A 15-day-old boy is brought to the emergency department due to 2 occurrences of green vomit this morning. The patient has been exclusively breastfed since birth but has shown little interest in feeding over the past 24 hours. His last stool was 2 days ago. The patient was born full term by uncomplicated vaginal delivery, and he had an uneventful nursery course, including the passage of meconium on the first day of life. Temperature is 36.7 C (98.1 F), blood pressure is 85/50 mm Hg, pulse is 142/min, and respirations are 46/min. Examination shows a fussy boy with dry mucous membranes and a mildly sunken anterior fontanelle. The abdomen is soft and distended. The mother is instructed to withhold breastfeeding, and intravenous fluids are given. Abdominal x-ray reveals no free air. Which of the following is the best next step in management of this patient?

Question

A 15-day-old boy is brought to the emergency department due to 2 occurrences of green vomit this morning.  The patient has been exclusively breastfed since birth but has shown little interest in feeding over the past 24 hours.  His last stool was 2 days ago.  The patient was born full term by uncomplicated vaginal delivery, and he had an uneventful nursery course, including the passage of meconium on the first day of life.  Temperature is 36.7 C (98.1 F), blood pressure is 85/50 mm Hg, pulse is 142/min, and respirations are 46/min.  Examination shows a fussy boy with dry mucous membranes and a mildly sunken anterior fontanelle.  The abdomen is soft and distended.  The mother is instructed to withhold breastfeeding, and intravenous fluids are given.  Abdominal x-ray reveals no free air.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d1aa_ef3a_bc81_112829dffeb7_MD0003_00 Bilious emesis in neonates is typically caused by intestinal obstruction (eg, duodenal atresia, volvulus) and is often a surgical emergency. This 2-week-old with previously normal feeding and stooling patterns has new-onset bilious emesis and abdominal distension concerning for malrotation with midgut volvulus (ie, intestinal torsion). Additional signs and symptoms of volvulus include poor feeding, dehydration (eg, dry mucous membranes, sunken fontanelle), and/or hypovolemic shock. malrotation with midgut volvulus Initial management of clinically stable patients (eg, normal vital signs) with bilious emesis includes cessation of enteral feeds, nasogastric tube decompression, administration of intravenous fluids, and diagnostic imaging. In patients with volvulus, an x-ray may identify dilated loops of bowel and air-fluid levels (due to intestinal obstruction) or pneumoperitoneum (due to intestinal perforation). However, x-rays may be normal and are insensitive for midgut volvulus; serial x-rays are unlikely to be diagnostic (Choice C). pneumoperitoneum Therefore, all hemodynamically stable infants with bilious emesis and a nondiagnostic x-ray, as seen in this patient, warrant an upper gastrointestinal (GI) series to evaluate for midgut volvulus. Diagnostic findings include an abnormally located ligament of Treitz on the right side of the abdomen (malrotation) and a duodenal corkscrew, or bird's-beak, appearance (volvulus). (Choice A) A contrast enema is indicated for distal bowel obstructions, such as Hirschsprung disease and meconium ileus (microcolon). Bilious emesis can occur; however, these conditions usually present with failure to pass meconium within the first 2 days of life and dilated loops of bowel on x-ray. Hirschsprung disease meconium ileus (Choice B) CT scan of the abdomen with intravenous contrast may identify midgut volvulus. However, an upper GI series is preferred for the evaluation of malrotation because it is more sensitive and has less radiation exposure. (Choice D) Pyloric stenosis, diagnosed by a hypertrophied pyloric muscle on ultrasound, typically presents at age 3-5 weeks with projectile vomiting, which is nonbilious due to gastric outlet obstruction. In addition, classic findings include visible peristaltic waves and a palpable abdominal mass, neither of which is seen in this patient. Educational objective: Malrotation with midgut volvulus usually presents with bilious vomiting in neonates. Initial evaluation in clinically stable patients includes abdominal x-ray, which may be normal. The gold standard for diagnosis is an upper gastrointestinal series, which shows a right-sided ligament of Treitz and a corkscrew duodenum. References: Imaging of malrotation in the neonate. (http://www.ncbi.nlm.nih.gov/pubmed/25454052)

A 15-Day-Old Boy Is Brought to the Emergency Department Due