Bilious vomiting in the newborn: How often is it pathologic?

Presented at the British Association of Paediatric Surgeons XLVIII Annual International Congress, London, July 2001.
https://doi.org/10.1053/jpsu.2002.32909Get rights and content

Abstract

Background/Purpose: Intestinal obstruction is one of the most common reasons for admission to a neonatal surgical unit and frequently is manifest by bilious vomiting. Not all cases of neonatal bilious vomiting are caused by intestinal obstruction. This study aimed to investigate the outcome of neonates with bilious vomiting. Methods: A prospective audit was undertaken of all neonates with a history of bilious vomiting referred to a regional pediatric surgical unit during a 2-year period (1998 to 2000). Infants with bilious nasogastric aspirates but no vomiting were not included. Demographic details, symptomatology, investigations, and final diagnoses were recorded. Subsequent clinical progress was ascertained by out-patient review or telephone interview. Results: Sixty-three consecutive neonates (35 boys, 28 girls) were identified with a median gestational age of 40 (range 31 to 42) weeks and median birth weight of 3.5 kg (range 1.67 to 4.64). Median age at presentation was 26 hours (range, 9 hr to 28 days). A surgical cause of bilious vomiting was identified in 24 (38%): Hirschsprung's disease (n = 9), small bowel atresia (n = 5), intestinal malrotation (n = 4), meconium ileus (n = 3), meconium plug (n = 1), colonic atresia (n = 1), and milk inspissation (n = 1). Nineteen of these had both abdominal signs and an abnormal plain abdominal radiograph, and 4 had an abnormal abdominal radiograph only. In one infant with intestinal malrotation, clinical examination and plain radiography were unremarkable. After definitive surgery, all 24 infants were well at a median age of 14 (7 to 28) months. No surgical cause for bilious vomiting was found in 39 (62%) neonates whose symptoms resolved with conservative management. Conclusions: These data emphasize the maxim that bilious vomiting in the newborn should be attributed to intestinal obstruction until proved otherwise. However, in this prospective audit, bilious vomiting was not caused by intestinal obstruction in 62% of cases, and most of these infants suffered no further sequelae. J Pediatr Surg 37:909-911. Copyright 2002, Elsevier Science (USA). All rights reserved.

Section snippets

Materials and methods

All neonates with a history of bilious vomiting referred to a regional pediatric surgical unit during a 2-year period (September 1998 to September 2000) were prospectively audited. Only infants with “green” vomiting witnessed by an experienced nurse, midwife, or doctor were included. Neonates with bilious nasogastric aspirates but no vomiting were not included. Demographic details, symptomatology, investigations, and final diagnosis were recorded. Routine clinical care remained unchanged during

Results

Sixty-three consecutive neonates (35 boys, 28 girls), in whom the dominant presenting feature was bilious vomiting, were identified. Their median gestational age was 40 weeks (range, 31 to 42) and birth weight was 3.5 kg (range, 1.67 to 4.64). Median age at presentation was 26 hours (range, 9 hrs to 28 days). Fifty were delivered vaginally (2 by forceps and 1 by ventouse extraction) and 13 by cesarian section. Forty-nine (78%) passed meconium within 24 hours of birth, and 11 of these had

Discussion

This prospective study shows that bilious vomiting in the neonatal period is not invariably associated with intestinal obstruction. This was the underlying cause in 38% of our cases. In the only previously published study of bilious vomiting in the newborn, a similar proportion of neonates (31 of 45 [69%]) were found to have no obvious surgical cause and were categorized as having idiopathic bilious vomiting.3 This same study found no correlation between delayed passage of meconium (>24 hr) and

Acknowledgements

The authors thank their pediatric surgical colleagues whose patients were included in this audit.

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Address reprint requests to M.D. Stringer, Department of Paediatric Surgery, Ward 11, Gledhow Wing, St James University Hospital, Beckett St, Leeds LS9 7TF, England.

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