Intended for healthcare professionals

Endgames Case Report

A few hours from disaster

BMJ 2012; 345 doi: (Published 09 July 2012) Cite this as: BMJ 2012;345:e4441
  1. Rami Radwan, foundation year 1, paediatric surgery,
  2. Ashok Daya Ram, specialist registrar, paediatric surgery,
  3. Simon N Huddart, consultant, paediatric surgery
  1. 1University Hospital of Wales, Cardiff CF14 4XW, UK
  1. Correspondence to: R Radwan ramiradwan{at}

A 4 month old boy was brought to our children’s assessment unit with a 12 hour history of multiple green bilious vomits and irritability. He was not tolerating anything orally and had last opened his bowels two days ago. Birth had been at term by normal vaginal delivery, with no complications. He was taking no regular drugs and had no family or social history of note.

When he was 2 weeks old he had been seen by his general practitioner for bilious vomiting and had been sent home on antacids. A week later, he presented with further bilious vomiting, now associated with constipation, and was treated conservatively with guidance given to his mother on diet. During a third presentation at the age of 2 months, this time for irritability and constipation, his mother was advised that this was a common symptom of colic in newborns.

When we examined him, his temperature was normal, his heart rate was 121 beats/min (normal range 100-160), and his respiratory rate was 40 breaths/min (30-60). His mucous membranes were dry, and capillary refill time was 3 s. On auscultation he had normal heart sounds and his chest was clear. His abdomen was soft, mildly tender, and he had no palpable masses. Routine blood tests showed a normal white blood cell count and a C reactive protein concentration of <1 mg/L.


  • 1 What are the differential diagnoses of neonatal bilious vomiting?

  • 2 What is malrotation and why does it predispose to midgut volvulus

  • 3 How should this patient be investigated?

  • 4 How is this condition managed?


1 What are the differential diagnoses of neonatal bilious vomiting?

Short answer

Bilious vomiting in a neonate should be treated as a surgical emergency until proved otherwise. The causes include intestinal malrotation and volvulus, duodenal atresia, jejunoileal atresia, meconium ileus, and necrotising enterocolitis.

Long answer

Neonatal bilious vomiting is always a worrying sign. All …

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