# 04 Emesis

Baby Emesis: projectile vomitting because of obstruction on **day 0**

* Normal feeding: not projectile, formula colored, occurs after eating
* Bilious: projectile, green, distal to biliary tree and ligament of treiz
* Non-bilious: projectile, not green

## Bilious

* malrotation
* duodenal atresia
* annular pancreas
* intestinal atresia

### Malrotation

* path: failure of rotation, strangulation, obstruction, vascular ischemia
* pt: normal pregnancy, normal uterine course, non polyhydramnio or Down syndrome. **Bilious** vomitting
* diagnosis
  * x-ray, double bubble. Normal gas pattern distal (happens late, chance for air to get into bowel)
  * upper GI series to confirm obstruction
* treatment
  * conservative manage
  * NG tube: decompress
  * surgery to cure, especially if volvulus

### Duodenal Atresia

* path: failure to recanulize. Blood flow is good. Making urine but not swallowing. Polyhydramnio
* pt: polydydramnios. Down syndrome. Biliary emesis
* diagnosis: (babygram) xray, double bubble, no gas beyond (too early for air to get in)
* treatment: surgery

### Annular Pancreas

* path: pancreas encircle duodenum. Failure of apoptosis
* pt: polyhydramnios, biliary emesis, down
* diagnosis: xray double bubble and no gas
* treatment: surgery

### Intestinal Atresia

* path: vascular accidents in utero. Vasospasm cut off blood supply. Atresia
* pt: mom does vasoconstrictor (cocaine). Maybe polyhydramnios (happens late). No Downs association
* diagnosis: xray double bubble, multiple air fluid levels (happens in multiple segments simultaneously). Each atretic = air fluid
* treatment
  * surgery, short gut
  * confront mom, prevent happening on next child

## Nonbilous

* TE fistula
* pyloric stenosis

### Tracheoesophageal Fistula

Many types. Most common type: blind pouch, fistula:

* Food goes to blind pouch, spill into lungs. 
* symptoms: nonbiliary emesis, **gurgling, bubbling out of mouth** (breathing through gastric secretions)
* diagnosis: NG tube that coils in blind pouch on X-ray
* treatment: parenteral, prepare for surgery reconnect

### Pyloric Stenosis

* path: hypertrophy of pylorus, gastric outlet obstruction
* pt: male, 2-8 weeks, normal feeds going to projectile, nonbilious vomitting
* diagnosis
  * olive shaped mass, visible peristaltic waves
  * US, donut sign
  * CMP: hypoCl, hypoK, high bicarb, metabolic alkalosis
* treatment
  * correct electrolyte with IVF first
  * pyloromyotomy