Bilious vomiting and intestinal obstruction — structured clinical encounter

Station 1 — recognition

The examiner asks what worries me most about this baby. I explain that bright green bilious vomiting in a neonate is malrotation with midgut volvulus until proven otherwise, and that the soft, comfortable abdomen does not reassure me because tenderness, distension, blood in the stool and shock are all late signs that appear only once the bowel is ischaemic. I treat this as a surgical emergency immediately. [1] [2]

Station 2 — resuscitation

Asked what I do first, I run resuscitation and referral together. I keep the baby nil by mouth, obtain intravenous access, give an isotonic fluid bolus and correct electrolytes and glucose, and pass a wide-bore nasogastric tube on free drainage to decompress the stomach and reduce aspiration risk. At the same time I call the paediatric surgical service, because time to theatre is the strongest determinant of whether the midgut survives. [1] [6]

Station 3 — imaging

Asked how I confirm the diagnosis, I explain that a stable baby has an urgent upper gastrointestinal contrast study, the reference test, which shows an abnormally low and right-sided duodenojejunal flexure and a corkscrew or beak in volvulus, while ultrasound may show inversion of the superior mesenteric vessels and a whirlpool. I stress that a normal plain film does not exclude malrotation, and that a peritonitic or shocked baby goes straight to theatre. [6] [2]

Station 4 — definitive care

The study confirms volvulus. Asked about the operation, I describe the Ladd procedure: counter-clockwise detorsion to restore perfusion, division of the obstructing Ladd bands, widening of the narrow mesenteric base, appendicectomy, and placement of the bowel in a non-rotated position, with resection of any frankly necrotic segment and a possible second-look laparotomy. I contrast this with the planned repair of a fixed atresia, which is not a race against ischaemia. [12] [7]

Station 5 — disposition and family

Finally I address disposition and safety-netting. This baby needs a paediatric surgical centre, which from a regional hospital means resuscitation and nasogastric decompression continued during retrieval. I counsel the family that early surgery for volvulus usually gives an excellent outcome, while delay risks loss of bowel and short-gut syndrome, and I make sure every clinician who later assesses a baby with green vomit holds the same rule to treat it as an emergency until proven otherwise. [3] [1]