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Long B, Easter J, Koyfman A. High risk and low incidence diseases: Pediatric digestive volvulus. Am J Emerg Med 2024; 82:153-160. [PMID: 38908340 DOI: 10.1016/j.ajem.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/10/2024] [Accepted: 06/12/2024] [Indexed: 06/24/2024] Open
Abstract
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.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Joshua Easter
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
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2
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Do WS, Lillehei CW. Malrotation. Surg Clin North Am 2022; 102:837-845. [DOI: 10.1016/j.suc.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Nundeekasen S, Dalrymple H, Moustafa A, Thomas G, Carmo KB. How should the neonatal retrieval team respond to the neonate referred with bilious vomiting? J Paediatr Child Health 2022; 58:774-781. [PMID: 34755923 DOI: 10.1111/jpc.15829] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/17/2021] [Accepted: 10/27/2021] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Sunaina Nundeekasen
- Newborn and Paediatric Emergency Transport Service, Sydney, New South Wales, Australia
| | - Hannah Dalrymple
- Newborn and Paediatric Emergency Transport Service, Sydney, New South Wales, Australia.,Grace Centre for Newborn Intensive Care, Children's Hospital Westmead, Sydney, New South Wales, Australia
| | - Ahmed Moustafa
- Newborn and Paediatric Emergency Transport Service, Sydney, New South Wales, Australia.,Grace Centre for Newborn Intensive Care, Children's Hospital Westmead, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Gordon Thomas
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Department of Surgery, Children's Hospital Westmead, Sydney, New South Wales, Australia
| | - Kathryn Browning Carmo
- Newborn and Paediatric Emergency Transport Service, Sydney, New South Wales, Australia.,Grace Centre for Newborn Intensive Care, Children's Hospital Westmead, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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4
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Messiahs BC, Pitcher RD. A digital audit of emergency upper gastrointestinal fluoroscopy workflow in children with bilious vomiting. SA J Radiol 2022; 26:2300. [PMID: 35402008 PMCID: PMC8991196 DOI: 10.4102/sajr.v26i1.2300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 12/05/2021] [Indexed: 11/28/2022] Open
Abstract
Background Bilious vomiting in children requires an urgent evaluation with upper gastrointestinal (UGI) fluoroscopy as it may herald life-threatening midgut malrotation with volvulus (MMWV). There are no published data available on the duration of time-critical UGI workflow steps. Objectives A digital audit of workflow in emergency UGI contrast studies performed on children with bile-stained vomiting at a large South African teaching hospital. Method A retrospective study was conducted from 01 May 2012 – 31 May 2019. A customised search of the institutional radiology information system (RIS) defined all children with bilious vomiting who underwent emergency UGI fluoroscopy. Extracted RIS timestamps were used to calculate the median duration of the ‘approval’, ‘waiting’, ‘study’ and ‘reporting’ times. One-way analysis of variance and Chi-squared tests assessed the association between key parameters and the duration of workflow steps, with 5% significance (p < 0.05). Results Thirty-seven patients (n = 37) with median age 0.8 months were included, of whom 20 (54%) had an abnormal C-loop. The median ‘total time’ from physician request to report distribution was 107 min (interquartile range [IQR]: 67−173). The median ‘approval’ (6 min; IQR: 1–15) and ‘reporting’ (38 min; IQR: 17–91) times were the shortest and longest workflow steps, respectively. Abnormal C-loops (p = 0.04) and consultant referrals (p = 0.03) were associated with shorter ‘approval’ times. The neonatal ‘waiting’ time was significantly longer than that for older patients (p = 0.02). Conclusion The modern RIS is an excellent tool for time-critical workflow analyses, which can inform interventions for improved service delivery.
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Affiliation(s)
- Bradley C Messiahs
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Richard D Pitcher
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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5
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Midura D, Statter MB. Surgical Emergencies in the Pediatric Office. Pediatr Rev 2022; 43:148-159. [PMID: 35229116 DOI: 10.1542/pir.2020-004916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Infants and children often present with common signs and symptoms that may or may not be manifestations of a surgical emergency. This review expands the differential diagnosis of several common presentations to include surgical causes suggesting surgical emergencies and the need for immediate referral to a pediatric surgeon. The presenting signs and symptoms reviewed include bilious emesis, abdominal distention, acholic stools, bloody stools, and scrotal mass.
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Affiliation(s)
- Devin Midura
- Department of Surgery, Montefiore Medical Center, Bronx, NY
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6
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Saline-Aided Ultrasound Versus Upper Gastrointestinal Series in Neonates and Infants With Suspected Upper Gastrointestinal Obstruction: A Prospective Multicenter Comparative Study. AJR Am J Roentgenol 2021; 218:526-533. [PMID: 34643106 DOI: 10.2214/ajr.21.26621] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Use of upper gastrointestinal (UGI) series to diagnose UGI obstruction has raised concern in neonates and infants given increased radiation sensitivity by developing organs. Objectives: To assess the diagnostic performance of saline-aided ultrasound for UGI obstruction in neonates and infants, in comparison with UGI series. Methods: This prospective multicenter study enrolled inpatients at three hospitals who were less than 1 year old and had suspected UGI obstruction between June 2015 and May 2018; patients with malrotation or pyloric stenosis on ultrasound were ineligible. Enrolled patients underwent both saline-aided ultrasound (saline administered by nasogastric tube) and UGI series. Surgical findings or at least one-year clinical follow-up served as reference for presence of UGI obstruction. Patients with UGI obstruction were classified in terms of level (proximal vs distal) and cause. Two radiologists independently interpreted saline-aided US examinations to assess interobserver agreement and then reached consensus. Two separate radiologists assessed upper GI series in consensus. Diagnostic performance for UGI obstruction presence and level was compared between modalities. Causes were assessed on saline-aided ultrasound. Results: A total of 209 neonates were included (median age 5 days; 116 male, 93 female); 124 (59.3%) had UGI obstruction (proximal in 108). Saline-aided ultrasound exhibited strong interobserver agreement for obstruction presence (κ=0.87) and level (κ=0.85). For presence of UGI obstruction, accuracy, sensitivity, and specificity were 94.7%, 98.4%, and 89.4% for saline-aided US, versus 89.5%, 95.2%, and 81.5% for UGI series. For obstruction level, accuracy, sensitivity, and specificity were 91.9%, 97.2%, and 56.3% for saline-aided US, versus 87.1%, 92.6%, and 50.0% for UGI series. Accuracy for presence was significantly higher for saline-aided US (p=.02); otherwise, these metrics were not different between tests (p>.05). For causes of UGI obstruction (annual pancreas, duodenal web, duodenal atresia, and duodenal stenosis), accuracy of saline-aided US ranged from 75.0% to 94.1%. Conclusion: Saline-aided US has high diagnostic performance for presence and level of UGI obstruction in neonates and infants, comparing favorably versus UGI series. Saline-aided US may have additional utility in evaluating causes of obstruction. Clinical Impact: Saline-aided US may serve as an initial screening modality for UGI obstruction in neonates and infants.
