• Paediatric Surgery
• Neonatology

It is surgical dogma that bilious (green) vomiting in the neonatal period is indicative of mechanical obstruction until proven otherwise. The proportion of babies with green vomiting who have a surgical cause for their symptoms is, however, well under 100%. Stringer in 2002 reported that bilious vomiting is, in fact, not caused by mechanical obstruction in 62% of patients.1

The work by Mohinuddin et al2 makes a useful contribution to our understanding of this subject. In this study, roughly half of term babies (46%), with bilious vomiting, transferred by the London Neonatal Transfer team for surgical assessment, had a surgical cause for this symptom. Fourteen per cent of babies in this study were found to have a time-critical diagnosis where a perforation was demonstrated or gut viability was potentially compromised.

This paper makes an important contribution by looking at whether clinical signs or X-ray findings can differentiate babies with surgical pathology from those without. It is probably unsurprising that an abnormal abdominal X-ray is strongly associated with surgical pathology. Indeed, many of the conditions reported in this study are associated with characteristic abdominal X-ray findings that …