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Difficulty: Very hardPediatric Gastrointestinal Disorders

A 28-day-old male infant is urgently evaluated in the emergency department after his parents noted a sudden onset of inconsolable crying and repeated episodes of vomiting over the past 5 hours. The vomitus was initially composed of digested breast milk but has recently become dark green. He was born at 38 weeks gestation without complications and had been feeding well until this morning. On physical examination, the infant appears mottled and lethargic. Vital signs reveal a temperature of 38.1°C (100.6°F), heart rate of 192/min, respiratory rate of 65/min with intercostal retractions, and blood pressure of 54/32 mm Hg. Capillary refill time is prolonged at 6 seconds. The abdomen is distended, markedly rigid, and exquisitely tender to palpation, with a faint erythematous discoloration of the periumbilical skin. Bowel sounds are absent. A portable plain radiograph of the abdomen demonstrates a paucity of distal bowel gas with no evidence of pneumoperitoneum. Which of the following is the most appropriate next step in the management of this patient?

  1. Emergent exploratory laparotomyAnswer
  2. B
    Upper gastrointestinal contrast series
  3. C
    Placement of a nasogastric tube, broad-spectrum antibiotics, and serial abdominal examinations
  4. D
    Endotracheal intubation and administration of nebulized albuterol
  5. E
    Intravenous fluid boluses and administration of sodium bicarbonate

Answer

Emergent exploratory laparotomy
The patient's presentation of bilious emesis, hemodynamic instability, and a rigid, erythematous abdomen is highly suspicious for midgut volvulus complicated by bowel ischemia and peritonitis. In any neonate with bilious emesis, malrotation with midgut volvulus must be suspected. While an upper gastrointestinal contrast series is the diagnostic test of choice for a hemodynamically stable infant, the presence of peritonitis, shock, or suspected bowel perforation mandates immediate emergent exploratory laparotomy (often to perform a Ladd procedure and assess bowel viability). Delaying surgery to perform diagnostic imaging in this critical setting severely increases the risk of irreversible bowel necrosis and death.

Step-by-Step Solution

1
Identify the primary symptom and its clinical significance
The patient is a neonate presenting with bilious emesis, which represents a surgical emergency (often midgut volvulus) until proven otherwise.
Bilious emesis in a neonate indicates a blockage distal to the ampulla of Vater.
2
Assess the patient's hemodynamic status and abdominal exam findings
The patient exhibits hypotension, prolonged capillary refill, and a rigid, tender abdomen with erythema.
These signs strongly indicate peritonitis, severe bowel ischemia, and systemic shock.
3
Determine the appropriate intervention pathway based on clinical stability
Due to hemodynamic instability and frank peritonitis, the standard diagnostic imaging pathway is bypassed in favor of immediate surgical intervention.
An upper GI series takes time and risks further bowel necrosis; unstable patients require an emergent laparotomy for source control and bowel salvage.

Key Concept

Management of neonatal midgut volvulus complicated by ischemia and peritonitis
Estimated Time:1m 30s
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Topics

Pediatric Gastrointestinal Disorders

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