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Umscheid JH, Nguyen KM, Vasudeva R, Agasthya N. Neonatal Appendicitis Presenting as Bilious Emesis and Septic Shock. Kans J Med 2021; 14:130-132. [PMID: 34084272 PMCID: PMC8158418 DOI: 10.17161/kjm.vol1414990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/22/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jacob H Umscheid
- Department of Pediatrics, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Khai M Nguyen
- University of Kansas School of Pharmacy, Wichita, KS
| | - Rhythm Vasudeva
- Department of Pediatrics, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Nisha Agasthya
- Department of Pediatrics, University of Kansas School of Medicine-Wichita, Wichita, KS
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Mohammad SA, Hamed EA, Shalaby MH, Eldieb LMR. Upper GI series in infants and children with vomiting: insights into ACR appropriateness criteria. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00289-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Although upper gastrointestinal series (UGI) series are frequently requested in pediatric radiology department, there are few articles investigating its value in children with vomiting. The purpose of this study was to review imaging findings perceived during UGI series in infants and children presented with vomiting in correlation to their symptoms based on the ACR appropriateness criteria. This was to identify clinical scenarios with higher diagnostic yield.
Results
A cross-sectional study including UGI series of 76 patients presented with vomiting (1 month–17 years) was performed. Patients were grouped according to their age into 5 groups and stratified according to the type of vomiting into 3 groups (bilious vomiting, new-onset nonbilious vomiting, intermittent nonbilious vomiting since birth). Associated symptoms were described with calculation of a novel clinical score. Radiological abnormalities in different age groups were described in relation to the type of vomiting. All patients with bilious vomiting or nonbilious vomiting associated with melena or dysphagia had abnormal findings. Gastroesophageal reflux was detected in 25% of cases. Patients with normal and abnormal study were compared according to their clinical score. The clinical score was significantly higher in the group of patients with abnormal findings (p < .001). Patients with recurrent chest symptoms and loss of weight had significantly higher rate of abnormal findings.
Conclusion
UGI series had a higher diagnostic yield in patients with bilious vomiting, children with nonbilious vomiting with higher clinical scores when associated with recurrent chest symptoms, loss of weight, dysphagia, or GIT bleeding especially melena.
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9
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Lee RA, Dassios T, Bhat R, Greenough A. Bilious Vomiting in the Newborn: A Three-Year Experience in a Tertiary Medical and Surgical Centre. Case Rep Pediatr 2020; 2020:8824556. [PMID: 33110665 PMCID: PMC7578730 DOI: 10.1155/2020/8824556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/16/2020] [Accepted: 09/29/2020] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Rebecca A Lee
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Theodore Dassios
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Science and Medicine, King's College London, London SE5 9RS, UK
| | - Ravindra Bhat
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Science and Medicine, King's College London, London SE5 9RS, UK
- Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London SE1 9RT, UK
- NIHR Biomedical Research Centre based at Guy's, St Thomas' NHS Foundation Trust, King's College London, London SE1 9RT, UK
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10
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van Druten J, Khashu M, Chan SS, Sharif S, Abdalla H. Abdominal ultrasound should become part of standard care for early diagnosis and management of necrotising enterocolitis: a narrative review. Arch Dis Child Fetal Neonatal Ed 2019; 104:F551-F559. [PMID: 31079066 DOI: 10.1136/archdischild-2018-316263] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 12/27/2022]
Abstract
Necrotising enterocolitis (NEC) is a leading cause of death and disability in preterm newborns. Early diagnosis through non-invasive investigations is a crucial strategy that can significantly improve outcomes. Hence, this review gives particular attention to the emerging role of abdominal ultrasound (AUS) in the early diagnosis of NEC, its performance against abdominal radiograph and the benefits of AUS use in daily practice. AUS has been used in the diagnosis and management of NEC for a couple of decades. However, its first-line use has been minimal, despite growing evidence demonstrating AUS can be a critical tool in the early diagnosis and management of NEC. In 2018, the NEC group of the International Neonatal Consortium recommended using AUS to detect pneumatosis and/or portal air in preterm NEC as part of the 'Two out of three' model. To facilitate widespread adoption, and future improvement in practice and outcomes, collaboration between neonatologists, surgeons and radiologists is needed to generate standard operating procedures and indications for use for AUS. The pace and scale of the benefit generated by use of AUS can be amplified through use of computer-aided detection and artificial intelligence.
