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Bilious Emesis in the Neonate
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Always abnormal — rule out malrotation with volvulus.
Decision
Outcome
Decision
Newborn with bilious emesis. Stability?
✓
Stable → abdominal X-ray
✓
Unstable → emergency laparotomy
Decision
X-ray finding?
✓
Free air → emergency laparotomy
✓
Dilated bowel loops, increased rectal tone or delayed meconium → contrast enema
✓
Double bubble sign → duodenal atresia
✓
Normal → upper GI series to rule out malrotation
Outcome
Emergent laparotomy
Decision
Contrast enema finding?
✓
Microcolon → meconium ileus
✓
Rectosigmoid transition zone → Hirschsprung disease
Outcome
Meconium ileus → CF workup; gastrografin enema may relieve; surgery if perforation
Outcome
Hirschsprung → rectal biopsy confirms (absent ganglion cells); surgical pull-through
Outcome
Duodenal atresia → surgical repair; check for trisomy 21
Decision
Upper GI?
✓
Right-sided ligament of Treitz / corkscrew → malrotation ± volvulus
✓
Normal → continue evaluation for other causes
Outcome
Ladd procedure emergently — volvulus can cause necrosis within hours
Outcome
Further workup — sepsis, NEC, intussusception
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