Neonatal bilious vomiting is due to congenital obstruction in GI tract. This will present in early neonatal life. Exact diagnosis should be made quickly and appropriate surgical intervention should be done immediately to save these unfortunate children.

1. NEONATAL BILIOUS VOMITING
A PROBLEM ORIENTED APPROACH
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2. Neonatal Bilious Vomiting
Dr.B.SELVARAJ MS;Mch; FICS;
ASSOCIATE PROFESSOR IN PEDIATRIC SURGERY
PONDICHERRY INSTITUTE OF MEDICAL SCIENCES
PONDICHERRY- 605014 INDIA
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3. OBJECTIVES
To discuss the differential diagnosis of biliary
emesis in neonates
To discuss appropriate workup to confirm the
diagnosis
To discuss the various treatment options
To make you confident in managing a newborn
with bilious vomiting
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4. A Neonate’s request to Surgeon
“Please exercise the greatest gentleness with
my diminutive tissues and try to correct the
deformity at first operation; give me blood
and proper amount of fluid and electrolytes;
add plenty of oxygen to anesthesia, and I will
show you that I can tolerate a terrific amount
of surgery. You will be surprised at the speed
of my recovery,and I shall be grateful to you”
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Dr.WILLIS POTTS

5. Neonatal Bilious Vomiting Causes
Meconium Peritonitis
Necrotising Enterocolitis
Hirschsprung’s Disease
Anorectal Malformation
Rarely Mesentric Cyst & Intestinal
Duplication
Incarcerated inguinal hernia
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Duodenal atresia/stenosis
Annular Pancreas
Malrotation&MGV
Intestinal Atresia: Jejunal&Ileal
Meconium Ileus
Meconium Plug

6. Neonatal Bilious Vomiting Causes
•MALROTATION & MGV
•MESENTRIC CYST& DUPLICATION
CYST
•CONGENITAL BANDS LIKE VI DUCT
BANDS
•MECONIUM ILEUS
•MECONIUM PLUG
•MECONIUM PERITONITIS
EXTRINSIC
•DUODENAL ATRESIA/STENOSIS
•JEJUNAL/ILEAL ATRESIA
•HIRSCHSPRUNG’S DISEASE
•NECROTISING ENTEROCOLITIS
CAUSES
MURAL
INTRA
LUMINAL

7. DUODENAL ATRESIA/STENOSIS
Failure of vacuolisation & recanalisation of solidcord state of
duodenum at 7 to 10 wks of intrauterine life
Proximal Stomach&Duodenum get dilated and hypertrophied
Bilious vomiting in Postampullary type
Failure to pass meconium
Minimal upper abdominal distension
Hydramnios in mother& Down’s syndrome in the child
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8. DUODENAL ATRESIA/STENOSIS- Types
Membrane Type
Simple
Fenestrated
Windsock Anomaly
Complete Mural discontinuity with connecting
fibrous cord
Complete Mural discontinuity without connecting
fibrous cord
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9. DUODENAL ATRESIA/STENOSIS- Types
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10. Duodenal Atresia/Stenosis Workup
Antenatal USG Abdomen
Double Bubble appearance
Postnatal AXR
Classical Double Bubble
Appearance
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11. Kimura’s Diamond Shaped
DUODENODUODENOSTOMY
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12. Duodenal Atresia- Windsock anomaly
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13. Duodenal Atresia- Post op care
Dysmotility due to Megaduodenum may require a
period of TPN
Transanastomotic feeding tube may obviate the
need for TPN
Graded introduction of enteral feeds as bowel
motility recovers
Prophylactic antibiotics for 48 hrs
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14. ANNULAR PANCREAS
A rim of pancreatic tissue encircles 2nd part of
duodenum
A defect in rotation and fusion of ventral analgae with
the dorsal analgae of pancreas
Clinical picture and radiological findings are akin to
Duodenal Atresia
Treatment also same as that of Duodenal Atresia
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15. ANNULAR PANCREAS
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16. PREDUODENAL PORTAL VEIN
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17. MALROTATION- Embryology
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18. Physiological Umbilical Hernia in Fetus
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19. MALROTATION
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20. MALROTATION- Different Degrees
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21. MALROTATION
Any defect/ deviation of normal midgut rotation leads
to Malrotation
60% of Malrotation patients present in neonatal
period
Most common type of Malrotation is caused by
Ladd’s band due to arrest of rotation at 180*
Midgut volvulus is due to narrow duodenocolic
isthmus
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22. MALROTATION
Bilious Vomiting
Passing scanty meconium
Upper abdominal distension
In Midgut volvulus Bleeding PR,abdominal
distension and vomiting
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23. MALROTATION- IMAGING STUDIES
AXR- “ Double Bubble Appearance”
Upper GI Series:
In Simple Malrotation Absence of C loop; DJ flexure &
jejunal loops on the right side of abdomen
In MGV “Corkscrew Appearance”
USG with Doppler scan:
Reversed position of SMA & SMV
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24. MALROTATION- IMAGING STUDIES
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Double Bubble
Appearance Corkscrew Appearance

