Bilious vomiting and neonatal intestinal obstruction — branching viva

Branching viva on the rule that bilious vomiting is obstruction until proven otherwise, the proximal-versus-distal classification and imaging choice, the immediate resuscitation pathway, the time-critical midgut volvulus decision, and the condition-specific definitive surgery.

branching clinical structured oral4 min readVerification in progress

Prompt

A term infant born after a pregnancy complicated by polyhydramnios vomits green-stained fluid at 18 hours of life. The examiner asks: 'Walk me through your assessment, your working diagnosis, your immediate management, and your definitive plan.'

Branch 1 — The rule and the colour test

Examiner: "The nurse tells you the vomit is green. What does that mean, and why?" [1]

A green or yellow-green vomit is bilious. Bile enters the duodenum at the ampulla of Vater, so for bile to appear in the vomit the obstruction must lie beyond the ampulla. This anatomical fact makes bilious vomiting a reliable bedside marker of obstruction and a surgical problem — I would treat it as obstruction until a contrast study or an operation says otherwise. [1]

Paediatrics Fellowship Pro

You have read the opening of this viva. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References6Show ledger

[1]Godbole P, Stringer MD Bilious vomiting in the newborn: How often is it pathologic? J Pediatr Surg, 2002.PMID 12037761
[4]Patterson KN, Cruz S, Nwomeh BC Congenital duodenal obstruction - Advances in diagnosis, surgical management, and associated controversies. Semin Pediatr Surg, 2022.PMID 35305801
[5]Svetanoff WJ, Srivatsa S, Diefenbach K Diagnosis and management of intestinal rotational abnormalities with or without volvulus in the pediatric population. Semin Pediatr Surg, 2022.PMID 35305800
[7]Haricharan RN, Georgeson KE Hirschsprung disease. Semin Pediatr Surg, 2008.PMID 19019295
[9]Sathe M, Houwen R Meconium ileus in Cystic Fibrosis. J Cyst Fibros, 2017.PMID 28986020
[10]Hajivassiliou CA Intestinal obstruction in neonatal/pediatric surgery. Semin Pediatr Surg, 2003.PMID 14655163