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Affiliation(s)
- Jacqueline van Druten
- School of Architecture Computing and Engineering, University of East London, London, Greater London, UK
| | - Minesh Khashu
- Perinatal Health, Bournemouth University, Poole, Dorset, UK.,Department of Neonatology, Poole Hospital NHS Foundation Trust, Poole, UK
| | - Sherwin S Chan
- Department of Radiology, Children's Mercy Hospitals and Clinics, Kansas City, Kansas, USA
| | - Saeed Sharif
- School of Architecture Computing and Engineering, University of East London, London, Greater London, UK
| | - Hassan Abdalla
- School of Architecture Computing and Engineering, University of East London, London, Greater London, UK
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11
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Bosa L, Martelossi S, Tardini G, Midrio P, Lago P. Early onset food protein-induced enterocolitis syndrome in two breastfed newborns masquerading as surgical diseases: case reports and literature review. J Matern Fetal Neonatal Med 2019; 34:390-394. [PMID: 30983441 DOI: 10.1080/14767058.2019.1608435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background: Food protein-induced enterocolitis syndrome (FPIES) is a non-immunoglobulin E cell-mediated gastrointestinal food allergy that primarily presents in infancy, as early as the first hours of life. FPIES is often misdiagnosed as sepsis, severe gastroenteritis, abdominal surgical emergency or even metabolic, neurologic, or cardiac disorders.Methods: We report two neonatal cases of cow's milk protein (CMP)-induced FPIES masquerading as surgical diseases. Our purpose is to highlight the diagnostic difficulties in FPIES in this age group and to provide further evidence of the important role played by the prenatal environment in the development of allergic diseases.Results: Case 1 is a 2-day-old boy born at 35th + 5 weeks of gestation admitted to our Neonatal Intensive Care Unit (NICU) for bloody diarrhea who started presenting apnea, crying, pallor, jaundice, and abdominal tenderness. Case 2 is a 3-day-old boy born at 38th +5 weeks of gestation admitted to our NICU for repeated bilious vomiting. Both patients were administered infant formula in the first hours of life, thereafter they received only breast milk. In both cases, CMP allergy was finally suspected and an extensively hydrolyzed formula was administered with the resolution of symptoms. A diagnosis of CMP-induced FPIES was made.Conclusions: FPIES is a heterogeneous disorder. Severe forms of FPIES could be mistaken for surgical diseases, such as necrotizing enterocolitis. A trial of food elimination should be considered whenever diagnostic tests are inconclusive. FPIES must be suspected even in breastfed infants.
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Affiliation(s)
- Luca Bosa
- Department of Woman's and Child's Health, Università degli Studi di Padova, Padova, Italy
| | | | - Giacomo Tardini
- Department of Woman's and Child's Health, Università degli Studi di Padova, Padova, Italy
| | - Paola Midrio
- Pediatric Surgery Unit, Ca' Foncello Hospital, Treviso, Italy
| | - Paola Lago
- Neonatal Intensive Care Unit, Ca' Foncello Hospital, Treviso, Italy
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Cullis PS, Mullan E, Jackson A, Walker G. An audit of bilious vomiting in term neonates referred for pediatric surgical assessment: can we reduce unnecessary transfers? J Pediatr Surg 2018; 53:2123-2127. [PMID: 30077417 DOI: 10.1016/j.jpedsurg.2018.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 06/21/2018] [Accepted: 07/05/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Between 20% and 50% neonates with bilious vomiting are diagnosed with surgical pathology. Distinguishing neonates requiring surgery remains challenging. Our aim was to conduct an audit of term neonates with bilious vomiting referred for assessment to identify characteristics of this cohort and management. Secondary aims were to identify factors predictive of surgical pathology. METHODS Infants <28 days referred for bilious vomiting from 2011 to 2015 were identified through cross-referencing multiple patient databases. Data obtained included clinical features, laboratory, radiological investigations and management. The sensitivity and specificity of tests were calculated and regression analyses were conducted to identify predictors of surgical pathology. RESULTS 351 eligible neonates were referred [46% female; mean gestation 39 + 6 weeks (SD 9.2 days); mean birthweight 3469 g (SD 558 g)]. Laboratory results were available for 68.7% patients, 88.9% underwent X-ray and 96.6% contrast studies. 11.7% had a surgical diagnosis [malrotation 4.6% (1.7% with volvulus)]. No single test available in peripheral centers could exclude a surgical diagnosis. In regression analyses, age > 72 h, presence of abdominal distension, raised CRP and abnormal X-ray were statistically significant predictors of surgical pathology, while only the former two were predictive of time-critical surgical pathology. CONCLUSION 11.7% neonates had surgical pathology, fewer than in previous studies. Only contrast fluoroscopy could exclude surgical pathology and therefore prevent transfer. A more sensitive, widely available test would be required to reduce unnecessary neonatal transfers. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Paul Stephen Cullis
- Department of Surgical Paediatrics, Royal Hospital for Children Glasgow, Glasgow, UK; University of Glasgow, Glasgow, UK
| | - Emily Mullan
- University of Glasgow, Glasgow, UK; Department of Neonatology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Allan Jackson
- University of Glasgow, Glasgow, UK; Department of Neonatology, Princess Royal Maternity Unit, Glasgow, UK; ScotSTAR Paediatric Retrieval Service, Paisley, UK
| | - Gregor Walker
- Department of Surgical Paediatrics, Royal Hospital for Children Glasgow, Glasgow, UK; University of Glasgow, Glasgow, UK.
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13
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Andronikou S, Arthur S, Simpson E, Chopra M. Selective duodenography for controlled first-pass bolus distention of the duodenum in neonates and young children with bile-stained vomiting. Clin Radiol 2018; 73:506.e1-506.e8. [PMID: 29397912 DOI: 10.1016/j.crad.2017.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 12/20/2017] [Indexed: 10/18/2022]
Abstract
AIM To compare "selective duodenograms" performed through nasogastric tubes advanced into the proximal duodenum against traditional contrast studies regarding visualisation of a first-pass bolus distention of the duodenum and frequency of inconclusive results. MATERIALS AND METHODS Retrospective comparison of "selective duodenograms" and traditional upper gastrointestinal contrast studies in neonates with bile-stained vomiting, regarding demonstration of the duodenal C-loop, first-pass bolus capture, degree of distention of the duodenum, and number of inconclusive studies. Statistical comparison was performed using the two-tailed Fishers exact and chi-squared tests. RESULTS There were 31 "selective duodenograms" and 70 traditional studies. The C-loop was demonstrated in 93% of traditional studies versus 100% in "selective duodenograms" and was demonstrated significantly more often during the first-pass (94% versus 73%; p=0.018) and more often with distention of the duodenum for "selective duodenography" (94% versus 56%, p<0.001). There were more inconclusive traditional studies (7% versus 3%; non-significant). CONCLUSION Emergency upper gastrointestinal tract studies performed in neonates using the "selective duodenogram" technique demonstrated the duodenum with 100% success, with significantly more frequent first-pass bolus visualisation and duodenal distention than traditional studies. The five (7%) inconclusive traditional studies, present a significant diagnostic conundrum in the emergency setting because emergency surgery must be contemplated without proof.
