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Question 3#

An infant presents to the emergency room with bilious emesis and irritability. Physical examination is notable for abdominal tenderness and erythema of the abdominal wall. Abdominal X-ray demonstrates dilated proximal bowel with air-fluid levels. What is the most appropriate next step in management, after resuscitation?

a. Upper gastrointestinal series
b. Barium enema
c. Gastrostomy
d. Laparotomy

Correct Answer is D

Comment:

The cardinal symptom of intestinal obstruction in the newborn is bilious emesis. Prompt recognition and treatment of neonatal intestinal obstruction can truly be lifesaving. Bilious vomiting is usually the first sign of volvulus, and all infants with bilious vomiting must be evaluated rapidly to ensure that they do not have intestinal malrotation with volvulus. The child with irritability and bilious emesis should raise particular suspicions for this diagnosis. If left untreated, vascular compromise of the midgut initially causes bloody stools, but eventually results in circulatory collapse. Additional clues to the presence of advanced ischemia of the intestine include erythema and edema of the abdominal wall, which progresses to shock and death. It must be re-emphasized that the index of suspicion for this condition must be high, since abdominal signs are minimal in the early stages. Abdominal films show a paucity of gas throughout the intestine with a few scattered air-fluid levels. When these findings are present, the patient should undergo immediate fluid resuscitation to ensure adequate perfusion and urine output followed by prompt exploratory laparotomy.