Bilious vomiting and intestinal obstruction

Overview & Definition

Picture a three-day-old baby who fed well, then suddenly vomits a mouthful of bright green fluid. That single colour changes everything. Bile is green because it enters the gut beyond the second part of the duodenum, so green vomit means the obstruction sits at or below that point, and in a neonate the diagnosis you must exclude first is malrotation with midgut volvulus. This is the surgical emergency that can strangle the entire small bowel within hours. [1] [2]

Intestinal obstruction is the mechanical or functional blockage of the flow of gut contents, and in children it announces itself through vomiting, abdominal distension, pain and failure to pass stool or wind. The level of the blockage shapes the picture: a high obstruction vomits early and bile-stained with little distension, while a low obstruction distends the abdomen and delays the passage of meconium before it vomits. Reading that pattern points you towards the cause and its urgency. [6] [7]

The task in the emergency is therefore not to make the final anatomical diagnosis but to act on the pattern. You resuscitate the child, decompress the stomach, and involve a surgeon and radiologist without delay, because the cost of treating a benign cause as an emergency is small while the cost of missing a volvulus is the loss of the entire midgut. Most bilious vomiting will turn out to be something less dangerous, yet every episode earns the same urgent respect. [1] [3]

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1. [1]Godbole P; Stringer MD Bilious vomiting in the newborn: How often is it pathologic? J Pediatr Surg, 2002.PMID 12037761
2. [2]Lampl B; Levin TL; Berdon WE; et al Malrotation and midgut volvulus: a historical review and current controversies in diagnosis and management. Pediatr Radiol, 2009.PMID 19241073
3. [3]Salehi Karlslätt K; Husberg B; Ullberg U; et al Intestinal Malrotation in Children: Clinical Presentation and Outcomes. Eur J Pediatr Surg, 2024.PMID 36882104
4. [4]Graziano K; Islam S; Dasgupta R; et al Asymptomatic malrotation: Diagnosis and surgical management: An American Pediatric Surgical Association outcomes and evidence based practice committee systematic review. J Pediatr Surg, 2015.PMID 26205079
5. [5]Dekonenko C; Sujka JA; Weaver K; et al The identification and treatment of intestinal malrotation in older children. Pediatr Surg Int, 2019.PMID 30810798
6. [6]Choi G; Je BK; Kim YJ Gastrointestinal Emergency in Neonates and Infants: A Pictorial Essay. Korean J Radiol, 2022.PMID 34983099
7. [7]Rich BS; Bornstein E; Dolgin SE Intestinal Atresias. Pediatr Rev, 2022.PMID 35490204
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9. [9]Sathe M; Houwen R Meconium ileus in Cystic Fibrosis. J Cyst Fibros, 2017.PMID 28986020
10. [10]Sadigh G; Zou KH; Razavi SA; et al Meta-analysis of Air Versus Liquid Enema for Intussusception Reduction in Children. AJR Am J Roentgenol, 2015.PMID 26496576
11. [11]Hukui J; Jones S; Coughlin K; et al Non-pathological bilious vomiting complicating therapeutic hypothermia for hypoxic ischaemic encephalopathy in neonates: a retrospective cohort study. BMJ Paediatr Open, 2017.PMID 29637099
12. [12]Ingoe R; Lange P The Ladd's procedure for correction of intestinal malrotation with volvulus in children. AORN J, 2007.PMID 17292689