A 10-day-old boy is brought to the emergency department by his mother due to persistent bilious vomiting for 10 hours. The patient has also been more irritable and has refused to feed. His last bowel movement was 24 hours ago. The patient was born at term via vaginal delivery with no prenatal or neonatal complications. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. Temperature is 37.9 C (100.2 F), blood pressure is 68/36 mm Hg, and pulse is 176/min. The patient appears lethargic. The fontanelles are open and flat. The neck is supple. The abdomen is firm and distended with hypoactive bowel sounds and tenderness to palpation. Rectal tone is normal, and there is a small amount of stool in the rectal vault. Stool testing is positive for occult blood. Plain abdominal x-ray is shown in the exhibit. Which of the following is the best next step in management of this patient?

Question

A 10-day-old boy is brought to the emergency department by his mother due to persistent bilious vomiting for 10 hours.  The patient has also been more irritable and has refused to feed.  His last bowel movement was 24 hours ago.  The patient was born at term via vaginal delivery with no prenatal or neonatal complications.  Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.  Temperature is 37.9 C (100.2 F), blood pressure is 68/36 mm Hg, and pulse is 176/min.  The patient appears lethargic.  The fontanelles are open and flat.  The neck is supple.  The abdomen is firm and distended with hypoactive bowel sounds and tenderness to palpation.  Rectal tone is normal, and there is a small amount of stool in the rectal vault.  Stool testing is positive for occult blood.  Plain abdominal x-ray is shown in the exhibit.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d61a_572c_bc81_eff2730a6a3b_MD0003_00 This patient with bilious emesis and abdominal distension has dilated bowel loops and air-fluid levels on abdominal x-ray, findings consistent with small-bowel obstruction. In a neonate with a normal rectal examination, this presentation is highly concerning for neonatal midgut volvulus (twisting of the small intestine), a complication of malrotation that frequently occurs in the first month of life but may develop at any age. abdominal x-ray malrotation The most common presentation of volvulus in an infant is bilious emesis. However, progressive intestinal ischemia and necrosis can lead to rapid clinical deterioration, as seen in this patient, with gastrointestinal (GI) bleeding (eg, hematochezia, hematemesis) or hypovolemic and/or septic shock. Patients may have signs of peritonitis due to intestinal perforation. For neonates with suspected volvulus (eg, bilious emesis, x-ray with dilated loops of bowel, normal rectal examination) who are hemodynamically stable, upper GI series (consisting of x-rays with contrast material for improved visualization) is the diagnostic gold standard. In contrast, in a neonate with bilious emesis who is hemodynamically unstable (eg, hypotension, tachycardia) or has peritoneal signs (eg, firm, distended, tender abdomen), like this infant, the next step in management is exploratory laparotomy. Surgical exploration should not be delayed for diagnostic or repeat imaging due to increased risk of mortality (Choices E and F). In patients with volvulus, surgery involves untwisting the volvulus to relieve the bowel obstruction and restore arterial blood flow; viable bowel is fixated to prevent future recurrence. (Choice A) Contrast enema can be performed for suspected Hirschsprung disease (HD) or intussusception, both of which can cause bilious emesis and signs of intestinal perforation. However, rectal examination in HD typically shows an expulsion of stool and gas due to distal obstruction relief, and birth history often reveals delayed passage of meconium. Intussusception typically presents in children age 6-36 months; this patient's age makes this diagnosis extremely unlikely. (Choices B and D) CT scan of the abdomen and pelvis and GI endoscopy can help to identify a source of GI bleeding (eg, polyps, malignancy, irritable bowel disease) in older children and adults but are avoided when possible in infants due to the risks associated with radiation and anesthesia. More important, this patient's firm abdomen, lethargy, and tachycardia are concerning for perforation, making surgical intervention the priority over diagnostic testing. Educational objective: Bilious emesis in a neonate with hemodynamic instability or peritoneal signs (eg, rigid abdomen) warrants emergency exploratory laparotomy. Malrotation with midgut volvulus, which can cause intestinal perforation and necrosis, should be considered in patients who also have a normal rectal examination and air-fluid levels on x-ray. References: Intestinal rotational abnormalities and midgut volvulus. (http://www.ncbi.nlm.nih.gov/pubmed/27894424)

A 10-Day-Old Boy Is Brought to the Emergency Department by His