vomitting newborn malrotation.ppt
TRANSCRIPT
Newborn vomiting:Bilious
Joseph A. Iocono, M.D.
University of Kentucky
Baby boy Ralph Upchurch
A 3 week-old boy is seen in the ED with a 4 hour history of emesis and dehydration. The baby was vibrant on arrival and placed in room V.
What is your differential diagnosis?
Differential Diagnosis
Gastroenteritis GERD Pyloric Stenosis Duodenal Atresia Malrotation/Volvulus
NEC Formula Intolerance Annular Pancreas Esophageal Atresia
History
What other points of the history do you want to know?
Consider the Following
Characterization of symptoms
Temporal sequence Alleviating /
Exacerbating factors:
Pertinent PMH, ROS, birth history
Relevant family hx. Associated signs and
symptoms
Baby boy Ralph Upchurch
It’s now midnight, 6 hours later, and you are consulted STAT and told his initial abdominal exam was benign but over the last 4 hours he has become listless and his heart rate is now 190 bpm. The vomiting has not stopped and you notice that mom’s shirt has a greenish stain.
Physical Exam
What are you looking for on Physical Exam?
Discuss NORMAL RANGE Vital Signs for a newborn
Physical ExamWhat to look for
Vital signs: instability, respiratory distress, Overall appearance: signs of dehydration, poor
perfusion Abdominal exam: peritonitis Rectal exam: heme positive?
Physical Exam, Ralph Upchurch
Vital signs: Temp. 99.8, Pulse 190, BP 75/30 Resp 45
Appearance: Baby is sleepy, does not respond to blood draw
Resp: Shallow breath sounds Abdomen: flat, hear groaning with exam
What labs do you need?
Would you like to revise your initial differential diagnosis?
Laboratory studies
Type and Cross CBC: BMP: evaluate for acidosis Blood gas: acidosis?
• In infants venous and even capillary blood gases allow for determination of acid-base status
Laboratory Values
132 98
3.8 12
16
48.2
359 9219
0.9
20
What do you think about the labs?
What would you do now?
Laboratory Values Discussion
Profound dehydration with metabolic acidosis.
Elevated WBC
Interventions to Consider
ABCs• Start resuscitation• Fluid bolus
• Proper bolus in newborn (20 ml/kg)
Other tests• X-ray?• Ultrasound?
Treatment now?
Malrotation Testing
Upper GI - best test for malrotation.
Duodeno-jejunal junction is normally:• To the left of midline• Level with or superior to the
pylorus• Located well posterior
Barium enema suggestive, but not diagnostic
Ultrasound may show SMV/SMA reversal
What would you do now?
Ralph Upchurch
Operate or get more tests?
Operative intervention
Indications• Unstable baby with peritonitis
• Positive UGI
Treatment – Ladd’s procedure• Immediate counterclockwise
rotation
(usually 270 degrees or more) –then wait!!
• Division of Ladd’s bands
• Mesenteric widening
• appendectomy
Malrotation with Midgut Volvulus A true surgical emergency !
Due to abnormal rotation and fixation.
50% of children with symptoms present within the 1st month.
Initial physical findings may be nonspecific. Initial radiographs are nondiagnostic, but may show gastric and proximal duodenal distention with minimal distal bowel gas.
Symptoms are due to either duodenal compression from Ladd’s bands or midgut volvulus.
Distention develops with midgut ischemia, ileus, acidosis, and shock.
Malrotation with Midgut Volvulus
“Bilious vomiting in a newborn is malrotation with midgut volvulus
until proven otherwise”
Anatomy of malrotation
Normal Malrotation
UGI Malrotation
Mid-Gut Volvulus
Summary
QUESTIONS?
Acknowledgment The preceding educational materials were made available through the
ASSOCIATION FOR SURGICAL EDUCATIONASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials wewelcome your comments/ suggestions at: