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newborn in the nursery a few hours after birth because the infant vomited and choked after feeding. Non-bilious emesis (clear not green). The nurse reports that she has to frequently suction oral secretions.
37WGA. Pregnancy complicated by polyhydramnios (too much fluid)
-normal abd, hrt, clear to auscultation, but coughing

upper gut obstruction, *before ampulla of vater* -
*T-E fistula (more common)
*esophageal atresia
*esophageal web, stenosis

If respiratory distress and scaphoid abdomen: consider diaphragmatic hernia (may be either non or Bilious…consider Duodenal Atresia)
Other: GE reflux (Not burped adequately), Cardiac lesions, CNS


what to do for non-bilious emesis newborn??

what can you see on XR esophageal atresia??

don't want to do barium swallow, do NG tube (actually OG tube- go thru mouth, like thick spaghetti) have pre-known length to get to stomach, if coils before, know there is obstruction in esophagus, can see on XR

-see no air in abdomen


DDX: non-bilious emesis in newborn: GI, metabolic, CNS, infectious causes

-GI: GERD, Overfeeding
-Neuro: Subdural hematoma, Hydrocephalus, Mass lesion
-Metabolic: Galactosemia, Hypercalcemia, Urea cycle defects, Amino academies
-Infectious: Sepsis, Meningitis, UTI, Gastroenteritis


DDX: non-bilious emesis in newborn: Anatomic causes

Cleft Palate
Laryngopharyngeal Cleft
Esophageal atresia
Tracheoesophageal (TE) fistula
Vascular ring
Antral web
Duodenal atresia/stenosis
Pyloric stenosis


esophageal atresia most commonly occurs with ??

coexisting tracheoesophageal fistula (92%). (This case is the rare, esophageal atresia without TEF.) *air in stomach*
-tracheoesophageal fold

-pure esophageal atresia will not have air in stomach


Children with Esophageal atresia usually present within ??
Treatment: ??

24-48 hours after birth with copious oral secretions and drooling. Choking, vomiting (non-bilious).
Aspiration pneumonia

Mackyo's case:
-make fistula in neck that drains, so no buildup
-fed by NG tube


At day ?? of gestation, a ventral diverticulum is formed from the caudal end of the primitive pharyngeal foregut. This laryngotracheal diverticulum undergoes elongation and differentiation to eventually form the larynx, trachea, bronchi, and lungs. In order to separate the dorsal foregut (future esophagus) from the ventral laryngotracheal diverticulum, ?? fuse to form a septum that completely separates these structures (eFig. 392.1). It is believed that ?? leads to the anomalies of esophageal atresia and tracheoesophageal fistula (TEF).

day 26 or 27

longitudinal tracheoesophageal folds

failure of these folds to completely form, or improper timing of their formation


Esophagus and trachea develop during ?? of life. Defects in the ?? can result in TEF and esophageal atresia.


mesenchyme separating the two

use gastrographing (not barium, would damage lungs)


TEF and VACTERL (if have one congenital problem, need to look for others)

V: Vertebral Hemivertebrae (etiology: sacral element agenesis, caudal regression, Dx: Plain radiography, spine US, MRI (if U/S +)
A: Anorectum Imperforate anus: Dx: Exam
C: Cardiac Structural congenital heart dz: Dx: Echo
T: TE fistula: Suspect with esophageal atresia
E: Esophageal atresia: Dx: NG tube passage with plain radiography
R: Renal Horseshoe kidney, renal collecting system anomalies: Dx: Renal ultrasound
L: Limb Radial hypoplasia, atresia: Dx: Plain radiography


DDX: What does this xray show? slide 24
Emesis may be bilious

"double-bouble" sign
duodenal atresia
-stomach is one bubble, proximal duodenum BEFORE atresia is 2nd bubble; no air below
-greenish vomiting as newborn


duodenal atresia: Due to insult during ?? week gestation:
failure of ?? of duodenum
Usually ?? part of duodenum
what is associated??

Results in occluded lumen
2nd or 3rd

Trisomy 21: Down's syndrome


XR slide 28: *scaphoid abdomen* ("sucked in"), breathing difficulties, cyanotic, +/- vomiting

Diaphragmatic hernia
-intestines protrude up in utero (typ. left side)
-hear bowel sounds in thorax, push on lungs
-need to intubate, NG tube to minimize air in gut
-need surgical intervention


4wk old infant has had 6 days of projectile vomiting, Nonbilious.
-vigorously feeds but vomits forcefully afterwards.
-full term infant who had been gaining weight until the vomiting started. Today decreased wet diapers and no stools

what metabolic condition worry about??

pyloric stenosis
-dry mucous membranes
-typically lose weight, may be jaundice (reabsorb indirect)
-palpable epigastric (RU abdomen) olive mass (5–15 mm), only in 13.6%
-look hungry, drink/eat vigorously and comes right back up, peristaltic wave (can see, very dehydrated)
*hyperchloremic metabolic alkalosis (vomiting up acid)*


pyloric stenosis: Projectile postprandial vomiting usually begins ??.
Vomiting starts at birth in about 10% of cases and onset of symptoms may be delayed in ??.
Vomitus is ??

between 2 and 4 weeks (3-6 wks??) of age but may start as late as 12 weeks (pyloric muscle takes time to hypertrophy) in ddx 0-3 mos

preterm infants

rarely bilious (proximal) but may be blood-streaked


pyloric stenosis ddx

Pylorospasm (non-bilious)
GE reflux (non-bilious)
Malrotation with midgut volvulus (bilious)
Gastric bezoar (non-bilious) (obstruction in stomach)
(CNS tumor)


what studies to do with pyloric stenosis??

