Lightning Learning: Bilious Vomiting
““Green bilious vomiting is an emergency in a newborn until proven otherwise!””
STOP!
Why do we care? Even if the baby appears well, there can be swift progression to bowel obstruction, which in turn can cause ischaemic bowel necrosis. This is because luminal obstruction is quickly followed by vascular obstruction. “Time is tissue!”
Why does GREEN matter? Bile is stored in the gallbladder and drains into the duodenum via the Ampulla of Vater. Any vomits containing bile could signify an obstruction at/or distal to the duodenum.
LOOK
WARNING: Green vomit, as a sign of bowel obstruction, is neither sensitive nor specific. Potentially, you will need to investigate the cause of the bilious vomiting further which sometimes turns out to be less serious than thought.
Immediate Management? Clearly if warranted, utilise an ABCDE approach. Such a baby may appear septic and require appropriate interventions. For this specific scenario…
Keep nil by mouth
Pass a NG tube for decompression
Commence maintenance IV fluids and antibiotics
Next? Speak to a tertiary paediatric surgical centre. Transfer may well be necessary for radiological and clinical evaluation +/- bowel surgery.
LEARN
So what are important causes?
Duodenal atresia
Malrotation and volvulus
Jejunoileal atresia
Meconium ileus
Meconium plug syndrome
Necrotising enterocolitis
Congenital hypothyroidism
Maternal MgSO4
Green breast milk
Further Reading:
- The management of bilious vomiting in the neonate (Burge DM et al.)
- Green for danger! Intestinal malrotation and volvulus (Williams H.)
Finally, check out our blog for more on this topic… http://bit.ly/em3bvin
