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