25. MALROTATION- IMAGING STUDIES
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Absence of C Loop
Jejunum on Rt side
Reversed position of
SMA & SMV

26. MALROTATION- Ladd’s Procedure
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Division of Ladd’s band
Widening of Duodenocolic
isthmus

27. Malrotation with Midgut Volvulus
Derotation of Volvulus
If bowel is viable leave it
If bowel not viable Resection
and EEA
If bowel viability is doubtful
Second look laparotomy
Complication Short bowel
syndrome
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28. JEJUNAL & ILEAL ATRESIA
Due to mesenteric vascular accident during fetal
life
Incidence 1 in 3000 livebirths
Present within 24hrs with bilious vomiting,not
passed meconium & abdominal distension
Proximal obstruction earlier & more severe is
the bilious vomiting
Distal obstruction more severe is the abdominal
distension
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29. JEJUNAL & ILEAL ATRESIA Types
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30. JEJUNAL & ILEAL ATRESIA Types
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31. JEJUNAL & ILEAL ATRESIA- AXR
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Jejunal Atresia
Triple Bubble Appearance
ILeal atresia
Multiple airfluid levels

32. JEJUNAL & ILEAL ATRESIA
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Barium Enema
Unused Microcolon

33. JEJUNAL ATRESIA- Tapering Jejunoplasty
End to back Anastomosis
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34. Jejunal & Ileal Atresia- Operative Techniques
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35. NECROTISING ENTEROCOLITIS
Disease of paradoxes- unknown etiology
Most likely mechanism vascular compromise to
GIT resulting bacterial invasion of portal venous
system
Common in premature babies
Occurs during 1st or 2nd wk of life after starting oral
feedings in babies weighing < 1.5 kgs
Distal Ileum & Rt colon are commonly involved
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36. NECROTISING ENTEROCOLITIS
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37. NECROTISING ENTEROCOLITIS
Affected bowel Dilated with mucosal necrosis and
subserosal collection of gas
Bilious vomiting,abdominal distension,rectal bleeding
and/or diarrhea
Abdominal wall edema, erythema and fixed
persistent loop of bowel
AXR Pneumatosis intestinalis, Gas in portal vein
and/or Free air in peritoneal cavity
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38. NECROTISING ENTEROCOLITIS-Staging
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39. NECROTISING ENTEROCOLITIS
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40. NECROTISING ENTEROCOLITIS- AXR
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Pneumatosis Intestinalis Portal Venous Gas