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Affiliation(s)
- S Andronikou
- Department of Paediatric Radiology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK; University of Bristol, Senate House, Tyndall Ave, Bristol, BS8 1TH, UK.
| | - S Arthur
- Department of Paediatrics, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK
| | - E Simpson
- Department of Paediatric Radiology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK
| | - M Chopra
- Department of Paediatric Radiology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK
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14
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Hukui J, Jones S, Coughlin K, Levin S, Foster JR. Non-pathological bilious vomiting complicating therapeutic hypothermia for hypoxic ischaemic encephalopathy in neonates: a retrospective cohort study. BMJ Paediatr Open 2017; 1:e000034. [PMID: 29637099 PMCID: PMC5843005 DOI: 10.1136/bmjpo-2017-000034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/03/2017] [Accepted: 08/09/2017] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Therapeutic hypothermia (TH) for moderate-to-severe neonatal hypoxic ischaemic encephalopathy (HIE) is generally described as safe. We performed this study to determine the incidence of bilious vomiting or bilious drainage (BVD) attributable to TH in this population. DESIGN A single-centre, retrospective cohort study. SETTING Neonatal and paediatric intensive care units (NICU and PICU) of a single tertiary care centre. PATIENTS All newborns with HIE who met criteria for TH between 2009 and 2014. INTERVENTIONS Cases were matched 1:1 for unit of care (NICU vs PICU), gestational age, gender, and Sarnat score with historic controls who did not receive TH. Groups were compared with Pearson's Χ2 analysis. Relative risk was calculated, and ORs were used to allow regression analysis. RESULTS Forty-seven patients met all inclusion criteria. The incidence of BVD in patients who received TH was 26%. The group exposed to TH was more likely to experience BVD compared with the control group with a relative risk of 6.0(95% CI 1.4 to 25.4), even after accounting for improper or unchecked nasogastric position, opioids and muscle relaxant use, OR=7.8(95% CI 1.4 to 43.3), and when positive blood culture was included in the regression model, OR=11.6(95% CI 1.2 to 115.0). Three patients underwent investigation and no patients had surgical pathology. CONCLUSION TH appears to be associated with non-pathological bilious vomiting or gastric drainage. Further prospective data are needed to identify the patients in whom investigation and intervention may be avoided.
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Affiliation(s)
- Julie Hukui
- Department of Paediatrics, Western University, London, Ontario, Canada
| | - Sarah Jones
- Department of Paediatrics, Western University, London, Ontario, Canada
- Department of Paediatric Surgery, Western University, London, Ontario, Canada
| | - Kevin Coughlin
- Department of Paediatrics, Western University, London, Ontario, Canada
| | - Simon Levin
- Department of Paediatrics, Western University, London, Ontario, Canada
| | - Jennifer Ruth Foster
- Department of Paediatrics, Western University, London, Ontario, Canada
- Department of Critical Care, Dalhousie University, Halifax, Nova Scotia, Canada
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Birajdar S, Rao SC, Bettenay F. Role of upper gastrointestinal contrast studies for suspected malrotation in neonatal population. J Paediatr Child Health 2017; 53:644-649. [PMID: 28425590 DOI: 10.1111/jpc.13515] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 12/19/2016] [Accepted: 12/28/2016] [Indexed: 11/28/2022]
Abstract
AIM Upper gastrointestinal (UGI) contrast study is the preferred radiological investigation to diagnose malrotation of intestine. We aimed to review the role of UGI contrast in neonates (term and preterm) who were clinically suspected to have malrotation. METHODS The study included a retrospective review of medical charts and radiology reports. RESULTS A total of 164 newborn infants underwent UGI contrast study to rule out malrotation during the study period (2006-2015). Median gestational age at the time of presentation was 38 weeks (interquartile range: 35.5-39.6 weeks). Median age for clinical presentation was day 2 of life (interquartile range: 2-5 days). Out of the 164 contrast studies, 112 were normal, whereas 52 were reported to have malrotation. Of those 52 infants, 47 were confirmed to have malrotation on surgery (positive predictive value: 90). Of the 112 infants with normal UGI contrasts, nine infants underwent laparotomy for ongoing clinical symptoms out of which four infants were diagnosed to have malrotation on laparotomy. There were 22 infants born at gestational age <32 weeks, who underwent UGI contrast studies to rule out malrotation. Their clinical symptoms were similar to necrotising enterocolitis. Of 22 preterm contrast studies, six were reported to have malrotation; of these, five had surgically confirmed malrotation. No complications related to the contrast study were noted in both term and preterm infants. CONCLUSION Current study reaffirms the role of UGI contrast study as the investigation of choice for diagnosis of malrotation, in both term and preterm infants. UGI contrast is safe and well tolerated even in preterm infants.
