A 4 day old, 37 1/2 week gestation male infant was having some difficulty breastfeeding at home. During a lactation consultant’s visit, he had a large yellow-green emesis that the lactation consultant felt had feculent material in it.
She recommended that a physician see him. In the emergency room, the patient had another emesis that was clearly bilious.
The past medical history and family history were negative.
The review of systems showed poor suck and swallowing with few wet diapers. The last stool was 2 days ago.
The pertinent physical exam revealed an ill-appearing infant with a decrease of 10% of body weight (Birth weight was 3123 grams). He had poor skin turgor with a slightly sunken anterior fontanelle.
The cardiac, pulmonary and rest of the HEENT examinations were normal. His abdomen was distended, slightly tender and some rushed abdominal sounds. He had no palpable organomegaly.
He was slightly hypotonic and sleepy. He would arouse to stimulation.
A nasogastric tube was placed with 50 cc of yellow-green gastric contents returned.
The local work-up included a complete blood count showing a hematocrit of 41% and a white blood cell count of 7500 with no left shift.
His electrolytes showed sodium = 130 mEq/L, potassium = 3.9mEq/L, chloride = 110mEq/L, and CO2 = 18 mEq/L. Liver enzymes and bilirubin were normal. Lactic acid was 4.0 mEq/L.
He was begun on Ampicillin and Gentamicin for presumed sepsis and had a work-up including blood cultures, urine cultures, cerebrospinal fluid cultures which eventually were negative.
An abdominal x-ray was unremarkable.
He was transferred to a larger institution for further radiology studies and surgical consultation.
The radiologic evaluation of an upper GI exam initially demonstrated markedly delayed emptying of contrast out of the proximal duodenum. A spot image demonstrates dilation of the proximal duodenum along with malrotation of the small bowel with the Ligament of Treitz (black arrow) noted to be projecting over the midline of the spine and lower than the level of the duodenal bulb. The Ligament of Treitz should normally be located over the left upper quadrant of the abdomen and at the same level as the duodenal bulb. Subsequent spot images demonstrated the proximal jejuneum to be in the right upper quadrant of the abdomen.
The diagnosis of of malrotation with midgut volvulus was made.
The patient’s clinical course included being taken to the operating room where a midgut malrotation with 270 degrees of volvulus was confirmed. The volvulus was devolved and viable bowel was found.
A Ladd’s procedure and appendectomy were performed. The patient tolerated the procedure and had an uneventful post-operative course.
As there is almost continuous production of gastrointestinal fluids and swallowing in utero, obstruction or injury causing abnormal peristalsis can by itself cause abdominal distension with vomiting. Abominal distension and vomiting is always abnormal.
Bilious emesis is also always abnormal and indicates ileus or obstruction distal to the common bile duct insertion into the duodenum.
Other associated symptoms may include sepsis, bleeding, pain and respiratory distress.
Treatment includes stopping feedings, decompression of the stomach, and prompt radiologic and surgical evaluation and treatment.
Normally during embryonic life, the primary gastrointestinal loop undergoes a 270 degree rotation counterclockwise around the superior mesenteric artery. If this normal rotation does not occur, the duodenum and cecum end up lying together near the epigastrium with the superior mesenteric artery and vein located centrally, forming a poorly fixated stalk.
Volvulus around this stalk causes obstruction of the duodenum and the superior mesenteric artery and vein. The volvulus causes abdominal obstruction, distension and emesis. Additionally, there is vascular compromise of the upper intestinal tract.
Intestinal malrotation and volvulus are surgical emergencies and need immediate attention.
The differential diagnosis for bilious emesis includes:
- Hirschsprung disease
- Intestinal atresia – distal duodenum, jejunal and ileal
- Intestinal duplication
- Intestinal malrotation and midgut volvulus
- Meconium plug and ileus
- Organomegaly causing obstruction
- Pancreas, annular
- Viscous perforation
Questions for Further Discussion
1. What is the differential diagnosis of non-bilious emesis in a newborn?
2. What is the differential diagnosis of other neonatal surgical emergencies?
3. Describe the Ladd’s procedure.
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
To view current news articles on this topic check Google News.
Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1998:69-82.
Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2003-2007.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competency performed.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
December 4, 2006