Education And Debate


BMJ 1996; 312 doi: (Published 27 January 1996) Cite this as: BMJ 1996;312:236
  1. Mark Davenport

    Surgically correctable causes of vomiting in infancy are unusual, but an awareness of this possibility is important in order to prompt appropriate referral and management. It is possible to consider the various conditions by the age of the infant.

    Surgically correctable causes of vomiting in infancy

    Infants up to one week old

    • Gastrointestinal atresias

    • Malrotation

    • Meconium ileus

    • Hirschsprung's disease

    Infants up to one month old

    • Gastro-oesophageal reflux

    • Pyloric stenosis

    Infants up to one year old

    • Intussusception

    • Inguinal hernia

    Clinical features suggesting a surgically correctable cause of vomiting

    • Bile stained vomit

    • Localised or asymmetric tenderness

    • Abdominal distension

    First week of life—in the postnatal ward

    Oesophageal atresia

    Infants with oesophageal atresia may well present on the postnatal ward or delivery suite with regurgitation of saliva, although clearly this is not strictly vomiting. Such babies are characteristically described as mucousy or bubbly, and there may have been a history of maternal polyhydramnios. The clinical diagnosis can be confirmed by attempting to pass a large nasogastric tube (8-10 French gauge) and then taking an x ray picture of the chest. Smaller gauge tubes may well coil in the upper pouch.

    Radiograph showing nasogastric tube curled in upper pouch of oesophageal atresia (arrow) and large isolated stomach bubble caused by an associated duodenal atresia.

    Gastrointestinal atresia

    Almost all upper gastrointestinal atresias such as duodenal or jejunal atresia present on the first or second day of life. The key clinical feature is vomiting of bile, and this certainly requires a surgical review. Polyhydramnios may again have been a feature during pregnancy, and in some infants prenatal vomiting of bile may mimic meconium stained liquor. Even the absence of bile from the vomit does not exclude duodenal atresia, as some 15% of even complete duodenal occlusions are supra-ampullary. Unlike other causes of a high intestinal obstruction, up to 30% of infants with duodenal atresia also have Down's syndrome.

    Incomplete upper gastrointestinal obstructions

    These can be less clear cut, and successful feeding may become established with perhaps only occasional …

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