. A normal stool does not exclude volvulus, and a non-specific radiograph is typical, not reassuring.
Next two hours:
- Nil by mouth, nasogastric tube on free drainage - the volume and colour of the aspirate are diagnostic information.
- Two intravenous cannulas; 10–20 mL/kg of 0.9% sodium chloride if perfusion remains poor, reassessing after each bolus because a neonate can compensate until they suddenly decompensate.
- Blood gas, glucose, full blood count, urea and electrolytes, CRP, blood culture, group and save.
- Broad-spectrum intravenous antibiotics if there is tenderness or any concern about ischaemia.
- Keep warm, hourly observations, urinary catheter for output, and document the abdomen at each review.
- Check the groins for a hernia.
Disposition: he has no peritonism and is not shocked, so the correct pathway is resuscitation and urgent transfer for an upper gastrointestinal contrast study at the paediatric surgical centre. Do not perform a local contrast study that delays the ambulance, and do not wait for a repeat radiograph. If he develops guarding, fixed discolouration or cardiovascular collapse, the pathway changes to laparotomy on site with consultant telephone support.
2. En route he becomes tachycardic at 210, the abdomen becomes rigid and he vomits bile-stained fluid; lactate is 6 mmol/L. What now?
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This is midgut volvulus with infarction until proven otherwise, and the priority is no longer the destination hospital - it is the nearest theatre.
Actions in the ambulance: high-flow oxygen, airway assessment, a 20 mL/kg crystalloid bolus and reassessment for a second, intravenous glucose, repeat blood gas and cross-match, nasogastric decompression, and intravenous antibiotics. Notify the receiving emergency department and the on-call consultant surgeon and anaesthetist so theatre is ready on arrival; if the current destination is further than a nearer hospital with paediatric anaesthesia, divert.
In theatre: resuscitate while the abdomen is prepped, then laparotomy through a transverse incision. If the bowel is viable, perform a Ladd procedure without dividing bands in a way that risks devascularisation, and place the bowel in a non-rotated position. If a segment is necrotic, resect it and either anastomose if the ends are healthy and the baby stable, or bring out a stoma. If the entire midgut is necrotic, do not resect indiscriminately - take a second look at 24–48 hours and involve the paediatric surgical team by phone during the operation.
Communication: consent by telephone from the parents with a witness and full documentation; explain that the bowel may need removal and that short bowel syndrome is a real possibility. Inform the tertiary centre and arrange retrieval or advice. Document the timeline precisely, because the decisions made during the transfer will be scrutinised.
3. The parents ask why he cannot have the scan at the district hospital before transfer. How do you respond?
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Answer plainly, without jargon, and without pretending to certainty.
Explain that bilious vomiting in a baby can mean the bowel has twisted on itself and is cutting off its own blood supply. The scan is only useful if it is done where a surgeon can act on the result immediately; at the district hospital, a scan would add an hour or more and might still need repeating, and the thing that matters most is time. Say clearly that he is stable now, which is exactly the right time to move him, and that moving a sick baby later is more dangerous than moving a stable one now.
Tell them who will meet them, what will happen on arrival (examination, possibly a contrast study, possibly an operation), and that they can travel with him or follow immediately. Be honest that if he deteriorates on the way, the team may need to stop at the nearest hospital with a theatre. Acknowledge that this is frightening and that they are not being asked to choose between two safe options - transfer is the recommendation.
Document the conversation, including the questions asked and the answers given. If English is not the family's first language, use an interpreter rather than a relative. Avoid promising that he will not need surgery; the honest position is that he might.