The Role of Ultrasound in Identifying the Cause of Bilious Vomiting in the Newborn

"nIntroduction: A standard teaching rule in pediatric surgery, is that bile vomiting in a neonate indicates intestinal obstruction until proven otherwise .However, there are some recent reports that show bilious vomiting was observed in conditions other than intestinal obstruction or malrotation in up to two thirds of cases. Intestinal malrotation can result in midgut volvulus, a condition that is usually fatal if not surgically corrected. The standard diagnostic test for confirming it is upper gastrointestinal contrast study. But there are increasing reports of using ultrasound for diagnosis of midgut volvulus. In this study, we evaluate the role of ultrasound as a complementary or single imaging method for identifying the cause of bilious vomiting. "nMaterials and Methods: All neonates with a history of bilious vomiting referred to the radiology department of Bahrami children’s hospital during a 1-year-period (from November 2007 to December 2008) were prospectively audited .Neonates in whom the cause of vomiting was evident in a plain abdominal film or had a nasogastric tube in the duodenum were excluded. Sonography was performed with a Sonoline G50 Ultrasound scanner (Siemens medical solutions, Erlangen, Germany) with 7.5 -MHz convex and 10-MHz linear transducers. Some neonates had follow-up UGI and/or contrast enema .However, the final outcome of the neonates was measured by surgery or with clinical follow-up during hospitalization in a few cases. "nResults: Twenty three consecutive neonates (15 boys, 8 girls) were enrolled in this study .Their median age was 8.2 days (1-27 days). A surgical etiology of bilious vomiting was identified in 18 ( 78%): duodenal stenosis or atresia ( n=5), jejunal atresia ( n=4), intestinal malrotation with or without volvulus ( n=4) in concordance with sonographic diagnosis . Hirschprung‘s disease (n=2), bowel stenosis (n=1) and imperforate anus (n=1) presented sonographically with a suspicious lower obstruction .There were two interesting cases of esophageal atresia with tracheoesophageal fistula that had bypassing gastric vomitus (n=1) and one case with hypertrophic pyloris stenosis with an initial impression of bilious vomiting. Four (17%) patients had normal ultrasound and preliminary admission diagnosis of a meconium plug or an intraluminal lesion at two cases whose symptoms resolved with further conservative management. Superior mesenteric artery (SMA) and superior mesenteric vein (SMV) were inverted in six neonates, had an anteroposterior position in three cases and were normal in 14. None of the patients with no