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Affiliation(s)
- Suresh Birajdar
- Department of Neonatology, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,Department of Neonatology, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
| | - Shripada C Rao
- Department of Neonatology, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Fiona Bettenay
- Department of Diagnostic Imaging, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
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Drewett M, Johal N, Keys C, J Hall N, Burge D. The burden of excluding malrotation in term neonates with bile stained vomiting. Pediatr Surg Int 2016; 32:483-6. [PMID: 26895031 DOI: 10.1007/s00383-016-3877-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE To determine the number of term infants with bilious vomiting (BV) referred to a neonatal surgical centre for exclusion of malrotation by upper gastrointestinal contrast (UGI) examination. METHODS Retrospective review of term (>37/40) neonates <28 days of age undergoing UGI for exclusion of malrotation between Jan 2010 and Dec 2014 in a neonatal network with 30,000 term deliveries annually. Only infants with BV in the absence of alternative clinical/radiological diagnosis were included. RESULTS One hundred and sixty-six infants met the inclusion criteria. Fourteen (9 %) infants had malrotation diagnosed by UGI and confirmed at laparotomy. Only 1 of 110 infants referred at 0-2 days of age had positive UGI compared to 13 of 56 infants referred after this age (p < 0.01). An increase in referrals followed the death of an infant from midgut volvulus and as a result one in 500 term infants are currently being referred. CONCLUSION Increasing awareness of the potential consequences of bilious vomiting appears to have resulted in increased referrals with no increase in detection of malrotation. Prospective studies are required to determine whether investigation of all infants with unexplained bilious vomiting is required and if it is possible to select cases for surgical referral.
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Affiliation(s)
- Melanie Drewett
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, University Hospitals Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Nav Johal
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, University Hospitals Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Charles Keys
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, University Hospitals Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Nigel J Hall
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, University Hospitals Southampton NHS Foundation Trust, Southampton, Hampshire, UK.,Faculty of Medicine, University of Southampton, Southampton, UK
| | - David Burge
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, University Hospitals Southampton NHS Foundation Trust, Southampton, Hampshire, UK.
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Ferguson L, Wennogle SA, Webb CB. Bilious Vomiting Syndrome in Dogs: Retrospective Study of 20 Cases (2002-2012). J Am Anim Hosp Assoc 2016; 52:157-61. [PMID: 27008323 DOI: 10.5326/jaaha-ms-6300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Bilious vomiting syndrome (BVS) is a condition historically associated with early morning vomiting of bile, but it is otherwise poorly characterized. The vomiting is thought to result from a reflux of duodenal fluid into the gastric lumen causing mucosal irritation. Medical records from Colorado State University Veterinary Teaching Hospital (CSUVTH) were searched for "canine" and "bilious vomiting syndrome" between 2002 and 2012. Visual inspection confirmed a diagnosis of BVS during the case history. The diagnosis remained BVS for the duration of the dog's contact with the hospital in 17 cases. Therapy involved frequent feedings, late evening meals, gastric acid reducers, prokinetics, and gastroprotectants. Twelve dogs improved with therapy. Five dogs did not improve or were lost to follow-up. The diagnosis of BVS was supplanted in three cases with gastric adenocarcinoma, dietary indiscretion, and hepatopathy. The patient most likely given a diagnosis of BVS would be a young, mixed-breed, castrated male dog with a chronic history of vomiting bile. Response to therapy suggests abnormal gastrointestinal motility, local gastritis, gastric pH, or stimulation of the emetic center may be important factors in BVS. Dogs diagnosed with BVS rarely received a diagnostic evaluation sufficient to qualify it as a diagnosis of exclusion.
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Affiliation(s)
- Leah Ferguson
- From the Department of Clinical Sciences, Colorado State University, Fort Collins, CO
| | - Sara A Wennogle
- From the Department of Clinical Sciences, Colorado State University, Fort Collins, CO
| | - Craig B Webb
- From the Department of Clinical Sciences, Colorado State University, Fort Collins, CO
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Bilious vomiting in two neonates due to an urinoma secondary to posterior urethral valves. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2015. [DOI: 10.1016/j.epsc.2015.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Palman J, Karam M, Chee Y, Kandala V. Neonatal acute lymphocytic leukaemia: an unusual presentation of a rare disease. BMJ Case Rep 2015; 2015:bcr-2015-210606. [PMID: 26178003 DOI: 10.1136/bcr-2015-210606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Infantile acute lymphocytic leukaemia (ALL) seldom presents within the first month of life. Most are diagnosed before birth. Postnatal diagnoses are easily recognisable when characteristic features are present, namely hepatosplenomegaly, leukaemia cutis or infiltrative disease of the extramedullar and central nervous system. However, some children present with vague and non-specific symptoms masquerading as other diseases. We report an unusual presentation of infantile ALL in a 19-day-old infant, who struggled with feeding after a diagnosis of gastro-oesophageal reflux disease since birth. To the best of our knowledge, this is the youngest case report of neonatal ALL, presenting with vomiting, lethargy and dehydration. The neonate presented to our paediatric assessment unit acutely due to progression of her symptoms. General physical examination was unremarkable apart from signs of lethargy and dehydration. Blood investigation revealed an incidental finding of high white cells, including 90% blast cells. Early diagnosis in this case meant early treatment and a good prognosis.
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Affiliation(s)
- Jason Palman
- Department of Paediatrics, East & North Hertfordshire, Stevenage, UK
| | - Maria Karam
- Department of Paediatrics, East & North Hertfordshire, Stevenage, UK
| | - Ying Chee
- Department of Paediatrics, East & North Hertfordshire, Stevenage, UK
| | - Vijay Kandala
- Department of Paediatrics, East & North Hertfordshire, Stevenage, UK
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Newborn with Bilious Emesis. Surgery 2015. [DOI: 10.1007/978-1-4939-1726-6_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Mohinuddin S, Sakhuja P, Bermundo B, Ratnavel N, Kempley S, Ward HC, Sinha A. Outcomes of full-term infants with bilious vomiting: observational study of a retrieved cohort. Arch Dis Child 2015; 100:14-7. [PMID: 25204734 DOI: 10.1136/archdischild-2013-305724] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
UNLABELLED Bilious vomiting in a neonate may be a sign of intestinal obstruction often resulting in transfer requests to surgical centres. The aim of this study was to assess the use of clinical findings at referral in predicting outcomes and to determine how often such patients have a time-critical surgical condition (eg, volvulus, where a delay in treatment is likely to compromise gut viability). METHODS 4-year data and outcomes of all term newborns aged ≤7 days with bilious vomiting transferred by a regional transfer service were analysed. Specificity, sensitivity, likelihood ratios, correlations, prior and posterior probability of clinical findings in predicting newborns with surgical diagnosis were calculated. RESULTS Of 163 neonates with bilious vomiting, 75 (46%) had a surgical diagnosis and 23 (14.1%) had a time-critical surgical condition. The diagnosis of a surgical condition in neonates with bilious vomiting was significantly associated with abdominal distension (χ(2)=5.17, p=0.023), abdominal tenderness (χ(2)=5.90, p=0.015) and abnormal abdominal X-ray findings (χ(2)=5.68, p=0.017) but not with palpation findings of a soft as compared with a tense abdomen (χ(2)=3.21, p=0.073). Abnormal abdominal X-ray, abdominal distension and tenderness had 97%, 74% and 62% sensitivity, respectively, with regard to association with an underlying surgical diagnosis. Normal abdominal X-ray reduced the posterior probability of surgical diagnosis from 50% to 16%. Overall, clinical findings at referral did not differentiate between infants with or without surgical or time-critical condition. CONCLUSIONS We recommend that term neonates with bilious vomiting referred for transfer are prioritised as time critical.
