Pediatric surgeons are trained to recognize bilious (green) emesis as a "red flag" that necessitates immediate attention to evaluate for surgical causes, specifically malrotation with midgut volvulus.
Godbole et al evaluated the outcome of 63 neonates with bilious emesis over a two-year period and noted that 38% had a surgical cause. Nine had Hirschsprung's disease, 5 had small bowel atresia, 4 had intestinal malrotation, 3 had meconium ileus, and one each had meconium plug, colonic atresia, and milk inspissation.
Importantly, one of the four neonates with malrotation had no abdominal signs or symptoms, as well as a normal abdominal radiograph at time of diagnosis. On the other hand, the majority of neonates with non-surgical causes had a normal exam and abdominal radiographs. .
Non surgical causes for bilious emesis were thought to mostly represent gastro-esophageal reflux and gastric dysmotility, metabolic disturbances, and/or sepsis.
All patients with bilious emesis need a thorough abdominal exam and an abdominal radiograph. Although a relatively small number of these patients (4/63) will have malrotation with potential midgut volvulus, a prompt evaluation with an UGI should always be considered given the potential catastrophic consequences of a missed midgut volvulus.
Godbole P, Stringer MD. Bilious vomiting in the newborn: how often is it pathologic? J Pediatr Surg 2002;37:909-911
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