An audit of bilious vomiting in term neonates referred for pediatric surgical assessment: can we reduce unnecessary transfers?

High risk and low incidence diseases: Pediatric digestive volvulus

INTRODUCTION

Pediatric digestive volvulus is a serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of pediatric digestive volvulus, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Pediatric digestive volvulus is a deadly condition most commonly associated with malrotation. It occurs when the stomach or small intestine twists on itself, resulting in ischemia and potentially strangulation with necrosis and perforation. Presentation differs based on the gastrointestinal (GI) segment affected, degree of twisting, and acuity of the volvulus. Gastric volvulus most commonly presents with retching with or without nonbilious emesis and epigastric distension with pain, while midgut volvulus typically presents with bilious emesis in infants. Patients with GI necrosis and perforation may present with hemodynamic compromise and peritonitis. If suspected, emergent consultation with the pediatric surgery specialist is necessary, and if this is not available, transfer to a center with a pediatric surgeon is recommended. Imaging includes plain radiography, ultrasound, or upper GI series, while treatment includes resuscitation, administration of antibiotics, and emergent surgical decompression and detorsion of the involved segments.

CONCLUSION

An understanding of pediatric digestive volvulus and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease.

Upper gastrointestinal series in healthy neonates with bilious vomiting-is it still obvious? A retrospective observational study

AIM

Demand for upper gastrointestinal contrast series (UGI) to investigate bilious vomiting (BV) has increased in recent years, mostly due to greater awareness of the need to rule out malrotation and midgut volvulus (MGV). We aimed to examine predictive value of clinical parameters in the management of healthy neonates presenting with BV and re-assess the role of UGI in their management.

METHODS

A retrospective cohort study including medical, imaging and surgical data of neonates who underwent UGI due to BV.

RESULTS

A total of 157 term neonates, eight neonates (5.1%) had confirmed surgical diagnosis of malrotation, five of them had malrotation with MGV, including two neonates who underwent extensive intestinal resection due to necrosis. Neonates with a combination of abnormal plain radiograph and abdominal distention had 10 times higher odds of malrotation diagnosis, adjusting for age at first BV (p = 0.017). Neonates with a combination of abnormal plain radiograph, abdominal distention and abdominal tenderness had 25 times higher odds of MGV (p = 0.002).

CONCLUSION

This study reaffirms the role of UGI as the current main diagnostic tool for malrotation and MGV. Physical examination and plain radiograph findings can help but cannot substitute UGI study.

How should the neonatal retrieval team respond to the neonate referred with bilious vomiting?

AIM

Bilious vomiting (BV) in the neonatal period may herald malrotation with life-threatening volvulus. In New South Wales, contrast fluoroscopy is not available in non-tertiary paediatric centres; therefore, transfer is required. An infant with BV referred to Newborn and Paediatric Emergency Transport Service is prioritised for urgent retrieval to a surgical centre for contrast fluoroscopy and paediatric surgical review. This study analysed how many neonates with BV needed retrieval to prevent bowel loss or to save one life and to identify predictors of malrotation and/or volvulus.

METHODS

All neonatal referrals (<29 days) to Newborn and Paediatric Emergency Transport Service between 31 July 2014 and 31 July 2020 with BV or aspirates were examined. Data on time of onset of BV, time of call for retrieval, vital signs, lactate level and blood glucose at referral, time of arrival at the surgical centre and outcome were analysed.

RESULTS

Of 391 neonates referred with BV, 113 (28.9%) had a surgical cause and 31 (7.9%) had a time-critical malrotation and/or volvulus. All 31 neonates were well at referral with normal vital signs including three neonates who subsequently died. Lactate levels at referral (1-7.5 mmol/L) were not predictive of outcome. The odds of a time-critical diagnosis increased with every day of age (odds ratio = 1.097), heart rate >140 (P = 0.04) and decreased for each kilogram of birthweight (odds ratio 0.475; confidence interval 0.294-0.768).

CONCLUSIONS

Neonates with BV require urgent referral to paediatric surgery and contrast fluoroscopy. Thirteen urgent transfers are required to preserve the bowel integrity and life in one baby.

Current assessment of parental and health professional perception of the colour of neonatal vomiting: Results of a scoping survey

PURPOSE

To determine current perceptions of doctors, nurses and parents for the colour of a neonatal vomit which should prompt an urgent surgical review.

METHODS

A voluntary scoping survey of parents/guardians of patients and non-surgical healthcare professionals was conducted with respondents asked to choose from 8 different selections in a colour swatch from pale yellow to dark green. A control group consisted of 13 paediatric surgeons. Data were analysed using the paired t test, Fishers exact test. A p value of < 0.05 was considered to be significant.

RESULTS

365 participants responded: 36% (131/365) parents, 18% (64/365) nurses and 46% (166/365) doctors. 4/365 (1%) did not state their role. 343 participants completed all questions and responses were analysed using total responses for each question. 82% (121/148) of doctors and 78% (50/64) of nurses had more than 3 years of post-graduate experience. Overall, 63% (227/361) of participants (100% paediatric surgeons, 78% other doctors, 75% nurses/midwives & 30% parents) considered dark and light green vomits to be a sign of intestinal obstruction. 67% (242/361) of participants (100% paediatric surgeons, 72% other doctors, 56% nurses/midwives and 62% parents) believed dark and light green vomiting needed an urgent surgical referral. There were significant differences between the control group and other groups in terms of whether the neonate could wait until the next day for a review; nursing staff (p = 0.0002), postnatal/midwifery (p =  < 0.0001), emergency medicine (p = 0.04), general practice (p = 0.002), neonatal (p = 0.0001) and paediatricians (p = 0.005). Only the neonatologists (p = 0.04), nursing staff (p = 0.001) and postnatal/midwifery (p = 0.004) believed that the neonate could have safe observation.

CONCLUSION

Although the perception that green vomiting is potentially serious is acknowledged by the majority of healthcare professionals surveyed, there is still a requirement for more targeted educational practices in nursing, midwifery and medical staff.

The adequacy of fluoroscopic upper gastrointestinal studies for suspected intestinal volvulus in a tertiary care centre vs. secondary centres: A regional multicentre study

INTRODUCTION

Early diagnosis and treatment of intestinal volvulus are important to reduce morbidity. A fluoroscopic upper GI study is the gold standard for diagnosis and may be performed in a secondary or tertiary care centre prior to surgery. It is important the reporting radiologist is confident in the findings. We aim to assess whether there is any difference in confidence and study quality between paediatric and general radiologists who work in secondary or tertiary care centres.

METHODS

Retrospective review of initial radiology reports and blinded review of the study images by paediatric radiologists.

RESULTS

A total of 277 children underwent a fluoroscopic study for intestinal volvulus over a four-year period. The majority were performed at a tertiary care centre, by paediatric radiologists. The confidence of initial reporting was higher in paediatric than general radiologists despite whether they worked in a secondary or tertiary care centre (P-value < 0.001). On retrospective review, studies performed by paediatric radiologists were rated as having a higher confidence in identifying the location of the duodenojejunal flexure. General radiologists tended to have a slightly higher rate of repeat studies but still low at 2.2%. Despite this, there was no significant difference in the diagnosis rates and secondary centre general radiologists excluded malrotation in 62% of studies likely reducing transfer rates.

CONCLUSION

Confidence in initial reporting and on review of the duodenojejunal flexure location in suspected intestinal volvulus is higher in paediatric radiologists compared with general radiologists, although diagnosis rates are no different.

Bilious Vomiting in the Newborn: A Three-Year Experience in a Tertiary Medical and Surgical Centre

BACKGROUND

Bilious vomiting in the newborn is common and requires urgent attention to exclude malrotation. The proportion of neonates with surgical abnormalities, however, is small, and there are other causes. Study Objectives. We reviewed our experience of infants with bilious vomiting to demonstrate the importance of input from the tertiary surgical and medical team to arrive at the correct diagnosis.

DESIGN

Admissions with bilious vomiting/aspirates of term born infants over a three-year period to a tertiary medical and surgical unit were reviewed.

RESULTS

During the study period, 48 infants were admitted with bilious vomiting. Forty-five infants had upper gastrointestinal (UGI) contrast studies, and only six had an abnormal study: four had malrotation and two had Hirschsprung's disease. Of the infants with a normal UGI study, no cause was identified in 20 cases, 13 infants were treated for sepsis, one had a meconium plug, one an ovarian cyst, and two infants were polycythaemic. One infant was diagnosed with bilateral polymicrogyria (PMG) on brain MRI and another was found to have hypochondroplasia FGFR3 skeletal dysplasia.

CONCLUSION

Neonates with bilious vomiting may have a variety of underlying diagnoses and need to be referred to a tertiary surgical and medical centre to ensure appropriate diagnosis is made.