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Affiliation(s)
- Syed Mohinuddin
- Neonatal Transfer Service, Barts Health NHS Trust, London, UK
| | - Pankaj Sakhuja
- Neonatal Transfer Service, Barts Health NHS Trust, London, UK
| | - Benjie Bermundo
- Neonatal Transfer Service, Barts Health NHS Trust, London, UK
| | | | - Stephen Kempley
- Department of Neonatal Medicine, Barts Health NHS Trust, London, UK Blizard Institute, Queen Mary School of Medicine and Dentistry, University of London, London, UK
| | - Harry C Ward
- Department of Paediatric Surgery, Barts Health NHS Trust, London, UK
| | - Ajay Sinha
- Department of Neonatal Medicine, Barts Health NHS Trust, London, UK Blizard Institute, Queen Mary School of Medicine and Dentistry, University of London, London, UK
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23
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Case 1: a newborn with bilious emesis. Pediatr Radiol 2014; 44:1462-9. [PMID: 25331023 DOI: 10.1007/s00247-014-2923-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Revised: 11/01/2013] [Accepted: 02/05/2014] [Indexed: 10/24/2022]
Abstract
In the introductory article of a new series geared toward pediatric radiology trainees, the radiological management of newborn bilious emesis is discussed through the details of a specific case.
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Abstract
The evaluation of the child with acute abdominal pain often poses as a diagnostic challenge due to the wide range of diagnoses. Surgical emergencies need to be rapidly identified and managed appropriately to minimize morbidity and mortality. Presenting symptoms, clinical examination, and laboratory findings can guide selection of diagnostic imaging. This article reviews common surgical causes of abdominal pain in children.
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Watanabe T, Takahashi M, Amari S, Ohno M, Sato K, Tanaka H, Miyasaka M, Fuchimoto Y, Ito Y, Kanamori Y. Olive oil enema in a pre-term infant with milk curd syndrome. Pediatr Int 2013; 55:e93-5. [PMID: 23910816 DOI: 10.1111/ped.12082] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 12/26/2012] [Accepted: 02/19/2013] [Indexed: 11/28/2022]
Abstract
Milk curd syndrome was first reported in the 1960s, but was gradually forgotten because of its low incidence thereafter. This condition in pre-term infants has been reported over the last decade and has again attracted neonatologists' attention. The present report describes a pre-term infant with milk curd syndrome. Abdominal distension was evident 14 days after the start of feeding with fortified expressed milk. Abdominal X-ray showed multiple intraluminal masses surrounded by a halo of air, and ultrasound indicated hyperechoic masses. Along with that history and the appearance of fecal impaction, the diagnosis of milk curd syndrome was confirmed. This baby was treated with olive oil enemas and successive colonic lavage for 3 days, and the symptoms were relieved. Olive oil enema, which softens hard stools and induces smooth movement of these stools, may be an effective and safe first-line treatment in pre-term infants with milk curd syndrome.
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Affiliation(s)
- Toshihiko Watanabe
- Division of Surgery, National Center for Child Health and Development, Tokyo, Japan.
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Alehossein M, Abdi S, Pourgholami M, Naseri M, Salamati P. Diagnostic accuracy of ultrasound in determining the cause of bilious vomiting in neonates. IRANIAN JOURNAL OF RADIOLOGY 2012; 9:190-4. [PMID: 23407700 PMCID: PMC3569550 DOI: 10.5812/iranjradiol.8465] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 09/04/2012] [Accepted: 09/08/2012] [Indexed: 12/26/2022]
Abstract
Background Plain radiography and contrast radiologic studies are traditionally the main options in evaluating neonates presenting with bilious vomiting. While ultrasonography (US) is more available, its diagnostic accuracy is in question. Objectives The purpose of this study is to determine the diagnostic accuracy of US in evaluating these patients with bilious vomiting. Patients and Methods All neonates with bilious vomiting or bilious nasogastric tube drainage presented to a children’s hospital in a 1.5-year period were included. US were performed in all patients. The results were compared with clinical and radiological data and the final diagnosis. We used chi-square and Fisher’s exact tests for analysis. Results The cause of bilious vomiting for 18 of the 23 included patients was surgical. All patients labeled as surgical candidates by US ended in surgery [positive predictive value (PPV) = 100%], while only 50% of the patients with inconclusive US were operated [negative predictive value (NPV) = 50%, Confidence Interval (CI) 95%: 29%-71%]. The sensitivity and specificity of US in diagnosing intestinal atresia (n = 9) was 89% [CI 95%: (68% - 100%)] and 100%. In cases with malrotation (n = 4) and midgut volvulus (n = 2), sonographic diagnosis was in concordance with final surgical diagnosis. Conclusion This study suggested that in cases in which US makes a certain diagnosis, its accuracy eliminates the need for further diagnostic tests, but if it is inconclusive, further radiological contrast studies should be tried to make the final diagnosis.
