Pediatrics [BABY EMESIS]

Introduction
Kids can spit up. A little bit of regurgitation (small volume,
nonprojectile, formula colored) is totally normal. Most pathologic
vomiting occurs very early in life (hours to days). Causes of pathologic
vomiting are largely anatomic - meaning surgery to correct.

Always have head trauma (central cause of vomiting) on the mind in

appropriate clinical scenarios (such as from abuse).

Step one is separate vomiting into bilious (connected to the duodenum)

and non-bilious (disconnected from the duodenum). “Disconnected”
means that stuff is coming out the in hole because it can’t get past some
obstruction. Bilious vomiting means that either the obstruction is distal
to the biliary tree or there’s no obstruction at all.

1) Bilious Vomiting
Green vomit is never normal; it’s indicative of an obstruction distal to
the ampulla of Vater. Fluid can go into the duodenum from the stomach,
but the only way out is the way it came in. The workup begins with an
X-ray (babygram). From there, the gas patterns can help differentiate
between diseases.

i. Duodenal Atresia
The duodenum fails to recanalize in utero. It presents as
Double-Bubble + No Distal Air = Duodenal Atresia
polyhydramnios in utero and bilious vomiting as a neonate. The
Surgery
XR reveals a double-bubble sign but there’s no distal air. The
Associated with Down syndrome
repair is surgical. This is commonly associated with Down
syndrome.

ii. Annular Pancreas

If there’s a double-bubble with/without distal air, it’s possible
Double-Bubble +/- Distal Air = Annular Pancreas
that the duodenum actually isn’t atretic. Instead, the pancreas did
Surgery
not fuse/migrate correctly and is putting a stranglehold on the
Also associated with Down syndrome
duodenum. It may be partial or complete obstruction. It’s a similar
presentation and treatment as duodenal atresia.

iii. Malrotation/Volvulus
Malrotation is incorrect alignment of the intestines due to failure
Double-Bubble + Normal Gas = Malrotation
to rotate during development. The timing of presentation varies
Upper GI series = Abrupt cutoff point
depending on the severity of any obstruction. The x-ray may be
Contrast enema = Abnormal cecum position
completely normal (though lack of gas distally could be a clue).
Will need corrective surgery
An upper GI series can show any abrupt cutoff in the GI tract.
Contrast enema can show abnormal positioning of the cecum.
Malrotation + Acute twist = Volvulus
Ultrasound utility is variable. These patients are setup to have a
Emergent surgery
volvulus which is acute twisting of the intestines around their
blood supply and can lead to ischemia. Fix with surgery.

iv. Intestinal Atresia

If there’s a double-bubble and multiple-air fluid levels it’s time
to talk to mom about her cocaine and/or tobacco use. This is
Double-Bubble + Air Fluid Levels = Intestinal Atresia
caused by vascular accidents in utero. Surgically remove the
Tell mom to stop cocaine / smoking
atretic areas.

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 Pediatrics [BABY EMESIS]

2) Non-bilious Vomiting
As noted above, vomit happens. Persistent non-bilious vomiting is often
related to the stomach or esophagus in etiology.

i. Pyloric Stenosis
If a baby (2-8 weeks of age) who has not had any problems
suddenly develops projectile vomiting after feeds, consider
pyloric stenosis. Physical exam will reveal an olive-shaped mass Boy with olive-shaped mass, projectile vomiting
and visible peristaltic waves. A CMP will reveal a Ultrasound = Donut
hypochloremic, hypokalemic, metabolic alkalosis which should Surgery = Pyloromyotomy
prompt immediate IVF for rehydration.

Stop. If the metabolic derangements have been identified fix them

first. The diagnosis is irrelevant - fix the metabolic derangements
(save baby) before doing anything else.

Definitive diagnosis is made with Ultrasound showing a “donut

sign.” Treatment is with pyloromyotomy. It’s more common in
boys (4:1).

ii. Tracheoesophageal fistula

There are five types; it’s essentially the lack of or presence of an
abnormal connection between the esophagus, trachea, and
stomach. The most common type is type C. This is where the
proximal esophagus is blind; the distal esophagus has an aberrant
connection running from the trachea to the stomach. These kids
will vomit everything (including secretions) from birth. Place a
NG tube and obtain an X-ray. NG tube should coil up in the
esophagus. There will be gas in the abdomen if the distal
esophagus is connected to either the proximal esophagus or to the
trachea. Keep the NG tube in, start parenteral nutrition, and call
surgery.

Look for bubbling and gurgling with respirations. There’s no

reason Type C has to be the one shown, other than it’s the most
common. The fistula presence and position, the atretic pouch and
position, etc all can vary. It’s the fact that the gastric contents mix
(either through fistula or because the baby can’t actually swallow)
that causes problems.

Non-bilious emesis after birth

X-ray = Coiled NG tube in esophagus
Intestinal air if distal esophagus connected
Correct surgically

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