Paeds · gastroenterology-hepatology-and-nutrition
Bilious vomiting and intestinal obstruction
Also known as Bilious vomiting · Green vomiting in the newborn · Neonatal intestinal obstruction · Malrotation · Midgut volvulus · Ladd bands · Ladd procedure · Duodenal atresia · Jejunoileal atresia · Meconium ileus · Double bubble
Fellowship guide to bilious vomiting and intestinal obstruction in children, built around the one rule that green vomiting in a neonate is malrotation with midgut volvulus until proven otherwise. The page covers the high versus low obstruction split, the anatomy that makes a narrow mesenteric base twist, the resuscitation and urgent imaging that precede the Ladd procedure, and the differential from duodenal atresia and meconium ileus to Hirschsprung disease and intussusception.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- Bilious (green) vomiting in a neonate is malrotation with midgut volvulus until proven otherwise, and demands nasogastric decompression, resuscitation and an emergency surgical opinion the same hour, not the next day
- A well-looking neonate with bilious vomiting can still have a volvulus that is strangling the entire midgut, because tenderness, distension and shock are late signs that appear once the bowel is already dying
- Abdominal distension with delayed passage of meconium and later vomiting points to a low obstruction such as Hirschsprung disease, ileal atresia or meconium ileus and still needs urgent assessment
- Blood in the stool, a tender rigid abdomen, discolouration of the abdominal wall or cardiovascular collapse in a child with obstruction signals bowel ischaemia or perforation and a move straight to theatre
- An older child or adolescent with recurrent bilious vomiting, intermittent central abdominal pain and failure to thrive can have intermittent volvulus on an undiagnosed malrotation and deserves an upper gastrointestinal contrast study
Life stages
Care settings
Clinical exam formats
Board mappings
- Recognition of bilious vomiting as a surgical emergency
- Causes of neonatal intestinal obstruction
- Resuscitation of the obstructed neonate
- Malrotation and midgut volvulus: diagnosis and the Ladd procedure
- Differentiating high and low neonatal obstruction
- Management of duodenal and jejunoileal atresia and meconium ileus
- The neonate with bilious vomiting
- Interpreting the plain abdominal radiograph and upper gastrointestinal contrast study
- Fluid and electrolyte management of the obstructed child
- Long case: the child with a complex gastrointestinal surgical history
- Short case: abdominal examination of the child with distension
- Gastroenterology and surgery: neonatal intestinal obstruction
- Acute surgical abdomen in the child
- Bilious vomiting and causes of intestinal obstruction
- Malrotation, volvulus and the Ladd procedure
- Assessment of the infant with vomiting and abdominal distension
- Neonatal intestinal obstruction
- Malrotation and midgut volvulus
- Bilious emesis in the newborn
- Patient Care: recognition and stabilisation of the surgical abdomen in children
- Medical Expert: bilious vomiting and intestinal obstruction in children
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]
References12ShowHide
- [1]Godbole P; Stringer MD Bilious vomiting in the newborn: How often is it pathologic? J Pediatr Surg, 2002.PMID 12037761
- [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]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]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]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]Choi G; Je BK; Kim YJ Gastrointestinal Emergency in Neonates and Infants: A Pictorial Essay. Korean J Radiol, 2022.PMID 34983099
- [7]Rich BS; Bornstein E; Dolgin SE Intestinal Atresias. Pediatr Rev, 2022.PMID 35490204
- [8]Kyrklund K; Sloots CEJ; de Blaauw I; et al ERNICA guidelines for the management of rectosigmoid Hirschsprung's disease. Orphanet J Rare Dis, 2020.PMID 32586397
- [9]Sathe M; Houwen R Meconium ileus in Cystic Fibrosis. J Cyst Fibros, 2017.PMID 28986020
- [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]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]Ingoe R; Lange P The Ladd's procedure for correction of intestinal malrotation with volvulus in children. AORN J, 2007.PMID 17292689