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Affiliation(s)
- Mehdi Alehossein
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Radiology, Bahrami Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Siamak Abdi
- Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Pourgholami
- Department of Radiology, Bahrami Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Naseri
- Department of Pediatrics, Bahrami Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Payman Salamati
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author: Payman Salamati, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Complex Hospital, Keshavarz Blvd., Tehran, Iran. Tel.: +98-2166581579, Fax: +98-2166581560, E-mail:
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Clark K, Thomas K, Herd F, Nanthakumaran S, Driver CP. Bile vomiting in paediatrics: what do we really know? Scott Med J 2011; 56:69-71. [PMID: 21670130 DOI: 10.1258/smj.2010.010015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Bile vomiting is clinically significant in neonates and children, indicating intestinal obstruction until proven otherwise. The aim of this study was to assess whether nursing staff within a children's hospital were able to accurately identify bilious vomiting and if a deficiency existed, whether educational posters could rectify this problem. A primary audit was conducted in the Royal Aberdeen Children's Hospital evaluating the ability of nursing staff to identify bile vomit and its significance. Educational posters were distributed and a secondary audit was conducted after six months to complete the audit cycle. The second audit also compared the knowledge of different medical professionals. In the primary audit, 41% of nurses selected the colour yellow, compared with 18% of nurses in the second audit with approximately 70% selecting dark-green. Thirty-three percent of nurses in the primary audit confirmed intestinal obstruction as the cause of bile vomiting, compared with 64% of nurses in the secondary audit. In conclusion, this study identified a deficiency in the recognition of bile vomiting among nurses, but demonstrates that the use of educational posters can significantly improve knowledge. This can be beneficial in the early recognition of this potential surgical emergency.
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Affiliation(s)
- K Clark
- Department of Paediatric Surgery, Royal Aberdeen Children's Hospital, Westburn Road, Aberdeen AB25 2ZG, UK
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Malhotra A, Lakkundi A, Carse E. Bilious vomiting in the newborn: 6 years data from a Level III Centre. J Paediatr Child Health 2010; 46:259-61. [PMID: 20337876 DOI: 10.1111/j.1440-1754.2009.01681.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bilious vomiting in the newborn is an urgent condition that frequently requires neonatal and paediatric surgical involvement. Investigations involve abdominal X-ray and contrast imaging in most cases. We aimed to describe the prevalence of surgical intervention in this cohort and assess the reliability of contrast imaging in accurate prediction of underlying condition. METHODS A retrospective audit of data from December 2001 to October 2007 was undertaken. Data on newborns admitted to a level III unit with bilious vomiting was extracted. Infants with bilious aspirates but no vomiting were excluded. RESULTS Sixty-one infants were admitted to the unit during the period with bilious vomiting. Most of them were out born (83.6%). Mean (and standard deviation) gestation was 38.3 weeks (+/-3.2); weight was 3173.5 grams (+/-717.6); day of admission was 3.68 days (1-28); and length of stay in the unit was 9.96 days (1-48). There were 52 (85.2%) abnormal X-rays and 21 (34.4%) abnormal contrast studies. Sixteen (26.6%) babies had laparotomies of which 6 were malrotations with volvulus, 2 small bowel obstructions, 2 meconium ileus, 2 Hirschsprung's disease, 2 other findings, while 2 were normal. Positive predictive value (number of accurate predictions of surgical findings) for barium contrast studies was 85.7% in this series. CONCLUSION Bile stained vomiting is a surgical emergency and prompt investigation is the key in the management. Contrast studies still form the backbone of such investigations.
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Affiliation(s)
- Atul Malhotra
- Monash Newborn, Monash Medical Centre, Melbourne, Australia.
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Affiliation(s)
- Latha Chandran
- State University of New York at Stony Brook, Stony Brook, NY, USA
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Affiliation(s)
- Peter J Strouse
- C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, Michigan 48109-0252, USA.
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Volvulus of a jejunal lymphatic vascular malformation presenting with bilious vomiting and the radiological appearances of malrotation. J Pediatr Surg 2008; 43:e33-5. [PMID: 18206443 DOI: 10.1016/j.jpedsurg.2007.08.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2007] [Revised: 08/29/2007] [Accepted: 08/30/2007] [Indexed: 01/07/2023]
Abstract
Bile-stained vomiting in infancy is abnormal. Malrotation with small bowel volvulus is probably the most worrying of possible causes because if untreated for too long, it can result in massive bowel necrosis. As a consequence, if examination or plain radiography does not suggest another cause, an upper gastrointestinal (GI) series is often performed to exclude malrotation. If the examination is normal however and symptoms settle, should investigation stop, or how far should it be pursued? Small bowel lymphatic vascular malformations in children are extremely rare but carry a risk of obstruction, volvulus, and loss of small bowel. We present a case of a 5-year-old boy referred to our unit with bilious vomiting and the radiological findings of malrotation on upper GI series. Interestingly, a previous upper GI series undertaken during the first year of life for intermittent bilious vomiting was normal. Operative findings were of a 16-cm cystic lymphatic vascular malformation of the jejunal wall causing a 360 degrees volvulus. The mesentery was derotated, and the cyst removed with the attached section of jejunum. This case highlights the need to reinvestigate patients with bilious vomiting despite a previous normal upper GI series. The case raises the issue of whether bilious vomiting, with a normal upper GI series, should be investigated further with an abdominal ultrasound scan to identify more unusual causes such as jejunal lymphatic vascular malformations.