41. NECROTISING ENTEROCOLITIS
Management
Start aggressive medical treatment immediately
Keep NPO,NGT aspiration & TPN
Broadspectrum Antibiotics
Physical, radiographic and ultrasonographic
evaluation Q6H for 1st 48 hrs in NICU
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42. NECROTISING ENTEROCOLITIS
Indications for Surgery
Pneumoperitoneum & signs of peritonitis
Edematous & Erythematous anterior abdominal wall
Fixed persistent loop of bowel
Portal venous gas
Sudden deterioration of baby during medical treatment
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43. NECROTISING ENTEROCOLITIS Surgery
Operative strategy depends on extend of involvement of
bowel
If perforation is small Direct suture closure or resection &
primary anastomosis is adequate
In extensive bowel necrosis Remove all gross gangrenous
bowel& do enterostomy
In doubtful bowel viability Second look laparotomy
In low birth weight infants with poor general condition do
just peritoneal drainage
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44. HIRSCHSPRUNG’S DISEASE
Craniocaudal migration of ganglion cells of the bowel
begins at 12th wk of gestation
Arrest of this migration produces an aganglionic segment
of bowel-absence of Aurbach’s & Meissener’s plexus
This aganglionic segment of bowel unable to relax &
peristaltic wave stops proximally- functional obstruction
Incidence 1 in 5000
Male:Female 4:1
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45. HIRSCHSPRUNG’S DISEASE
Mutations in RET proto-oncogene are commonly
associated with Hirschsprung’s disease
Not passed/ delayed passage of meconium
Abdominal distension
Bilious vomiting
Fever & diarrhea suggest Toxic megacolon
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46. HIRSCHSPRUNG’S DISEASE Classification
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47. HIRSCHSPRUNG’S DISEASE
Workup
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AXR: Dilated Bowel
Loops
Barium Enema: Swan Neck
Appearance

48. HIRSCHSPRUNG’S DISEASE
Workup
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Absence of
ganglion cells in
myenteric plexus
Suction rectal bx
Noblet Rectal Mucosal
Suction Biopsy Gun

49. HIRSCHSPRUNG’S DISEASE
Management
Empty bowel with saline enema (30 to 50 ml) daily
If can successfully decompress the bowel- continue
rectal washouts for 45 days
If unable to decompress the bowel- do Rt transverse
colostomy or Levelling colostomy
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50. HIRSCHSPRUNG’S DISEASE
Colostomy
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51. HIRSCHSPRUNG’S DISEASE
Swenson’s
Rectosigmoidectomy
Soave’s Transabdominal
Endorectal Pullthrough
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52. HIRSCHSPRUNG’S DISEASE
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53. HIRSCHSPRUNG’S DISEASE
Duhamel’s Retrorectal
Pullthrough
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54. HIRSCHSPRUNG’S DISEASE
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De La Torre’s Transanal
Endorectal Pullthrough

55. MECONIUM ILEUS
Uncomplicated cases show impacted meconium
in terminal ileum- inspissated tar like meconium
Accounts for 9 to 10% of all neonatal intestinal
obstructions
Present in 8 to 10% of cystic fibrosis patients at
birth
Complicated cases include volvulus,perforation
and peritonitis with sepsis
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56. MECONIUM ILEUS
Signs depend on degree of obstruction and
complications
Significant abdominal distension may develop
during neonatal period
General status progressively deteriorates with
incipient sepsis in cases of perforation
In perforation the scrotum or labia may have
greenish discoloration due to patent processus
vaginalis
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57. MECONIUM ILEUS
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58. MECONIUM ILEUS- Imaging Studies
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Disparate sized bowel
loops
Soap bubble appearance-
Neuhauser’s sign

59. MECONIUM ILEUS- Management
60 to 70% of simple Meconium ileus can be successfully
treated with Gastrograffin enema
Other 30% need operative management
Goal of surgery is to remove the abnormal meconium from
GIT & maintain adequate length of bowel
Surgery consists of resection& anastomosis of involved
segment and/or roux-en-y ileostomy
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60. MECONIUM ILEUS- Management
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61. MECONIUM ILEUS- Management
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Paul Mikulicz
Double Barrel
Ileostomy
Bishop-Koop’s
Distal chimney
Ileostomy
Santulli’s
Proximal chimney
Ileostomy

62. MECONIUM PLUG
A long plug of mucus and sticky meconium in rectum
& distal colon results low intestinal obstruction
Due to immaturity of colonic & rectal expulsive
mechanism
Often associated with neonatal Hirschsprung’s
disease
Rectal exam/rectal wash results in expulsion of the
plug and relief of intestinal obstruction
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63. MECONIUM PLUG
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64. MECONIUM PERITONITIS
Intrauterine perforation of intestine leakage of meconium
into peritoneal cavity reaction of peritoneum to this leaked
meconium
Due to intrauterine vascular compromise of intestine
ischemia&perforation as early as 4th month of intrauterine life
Different pathological types Meconium pseudocyst,
generalised adhesive peritonitis,meconium ascites & infected
meconium peritonitis
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65. MECONIUM PERITONITIS
Often associated with cystic fibrosis & Prognosis is poor
Bilious vomiting, failure to pass meconium and abdominal
distension
Abdominal wall edema, erythema and free fluid in peritoneal
cavity
AXR multiple air fluid levels and peritoneal calcifications
Surgical treatment releasing of adhesions, removal of
devitalised tissues, closure of perforation, intestinal resection&
anastomosis
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66. MECONIUM PERITONITIS
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Meconium Ascites
Central bowel loops
Amorphous calcification
Multiple focal calcifications
Dilated bowel loops

