Neonatal Bilious Emesis Guideline

Guideline · Aug 2019 · 1 min read

In brief

Clinical guideline for evaluating and managing bilious emesis in neonates, a surgical emergency requiring prompt assessment for malrotation, midgut volvulus, and other causes of intestinal obstruction.

Written by the GCMD Library team from the guideline.

Initial Assessment and Imaging

Neonates presenting to the ED with bilious emesis require immediate two-view abdominal radiographs (2V AXR). This initial imaging helps determine the urgency of surgical intervention and guides subsequent diagnostic workup.

Criteria for Urgent Surgical Intervention

Immediate operative management is indicated for neonates with acute abdomen, ill-appearing clinical status, or other concerns identified by the surgical team. These patients should be booked as emergency (A) cases with consideration for bolus resuscitation en route to the operating room.

Distal Obstruction Evaluation

When distal intestinal obstruction is suspected, upper GI series and contrast enema studies are indicated. The sequence of these studies should be determined through discussion between the Surgery Attending/Fellow and Radiology Attending.

Upper GI Study Interpretation and Management

A positive upper GI study indicating malrotation or volvulus requires immediate operative intervention as an emergency case. Negative studies warrant continued observation and potential return to the ED for further evaluation if symptoms persist.

Statements in this guideline

A two-view abdominal X-ray should be obtained for neonates presenting with bilious emesis.
Recommendation
Urgent surgical intervention is indicated for neonates with bilious emesis who have an acute abdomen, appear ill, or have other concerns identified by the surgical team.
RecommendationIndications for urgent surgery intervention
Neonates requiring urgent surgical intervention should be booked as an A case and bolus resuscitation should be considered en route to the operating room.
Recommendation
When distal obstruction is suspected, upper GI and contrast enema studies should be performed, with the sequence of studies discussed with the Surgery Attending or Fellow and Radiology Attending.
Recommendation
An upper GI study should be performed when distal obstruction is not suspected.
Recommendation
A positive upper GI study is an indication to proceed to the operating room, booking as an A case with consideration of bolus resuscitation en route.
Recommendation

Full text

Neonate in ED with bilious emesis 2V AXR Need for urgent surgical intervention? Yes No Return to ED for further work-up/observation To OR•Book as A case•Should consider bolus resuscitation enroute to OR Indications for urgent surgery intervention:•Acute abdomen•Ill-appearing•Other concerns per surgical team Concern for distal obstruction?YesUpper GI and contrast enema(discuss sequence of studies with Surgery Attending/Fellow and Radiology Attending) No UGIPositiveTo OR•Book as A case•Should consider bolus resuscitation enroute to OR Negative Updated 1/2019

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