
Am Fam Physician. 2000;61(9):2791-2798
Bilious vomiting in newborns is an urgent condition that requires the immediate involvement of a team of pediatric surgeons and neonatologists for perioperative management. However, initial detection, evaluation and treatment are often performed by nurses, family physicians and general pediatricians. Bilious vomiting, with or without abdominal distention, is an initial sign of intestinal obstruction in newborns. A naso- or orogastric tube should be placed immediately to decompress the stomach. Physical examination should be followed by plain abdominal films. Dilated bowel loops and air-fluid levels suggest surgical obstruction. Contrast radiography may be required. Duodenal atresia, midgut malrotation and volvulus, jejunoileal atresia, meconium ileus and necrotizing enterocolitis are the most common causes of neonatal intestinal obstruction.
Type of obstruction | Cause and incidence | Age of onset and presentations | Diagnostic procedure and findings | Preoperative management interval before surgery | Treatment | Postoperative management | Prognosis |
---|---|---|---|---|---|---|---|
Duodenal atresia | Embryogenic; occurs in 1 per 5,000 live births; 25% have Down syndrome | Few hours after birth; bilious vomiting, no distention | Abdominal film, “double-bubble” sign | Nasogastric suction, IV fluids; 24 to 48 hours | Diamond-shaped duodenoduodenostomy | No oral intake, nasogastric suction; feeding at 2 to 3 days after surgery | Good unless associated with serious anomalies |
Malrotation with volvulus | Incomplete bowel rotation occurring during 7th to 12th weeks of gestation | At 3 to 7 days; bilious vomiting, rapid deterioration with volvulus | Upper GI spiral sign on ultrasound; abnormal location of the superior mesenteric vessels | Nasogastric suction, IV fluid; STAT surgery for symptomatic patients, within daysfor others | Ladd's procedure; may require a second laparotomy | No oral intake; nasogastric suction | Good without bowel resection, difficult with short-gut syndrome after bowel resection |
Jejunoileal atresia | Mesenteric vascular accident during fetal life in 1 per 3,000 live births | Within 24 hours of birth; vomiting, abdominal distention | Air-fluid levels on abdominal film | Nasogastric suction, IV fluids; 12 to 24 hours | Resection(s) and anastomosis(es) | No oral intake, nasogastric suction; feeding at 2 to 4 days after surgery | Good unless excessive loss of bowel |
Meconium ileus | Genetic, occurs in 15% of newborns with cystic fibrosis, and in 1 per 5,000 to 10,000 live births | Immediately after birth; abdominal distention, bilious vomiting | Abdominal film; distention, air-fluid levels, sweat test, “ground-glass” sign | Decompression | Enterostomy if complicated; Gastrografin enema plus IV fluids | Acetylcysteine (Mucomyst), pancreatic enzymes | Depends on the systemic problems |
Necrotizing ileus | Cause unknown in 2.4 per 1,000 live births | 10 to 12 days after birth; distention, vomiting, bloody stools | Abdominal film; distention, pneumatosis, air in the aortal vein | Nasogastric suction, IV fluids, nutrition, antibiotics for 10 days. When perforated, immediate surgery | Resection of necrotic bowel and enterostomy | Same as preoperative management | 25% need surgery (65% survival rate) 75% can be treated medically (95% survival rate) |
Duodenal Atresia

Midgut Malrotation and Volvulus

Jejunoileal Atresia


Meconium Ileus

Necrotizing Enterocolitis
