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Bilious vomiting in newborns is an urgent condition that requires the immediate involvement of a team of pediatric surgeons and neonatologists for perioperative management. However, initial detection, evaluation and treatment are often performed by nurses, family physicians and general pediatricians. Bilious vomiting, with or without abdominal distention, is an initial sign of intestinal obstruction in newborns. A naso- or orogastric tube should be placed immediately to decompress the stomach. Physical examination should be followed by plain abdominal films. Dilated bowel loops and air-fluid levels suggest surgical obstruction. Contrast radiography may be required. Duodenal atresia, midgut malrotation and volvulus, jejunoileal atresia, meconium ileus and necrotizing enterocolitis are the most common causes of neonatal intestinal obstruction. (Am Fam Physician 2000;61:2791-8.)
When a neonate develops bilious vomiting, one should suspect a surgical condition. After a focused physical examination, a nasogastric or orogastric catheter should be placed for gastric decompression to prevent further vomiting and aspiration. This should be done before any diagnostic or therapeutic maneuvers are performed. Establishment of an intravenous line should follow for administration of fluid, electrolytes and nutrition. When the patient is hemodynamically stabilized, appropriate imaging studies of the abdomen should be performed. These would include plain abdominal films and/or contrast studies. When dilated bowel loops and air-- fluid levels are demonstrated, the diagnosis of a surgical abdomen is suggested, and urgent consultation with a pediatric surgeon is indicated, preferably in a pediatric surgical center. Gastric decompression, hydration and secured airway must be completed before initiating transport of the patient. Intestinal obstruction with bilious vomiting in neonates can be caused by duodenal atresia, malrotation and volvulus, jejunoileal atresia, meconium ileus, and necrotizing enterocolitis (Table 1).
Duodenal Atresia
Duodenal atresia is a congenital obstruction of the second portion of the duodenum. Its etiology is believed to be failure of recanalization of this bowel segment during the early gestational stage. The pregnancy is associated with polyhydramnios, as it is in many cases where the infant is subsequently discovered to have an intestinal obstruction. Duodenal atresia occurs in 1 per 5,000 to 10,000 live births, involving male infants more commonly than female infants. Down syndrome occurs in about one-quarter of these patients; congenital heart disease occurs in about 20 percent of them.
Duodenal atresia may result...