Bile stained vomiting in the neonatal period

Bile stained vomiting is a ‘red flag' symptom and may indicate intestinal obstruction. The challenge is to select which patients may have a time critical surgical condition, for example volvulus (where a delay in treatment is likely to compromise gut viability), and urgent referral for assessment in a paediatric surgical unit is indicated. Mohinuddin and colleagues report the outcome of 163 neonates with bile stained vomiting referred to their unit over a 4 year period. A surgical diagnosis was more common in infants with abdominal distension (although not a tense abdomen), abdominal tenderness and an abnormal plain abdominal X-ray—sensitivity 74%, 62% and 97%. A normal plain abdominal X-ray reduced the risk from 50% to 16% overall, although didn't exclude a surgical cause of the vomiting. The presence of a soft abdomen was not predictive. Clinical signs/plain radiology were not predictors of whether the surgical condition was time critical or not. The dataset is interesting and of course only reflects cases referred to the unit. It does however suggest that if bile stained vomiting is present (and confirmed) urgent referral to a paediatric surgical centre is indicated. In an accompanying editorial Simon Blackburn discusses …