The surgical newborn — bilious vomiting with a double-bubble

Clinical information for the examiner

Setting: Postnatal ward, 18 hours of life. Term male infant, spontaneous vaginal delivery, birth weight 3.1 kg. Pregnancy was complicated by polyhydramnios; antenatal ultrasound showed a double-bubble. Apgars were 9 and 9. ^[4]

On your arrival:

• The infant is alert but mildly dehydrated; the anterior fontanelle is slightly sunken. ^[10]
• Vomit is documented as "green, bile-stained" — the colour test is positive. ^[1]
• The abdomen is soft, non-distended and non-tender (a proximal obstruction pattern). ^[10]
• The perineum shows a normal patent anus in the correct position, excluding an anorectal malformation. ^[10]
• Dysmorphic features consistent with Down syndrome are noted (brushfield spots, single palmar crease, hypotonia). ^[4]

Investigation provided: A plain abdominal radiograph shows two large gas-filled structures in the upper abdomen (the stomach and the dilated proximal duodenum) with no distal bowel gas — the classic double-bubble. ^[4]