Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.
-
Upload
clifford-oconnor -
Category
Documents
-
view
212 -
download
0
Transcript of Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.
![Page 1: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/1.jpg)
Newborn vomiting:Bilious
Joseph A. Iocono, M.D.
University of Kentucky
![Page 2: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/2.jpg)
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.
![Page 3: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/3.jpg)
What is your differential diagnosis?
![Page 4: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/4.jpg)
Differential Diagnosis
Gastroenteritis GERD Pyloric Stenosis Duodenal Atresia Malrotation/Volvulus
NEC Formula Intolerance Annular Pancreas Esophageal Atresia
![Page 5: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/5.jpg)
History
What other points of the history do you want to know?
![Page 6: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/6.jpg)
Consider the Following
Characterization of symptoms
Temporal sequence Alleviating /
Exacerbating factors:
Pertinent PMH, ROS, birth history
Relevant family hx. Associated signs and
symptoms
![Page 7: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/7.jpg)
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.
![Page 8: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/8.jpg)
Physical Exam
What are you looking for on Physical Exam?
Discuss NORMAL RANGE Vital Signs for a newborn
![Page 9: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/9.jpg)
Physical ExamWhat to look for
Vital signs: instability, respiratory distress, Overall appearance: signs of dehydration, poor
perfusion Abdominal exam: peritonitis Rectal exam: heme positive?
![Page 10: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/10.jpg)
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
![Page 11: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/11.jpg)
What labs do you need?
![Page 12: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/12.jpg)
Would you like to revise your initial differential diagnosis?
![Page 13: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/13.jpg)
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
![Page 14: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/14.jpg)
Laboratory Values
132 98
3.8 12
16
48.2
359 9219
0.9
20
![Page 15: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/15.jpg)
What do you think about the labs?
![Page 16: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/16.jpg)
What would you do now?
![Page 17: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/17.jpg)
Laboratory Values Discussion
Profound dehydration with metabolic acidosis.
Elevated WBC
![Page 18: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/18.jpg)
Interventions to Consider
ABCs• Start resuscitation• Fluid bolus
• Proper bolus in newborn (20 ml/kg)
Other tests• X-ray?• Ultrasound?
Treatment now?
![Page 19: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/19.jpg)
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
![Page 20: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/20.jpg)
What would you do now?
![Page 21: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/21.jpg)
Ralph Upchurch
Operate or get more tests?
![Page 22: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/22.jpg)
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
![Page 23: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/23.jpg)
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.
![Page 24: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/24.jpg)
Malrotation with Midgut Volvulus
“Bilious vomiting in a newborn is malrotation with midgut volvulus
until proven otherwise”
![Page 25: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/25.jpg)
Anatomy of malrotation
Normal Malrotation
![Page 26: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/26.jpg)
UGI Malrotation
![Page 27: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/27.jpg)
Mid-Gut Volvulus
![Page 28: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/28.jpg)
Summary
![Page 29: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/29.jpg)
QUESTIONS?
![Page 30: Newborn vomiting: Bilious Joseph A. Iocono, M.D. University of Kentucky.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649cf95503460f949caee7/html5/thumbnails/30.jpg)
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: