A 12-hour-old girl in the neonatal intensive care unit has bilious emesis. She was born at 35 weeks gestation by vaginal delivery to a 22-year-old woman who did not receive prenatal care and used cocaine during her pregnancy. The infant has urinated but has not had a bowel movement. She was able to take 2 bottle feeds by mouth but has been vomiting green fluid since the third feed. Birth weight was 2 kg (4 lb 6 oz), which is small for gestational age. Temperature is 36.9 C (98.4 F), pulse is 160/min, and respirations are 40/min. The abdomen is distended. The rest of the examination is unremarkable. Abdominal x-ray is shown below. Which of the following is the most likely diagnosis in this patient?

Question

A 12-hour-old girl in the neonatal intensive care unit has bilious emesis.  She was born at 35 weeks gestation by vaginal delivery to a 22-year-old woman who did not receive prenatal care and used cocaine during her pregnancy.  The infant has urinated but has not had a bowel movement.  She was able to take 2 bottle feeds by mouth but has been vomiting green fluid since the third feed.  Birth weight was 2 kg (4 lb 6 oz), which is small for gestational age.  Temperature is 36.9 C (98.4 F), pulse is 160/min, and respirations are 40/min.  The abdomen is distended.  The rest of the examination is unremarkable.  Abdominal x-ray is shown below.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d682_dcca_bc81_45bdd59fd3f0_MD0003_00 The bilious emesis, abdominal distension, and x-ray findings in this neonate are consistent with jejunal atresia. Intestinal atresia can occur anywhere along the gastrointestinal tract. Atresia of the jejunum or ileum is thought to occur due to a vascular accident in utero that causes necrosis and resorption of the fetal intestine, leaving behind blind proximal and distal ends of intestine. Risk factors include poor fetal gut perfusion from maternal use of vasoconstrictive medications or substances such as cocaine and tobacco. In contrast to duodenal atresia, jejunal and ileal atresia are not associated with chromosomal abnormalities. A triple bubble sign and gasless colon on abdominal x-ray (above) reflects gas trapping in the stomach, duodenum, and jejunum. Treatment should begin with resuscitation and stabilization of the patient, followed by surgical correction. Prognosis depends on the length of affected bowel as well as the patient's gestational age and birth weight. (Choice A) This infant is premature with intrauterine growth restriction (low birth weight) due to prenatal cocaine exposure. After birth, these infants are at risk for withdrawal symptoms, including irritability, tremors, and high-pitched cry. This patient's bilious emesis and x-ray, however, are highly suggestive of bowel obstruction. (Choice B) Duodenal atresia is thought to result from failure of the duodenum to recanalize and presents with abdominal distension and bilious emesis. X-ray reveals a double bubble rather than the triple bubble seen in this patient. double bubble (Choice C) Hirschsprung disease can present with abdominal distension and bilious emesis as well as delayed passage of meconium (age >48 hours). This infant is only 12 hours old and is not expected to have passed meconium yet. Because the obstruction is typically at the level of the rectosigmoid junction, dilated loops of bowel would be seen on x-ray, making this diagnosis less likely. dilated loops of bowel (Choice E) Necrotizing enterocolitis typically presents as abdominal distension, bloody stools, and vital sign instability in premature infants. The hallmark finding on x-ray is pneumatosis intestinalis (extravasation of gas into the damaged bowel wall). pneumatosis intestinalis (Choice F) Pyloric stenosis most commonly presents at age 3-6 weeks with nonbilious, projectile vomiting. An olive-shaped mass is sometimes palpable in the epigastric area. This patient's age and bilious emesis make this diagnosis unlikely. Educational objective: Jejunal atresia presents with bilious vomiting and abdominal distension. Abdominal x-ray reveals a triple bubble sign and gasless colon. Risk factors include prenatal exposure to cocaine and other vasoconstrictive substances. References: Malrotation and intestinal atresias. (http://www.ncbi.nlm.nih.gov/pubmed/25448782) The diagnostic value of the triple bubble sign in proximal jejunal atresia: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/15030076)

A 12-Hour-Old Girl in the Neonatal Intensive Care Unit Has