Bilious vomiting and intestinal obstruction — formative SAQs

SAQ 1 — The neonate who suddenly vomits green (10 marks, 15 minutes)

A 4-day-old term baby who has fed and stooled normally suddenly vomits a large amount of bright green fluid. On arrival he is alert with a soft, only mildly full abdomen and normal observations. [1]

a) State the diagnosis that must be excluded first and explain, using the anatomy, why it is so dangerous. (3 marks) [2] [12]

b) Outline your immediate resuscitation and the single most useful confirmatory investigation, and state when you would bypass imaging entirely. (4 marks) [1] [6]

c) Describe the key steps of the definitive operation for a confirmed midgut volvulus. (3 marks) [12] [2]

SAQ 2 — The newborn with a distended abdomen (10 marks, 15 minutes)

A 2-day-old term baby has progressive abdominal distension, has not passed meconium, and has now begun to vomit bile-stained fluid. The perineum looks normal on inspection. [7]

a) Explain why this pattern points to a low rather than a high intestinal obstruction. (2 marks) [6] [7]

b) Give a differential diagnosis for a low neonatal obstruction and the investigation that helps distinguish them. (4 marks) [7] [8]

c) Outline your initial management and the specific tests you would arrange if meconium ileus or Hirschsprung disease is suspected. (4 marks) [8] [7]