A 2-week-old full-term female infant is brought to the emergency department due to a 12-hour history of persistent bilious vomiting. The parents report that she has become increasingly lethargic and has not had a wet diaper in the past 18 hours. On physical examination, her temperature is 37.6°C (99.7°F), heart rate is 185/min, respiratory rate is 55/min, and blood pressure is 55/35 mm Hg. The abdomen is notably distended and rigid to palpation with involuntary guarding. Bowel sounds are absent. Capillary refill is delayed at 4 seconds. An upright abdominal X-ray reveals a paucity of distal bowel gas. Following initial fluid resuscitation, what is the most appropriate next step in management?
- ANasogastric tube placement and serial abdominal examinations
- BComputed tomography (CT) scan of the abdomen
- Immediate exploratory laparotomyAnswer
- DUpper gastrointestinal (GI) series
- EAdministration of intravenous broad-spectrum antibiotics as definitive therapy
Answer
Immediate exploratory laparotomy
The correct answer is immediate exploratory laparotomy. This neonate presents with bilious vomiting, signs of decompensated shock (hypotension, severe tachycardia, delayed capillary refill), and a rigid abdomen. In a neonate, bilious emesis is a surgical emergency most often caused by malrotation with midgut volvulus. The presence of a rigid abdomen indicates peritonitis, highly suspicious for bowel ischemia, necrosis, or perforation. In a hemodynamically unstable patient with an acute surgical abdomen, diagnostic imaging must be bypassed in favor of immediate exploratory laparotomy to prevent irreversible bowel loss and mortality.
Step-by-Step Solution
Key Concept
Management of Midgut Volvulus with Peritonitis
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