Bilious Vomiting in a 3-Month Old
Radiology Cases in Pediatric Emergency Medicine
Volume 3, Case 17
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
This is a 3-month old female who is brought to the
E.D. this evening for vomiting. She began vomiting last
night. She vomited twice last night and 8 times today.
Initially, the vomitus was yellow in color but the last 3
episodes have been green. There is no history of
diarrhea. She has a history of feeling warm, but her
temperature was not measured at home. She last
passed a stool yesterday. She is urinating less, only
twice since this morning. Her past history is significant
for poor weight gain and an illness one month ago
characterized by vomiting four times which resolved on
its own. She normally feeds a partially hydrolyzed
formula because of "colic".
Exam: VS T37.5 (rectal), P168, R38, BP not
obtained because of crying. Wt 4.94 kg (25th
percentile). She is alert, crying, difficult to console.
She arches her back at times and appears to be in
pain. Her color is slightly pale. Anterior fontanelle soft
and flat. No tears when crying. Her eyes appear to be
somewhat sunken. Oral mucosa sticky. Neck supple
(difficult to be certain). Heart regular, tachycardic.
Lungs clear. Not coughing. Abdomen firm, difficult to
examine. Bowel sounds are diminished but present.
No detectable masses, but because of the firmness,
this is inconclusive. No hernias. Rectal exam no stool.
Residue is guaiac negative. Color slightly pale and
mottled. Capillary refill time in the lower extremities is
3-4 seconds. Turgor good.
Laboratory studies are drawn and an IV is begun.
She is given a lactated Ringers solution fluid bolus and
is continued on an IV infusion. After the fluid bolus, she
is no longer crying. She is not fussy and her abdominal
exam is now soft with active bowel sounds. No masses
are palpable. Her color looks better. She is sent to the
imaging department for an abdominal series.
View abdominal series.
Na 138, K 4.3, Cl 101, Bicarb 21
Glucose 95, BUN 11, Creat 0.5
CBC WBC 12.0, 3% bands, 47% segs, 40% lymphs,
7% monos, Hgb 11.9, Hct 35.7, platelets 596,000
The abdominal films show decreased intestinal gas
with gastric and duodenal bulb distention. This
is felt to be consistent with a duodenal obstruction.
Would you order a barium enema, an UGI series, or
an ultrasound at this point?
What would each of these studies be most effective
in ruling out?
Since your decision should be based on what you
think the most likely diagnosis is, what is the most likely
diagnosis at this point?
Common causes of a bowel obstruction in this age
group include pyloric stenosis, volvulus, and
intussusception. Other possibilities include constricting
bands overlying bowel, intraluminal webs, intestinal
stenosis, annular pancreas, etc.
An ultrasound would be the best study to evaluate a
possible pyloric stenosis. An UGI series can also be
performed to diagnose pyloric stenosis, but ultrasound
involves no radiation, it does not require oral contrast,
and it is more accurate than an UGI series in
diagnosing pyloric stenosis. Her clinical findings are not
consistent with pyloric stenosis. Her vomiting is not
projectile in nature and it is not associated with feeding.
Her vomitus is definitely bilious suggesting an
obstruction below the pylorus.
An intussusception would be most accurately
visualized on a barium enema. Ultrasound is capable
of making the diagnosis most of the time. However, if
the ultrasound is negative, how certain can you be that
intussusception has been ruled out. In other words,
what is its false negative rate. Since ultrasound is
highly operator and interpreter dependent, these factors
must be discussed with the ultrasonographer on call in
order to decide whether ultrasound is a plausible option
to rule out intussusception. In cases which have a high
likelihood of intussusception, a barium enema would be
better since the barium enema has the additional
advantage of potentially reducing the intussusception
most of the time. This is not possible with ultrasound.
Air contrast enema has also been used in the diagnosis
and reduction of intussusception. This option should be
discussed with your radiologist.
In our patient's case, a malrotation with volvulus is
the most likely diagnosis. The abdominal radiographs
suggest a high obstruction just distal to the gastric
outlet since there is a paucity of gas distal to the
stomach. Her history of colic and the previous vomiting
episode raises the possibility of intermittent volvulus
which is often a presentation for malrotation. Although
bilious emesis can occur with any type of bowel
obstruction (including lower obstructions such as
intussusception) and even an ileus, it is also suggestive
of a high obstruction. Radiographically, an ileus should
have a good distribution of gas throughout the
abdomen. Our patient's abdominal radiographs are
highly suggestive of an obstruction and not an ileus
because of the poor gas distribution.
An ultrasound of the abdomen is performed. It is
negative for pyloric stenosis and there are no findings to
suggest an intussusception. An upper GI series is
ordered. It initially shows no barium passing out of the
stomach. However a subsequent view following the
administration of thin barium shows the following:
View upper GI series film.
This pattern of contrast flow, sometimes referred to
as a corkscrew (black arrow), shows thin barium flowing
in a spiral fashion through a restricted bowel lumen.
This indicates the presence of a midgut volvulus.
Compare this to the diagram of a midgut volvulus.
View diagram of a midgut volvulus.
You can see the tight strangulation of the upper
small bowel volvulus forming a spiraling corkscrew
pattern as seen in the UGI series.
It may be difficult to radiographically demonstrate a
volvulus in all instances. Plain abdominal radiographs
may range from gasless to normal. A barium enema
may be able to demonstrate the cecum in the wrong
place suggesting a malrotation and a likely associated
midgut volvulus. An upper GI series may fail to
demonstrate the volvulus itself, however, it will show a
sudden obstruction in the bowel lumen where the
barium fails to pass. Using thin barium or soluble
contrast may help to demonstrate the volvulus,
however, it may be necessary to take the patient to
surgery based on indirect radiographic findings alone.
An UGI series may also demonstrate malrotation
(with or without a volvulus) by demonstrating
malpositioning of the duodenal-jejunal junction.
Examine the UGI film again.
View UGI film.
The black arrow points to the duodenal-jejunal
junction. The normal duodenum starts at the gastric
outlet (duodenal bulb) and extends toward the right. It
then loops around downward and to the left, and then
superiorly and to the left so that the duodenoal-jejunal
junction is normally to the left of the spine at the same
level as the duodenal bulb. In this case, the
duodenal-jejunal junction is clearly inferior to the
duodenal bulb. This indicates the presence of a
Case 8 in Volume 2 (Recurrent Abdominal Pain and
Vomiting in a 7-Year Old) discusses the anatomy and
the radiographic findings in malrotation and volvulus in
more detail. Refer to this case to clarify any questions
you may have regarding malrotation and volvulus.
Can you answer the following questions?
1. Does a normal barium enema effectively rule out
a midgut volvulus?
2. Does a normal barium enema effectively rule out
3. Why does a malrotation predispose one to a
4. What are the radiographic findings seen in
malrotation on UGI series and barium enema (in the
absence of volvulus)?
5. Does a normal plain abdominal film (no air fluid
levels, normal gas distribution, no distended bowel) rule
out a volvulus?
6. Describe the difference between midgut volvulus,
cecal volvulus, and sigmoid volvulus?
7. Which type of volvulus does malrotation
predispose one to?
Vomiting and abdominal pain are common reasons
for children seeking emergency care. To confidently
rule out a volvulus and malrotation clinically and
radiographically, one must be familiar with the
topics above. Refer to Case 8 in Volume 2 for a
discussion on these topics.
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