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Louie JP. Essential Diagnosis of Abdominal Emergencies in the First Year of Life. Emerg Med Clin North Am 2007; 25:1009-40, vi. [DOI: 10.1016/j.emc.2007.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
BACKGROUND/PURPOSE Pediatric surgeons consider bile vomiting in the neonate a potential surgical emergency. The reported rate of surgical intervention is 30% to 40%, but as most neonates are born outwith pediatric surgical centers, referral of these babies is at the neonatologists' discretion. The aim of this study was to determine the referral policy of neonatologists in the West of Scotland for a neonate with bile vomiting. METHODS Questionnaires were sent to all neonatologists in the West of Scotland to determine the management plan for a neonate with a single bile vomit or repeated bile vomits. Respondents were asked to indicate whether they would advocate postnatal ward observation, admission to the special care baby unit, abdominal x-ray, or upper gastrointestinal contrast study, or refer to pediatric surgeons. Respondents were asked to prioritize these options numerically. RESULTS A return rate of 81% was achieved. Most neonatologists (80%) would admit a neonate with a single bile vomit to the special care baby unit, but more than 50% did not consider an upper gastrointestinal contrast study appropriate. One third felt that pediatric surgical referral is not appropriate for a single bile vomit. In a neonate with persistent bile vomiting, pediatric surgical referral was considered the highest priority. CONCLUSION Neonatologists use a policy of observation for neonates with a single bile vomit. Those neonates with no further bile vomiting are unlikely to be referred. Pediatric surgeons are not referred a significant proportion of neonates that vomit bile.
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Affiliation(s)
- Gregor M Walker
- Department of Paediatric Surgery, Royal Hospital for Sick Children, NHS Greater Glasgow, G3 8SJ Glasgow, United Kingdom.
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Walker GM, Neilson A, Young D, Raine PAM. Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study. BMJ 2006; 332:1363. [PMID: 16737979 PMCID: PMC1476724 DOI: 10.1136/bmj.38859.614352.55] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To identify the colour that different groups of observers thought represented bile in a newborn's vomit. DESIGN Questionnaires displaying eight colours (pale yellow to dark green). SETTING General practices in Glasgow, postnatal ward and level III special care baby unit in a university teaching hospital, and mother and toddler groups in Glasgow. PARTICIPANTS 47 general practitioners, 29 nurses on the baby unit, 48 midwives, and 41 mothers of babies and infants. OUTCOME MEASURES Participants indicated which colour would represent bile in a baby's vomit. More than one colour could be chosen. Respondents were also asked to indicate one colour that was the best match for bile. RESULTS When any colour could be chosen, 12 (25%) general practitioners, 1 (3%) nurse on the baby unit, 5 (10%) postnatal midwives, and 23 (56%) parents did not consider green an appropriate colour for a baby's vomit containing bile. Twenty three (49%) general practitioners, 7 (24%) neonatal nurses, 15 (31%) postnatal midwives, and 29 (71%) parents thought yellow was the best colour match. CONCLUSIONS There is little agreement about the colour of bile vomit in a newborn. It is more pertinent to ask parents about the colour of vomit rather than whether it contained bile. Many general practitioners and parents do not recognise green as an appropriate colour for bile in the vomit of newborns, which may delay surgical referral. Though yellow vomit does not exclude intestinal obstruction, the presence of green vomiting in a baby is a surgical emergency and requires expeditious referral.
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Affiliation(s)
- Gregor M Walker
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Glasgow G3 8SJ.
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El-Chammas K, Malcolm W, Gaca AM, Fieselman K, Cotten CM. Intestinal malrotation in neonates with nonbilious emesis. J Perinatol 2006; 26:375-7. [PMID: 16724079 DOI: 10.1038/sj.jp.7211507] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Intestinal malrotation is a relatively uncommon condition with diverse outcomes. Familiarity with variations in the presentation of malrotation is imperative as early diagnosis and prompt subsequent surgical intervention are essential to optimizing outcome. The most frequent clinical sign in the neonate is bile-stained emesis. We report three cases of unsuspected malrotation that were diagnosed in neonates with a history of nonbilious emesis who were assessed for presumed gastroesophageal reflux or aspiration. Gastroesophageal reflux is a common condition among newborns, and can be a subtle presentation of malrotation. Clinicians should consider malrotation as a possible cause of reflux, particularly in infants with unusually pathologic or persistent symptoms necessitating ongoing treatment for reflux.
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Affiliation(s)
- K El-Chammas
- Department of Pediatrics, American University of Beirut Medical Center, Beirut, Lebanon
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Abstract
The acute abdomen in the newborn provides challenging problems from many aspects, not only with regard to diagnosis, resuscitation and treatment, but also now with prenatal management. Most conditions are uncommon and treatment in specialist centres enables concentration of appropriate resources and expertise. Co-morbidity is common, particularly in the preterm or low birth weight infant. A multi-disciplinary team of surgeons, anaesthetists, neonatologists, radiologists, cardiologists, obstetricians, nurses, physiotherapists and other health professionals experienced in dealing with extremely small infants will provide the best outcome. The infant should be resuscitated and, as soon as conditions permit, transferred to a specialist surgical centre with intravenous fluids, gastric tube drainage and circulatory, respiratory and general support as needed. This involves close liaison within healthcare networks and readily available patient transfer facilities. Surgery itself should be carried out in a theatre fully equipped for neonatal surgery. A gentle touch is essential because of the fragility of the tissues, and painstaking care should be taken with blood loss.
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Affiliation(s)
- M N de la Hunt
- Department of Paediatric Surgery, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK.
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Berrocal T, Gayá F, de Pablo L. Aspectos embriológicos, clínicos y radiológicos de la malrotación intestinal. RADIOLOGIA 2005. [DOI: 10.1016/s0033-8338(05)72843-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Strouse PJ. Disorders of intestinal rotation and fixation ("malrotation"). Pediatr Radiol 2004; 34:837-51. [PMID: 15378215 DOI: 10.1007/s00247-004-1279-4] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2004] [Accepted: 06/15/2004] [Indexed: 11/29/2022]
Abstract
Malrotation with volvulus is one of the true surgical emergencies of childhood. Prompt radiological diagnosis is often paramount to achieving a good outcome. An understanding of the normal and anomalous development of the midgut provides a basis for understanding the pathophysiology and the clinical presentation of malrotation and malrotation complicated by volvulus. In this essay, the radiologic findings of malrotation and volvulus are reviewed and illustrated with particular attention to the child with equivocal imaging findings.
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Affiliation(s)
- Peter J Strouse
- Section of Pediatric Radiology, C.S. Mott Children's Hospital, University of Michigan Medical Center, 1500 East Medical Center Drive, MI, Ann Arbor 48109-0252, USA.
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