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Bilious vomiting in full term newborn infants: does it always foretell an impending surgical catastrophe?

Presented at the Neonatal Society 2016 Spring Meeting.

Sand L1, Davies B2, Budge H1, Ojha S1,3

1 Academic Child Health, School of Medicine, University of Nottingham, Nottingham, UK
2 Department of Paediatric Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
3 Neonatal Intensive Care Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK

Background: Bilious vomiting in term-born infants is presumed to be a sign of potentially catastrophic surgical pathology until proven otherwise (1). Several studies have attempted to quantify the risk of surgical pathology in infants with bile in their vomitus and have found a high level risk ranging from 20% to 51% (1-5). However, there are wide variations in how these infants are managed by different Neonatologists/Paediatricians (6). The aim of this study was to ascertain the true incidence of surgical pathologies among term-born infants with bilious vomiting and to investigate the diagnostic accuracy of available investigations.

Methods: A retrospective case series was analysed to include all term-born infants with bilious vomiting, without any antenatal concerns of gastrointestinal (GI) abnormalities, from the cohort of all infants who were born in a large maternity service between 01 January 2007 and 31 August 2015. Data were extracted from electronic patient records of two Level III NICUs that provide neonatal care to all infants born within this maternity service and follow a uniform policy of admitting and investigating all infants with bilious vomiting. Infants who were transferred in from other hospitals were excluded. Incidence of surgical and other pathologies were calculated and diagnostic accuracy tests were performed for clinical findings and radiological investigations.

Results: 87,628 infants were born at term gestation during this period. Of these, 151 (0.2%) presented with bilious vomiting. 22 (14.6%) of these had a surgical pathology including 14 (9.3%) who underwent surgery. 5 (3.3%) had malrotation ± volvulus and may have suffered catastrophic intestinal loss without prompt surgical intervention. In addition, 48 (31.7%) were treated for sepsis (1, positive blood culture; 47, presumed diagnosis based on clinical features and raised inflammatory makers). Diagnostic accuracy of the abdominal X-ray as reported by Paediatric Radiologists was calculated. All infants with a surgical pathology had abnormal abdominal X-rays (sensitivity 100%) although the specificity of the report was 53.9% as there were a variety of non-specific findings. GI contrast study was performed in 119 (78.8%) of cases. 14 of these were reported abnormal (13 true positives; 1 false positive (normal finding on laparotomy); sensitivity, 90.9%; specificity; 91.6%). One infant with malrotation had an abnormal X-ray but a normal GI contrast report. The diagnosis was confirmed on laparotomy performed due to persistent clinical signs of abdominal pathology.

Conclusion: We found that the incidence of surgical pathology in term-born infants with bilious vomiting (15%) is lower than that reported previously in studies. The existing reports are from tertiary surgical (1,3) or transport services (4) and are likely to be biased by the variation in practice of clinicians in the refereeing centres (6). However, we did find a small proportion (3.3%) have potentially disastrous conditions, which require prompt surgical attention. All infants with any surgical condition had abnormal X-rays. The correct management strategy for an apparently well infant with bilious vomiting will continue to fuel debates but findings from previous reports are difficult to generalise due to the inherent selection bias in case series from tertiary referral services. We have attempted to clarify this with a study that includes all term infants who presented with bilious vomiting within a well-defined population and found a much smaller risk than reported previously. We suggest that careful clinical assessment and review of abdominal X-ray should precede further investigations and surgical management in such cases.

Corresponding author: shalini.ojha@nottingham.ac.uk

References
1. Malhotra et al. (2010), J Paed & Child Health 46: 259.
2. Lilien et al. (1986) Am J Dis Child, 140: 662.
3. Godbole & Stringer (2002) J Paed Surgery, 37:909.
4. Mohinnudin et al. (2015) Arch Dis Child 100: 14.
5. Kao (1994), Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi 35:202.
6. Walker and Raine (2007) J Pediatr Surg 42:714.

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