67. Neonatal Bilious Vomiting - Algorithm
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68. Neonatal Bilious Vomiting
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History Physical Plain
XRay
Contrast
studies
Diagnosis Treatment
1
Bilious
vomiting
Not passed
meconium
Maternal
hydramnios
Upper
abdominal
distension
VGP
Down’s
syndrome
Double
Bubble
appearan
ce
Barium
meal :
Duodenal
obstructio
n
Duodenal
Atresia
Or
Annular
Pancreas
Kimura’s
Diamond
Shaped
Duodeno
duodenosto
my
2
Bilious
Vomiting
Infrequent
passage of
small amount
of meconium
Upper
abdominal
distension
Double
Bubble
Appearanc
e
Paucity of
gas in
distal
bowel
Barium
meal:
Absence of
C loop
Duodenum
Cork screw
appearanc
e
Malrotatio
n
Midgut
volvulus
Ladd’s
Procedure
Derotation
Resection
Anastomosi
s

69. Neonatal Bilious Vomiting
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N
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History Physical Plain
XRay
Contrast
studies
Diagnosis Treatment
3
Bilious
vomiting
Not passed
meconium
Abdominal
distension
Empty rectum
Triple
bubble
appearanc
e
Multiple air
fluid levels
Barium
enema :
Micro
colon
Jejunal
atresia
Or
Ileal
atresia
Resection&
End to
back
anastomosi
s
4
Bilious
Vomiting
Passing
meconium
Prematurity&
Birth asphyxia
Bleeding PR
Sick child
Septicemia
Abdominal
distension
Signs of
Peritonitis
Pneumato
sis
intestinalis
Portal
venous
gas
Free
peritoneal
gas
------------
Necrotisin
g
enterocoliti
s
Aggressive
medical
treatment
If it faills
Surgical
intervention

70. Neonatal Bilious Vomiting
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N
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History Physical Plain
XRay
Contrast
studies
Diagnosis Treatment
5
Delayed
passage of
meconium
Vomiting
Gross
abdominal
distension
P/R:Explosive
passage of
meconium &
flatus
Distended
bowel
loops
Barium
enema:
Swan neck
appearanc
e
Hirschspru
ng’s
disease
Pullthrough
operation
with or
without
colostomy
6
Bilious
Vomiting
Failure to
pass
meconium
Moderate to
severe
abdominal
distension
Disparate
sized
bowel
loops
Soap
bubble
appearanc
e
Barium
Enema:
Microcolon
Meconium
ileus
Gastrograffi
n enema
Resection
anastomosi
s
Bishop-
koop &
Santulli
Ileostomy

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N
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History Physical Plain
XRay
Contrast
studies
Diagnosis Treatment
7
Bilious
vomiting
Failure to
pass
meconium
Moderate to
severe
abdominal
distension
P/R: Child
passes plug
Distended
bowel
loops --------------
Meconium
plug
syndrome
Rectal
washouts
8
Bilious
Vomiting
Failure to
pass
meconium
Severe
abdominal
distension
Abdominal
wall edema &
erythema
Multiple air
fluid levels
Peritoneal
calcificatio
n
Free
peritoneal
gas
Barium
Enema:
Microcolon
Meconium
peritonitis
Release pf
adhesions
Closure of
perforation
Resection
&
Anastomosi
s

72. TAKE HOME MESSAGE
“YELLOW COLOR VOMITUS IS
THE RED SIGNAL OF
INTESTINAL OBSTRUCTION
UNLESS PROVED OTHERWISE”
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