U/S: width and length of pyloric muscle; will do sx based on US

upper GI with barium: try to avoid to minimize radiation (adults: apple-core lesion) see think white line getting thru, like "string-sign"


lab studies with pyloric stenosis

Hypochloremic metabolic alkalosis (correct before sx!)
This patient:
Sodium: 135 Chloride: 90 Potassium: 3
CO2: 35 (typ: 22, here too high, think metabolic acidosis)
-May have indirect hyperbilirubinemia


pyloric stenosis epidemiology/associations

6-8 per 1000 births, 5:1 male
Non bilious emesis
Acquired condition:
Thickening of pyloric muscle, Most typically 2-12 weeks of age
Peristaltic waves “caterpillar stomach”
May be associated with erythromycin


pyloric stenosis imaging

XR: large stomach decreased bowel gas
US: elongation (> 15mm) and thickening of pylorus (4mm)
Barium Upper GI: “String sign”, or “beak of barium”


pyloric stenosis tx

IV fluids and electrolyte replacement
When stable (after correcting Hypochloremic metabolic alkalosis!)-->Surgical intervention: pyloromyotomy


3wk old infant w/ bilious emesis 1day, irritable and not consolable.
Prior hx: NSVD, no pregnancy complications, Poor weight gain.
On exam: T: 98.6F, P:180 (high), BP 70/40 (minimal)
Abdomen: distended
-continues to have green emesis (BILIOUS)
ddx? infection and anatomical
*think congenital* (probably not atresia?, would have presented earlier)

Infectious: Peritonitis, Viscous perforation, Necrotizing enterocolitis, Neonatal sepsis

Anatomic: Intestinal atresia (usually duodenal atresia, also jejunal or ileal), Duodenal stenosis, Intussusception, Intestinal *malrotation w/ midgut volvulus*, Annular pancreas, Duodenal web, Organomegaly → obstruction



can present few wks after birth or could happen right after
-bilious vomit, abd. distension


in premies worry about ??

necrotizing enterocolitis
-dilatation and can perforate


what studies for bilious emesis baby??

plain XR: do see air in rectum, but not much air in rest of abdomen-->do barium next: see corkscrew: implies twisting (malrotation-->volvulus), "beak sign": contrast stops
-her case: cecum on left: malrotation

-Chem, CBC


malrotation FA

Anomaly of midgut rotation during fetal development--> Žimproper positioning of bowel, formation of fibrous bands (*Ladd bands*). Can lead to volvulus, duodenal obstruction.


volvulus FA

Twisting of portion of bowel around its mesentery; can lead to obstruction and infarction Can occur throughout the
GI tract. *Midgut volvulus* more common in infants and children (from malrotation). *Sigmoid (more distal, from constipation, etc.) volvulus* more common in elderly.


GI embryology: Both duodenojejunal and ileocolic portion of bowel rotate ?? around the axis of omphalomesenteric vessels.
With normal rotation, duodenojejunal junction positioned in ?? and cecum positioned in ??
Result in long, fixed base between ?? that keeps mesentary from twisting

counterclockwise 270 degrees
ligament of Treitz and cecum


malrotation, volvulus is a ??

malrotation usually presents??

surgical emergency, want to tx before necrosis sets in
39% present within first 10 days of life, more than 90% present within 3 months, but can occur at any age (if volvulus occurs later) *Bilious emesis*


other bilious emesis ddx

annular pancreas: develops around intestine-->obstruction


9mo w. intermittent episodes of severe irritability, crying and pulling up his legs to abdomen, alternating with periods of lethargy (possibly neurotoxins)
-small amount of blood in the diaper.
T: 99. BP 93/66 RR18 P100
The child is drowsy. Abdomen: palpable *sausage shaped mass* right abdomen. Mild abdominal tenderness to palpation
"currant-jelly stool"

Ovarian pathology (torsion)
Meckel diverticulum as lead point for intussusception


LGIB: newborn

necrotizing enterocolitis
malrotation w. volvulus
allergic proctocolitis
Hirschprung dis w. enterocolitis
hemorrhagic disease of newborn


LGIB: infant

anal fissure
infectious colitis
allergic proctocolitis
meckel diverticulum
lymphonodular hyperplasia
malrotation w. volvulus
Hirschprung dis. w. enterocolitis
anatomic duplication
immune deficiency


LGIB: child/adolescent

anal fissure
infectious colitis
meckel diverticulum
lymphonodular hyperplasia
solitary rectal ulcer


Intussusception FA: Telescoping of ?? into ??, commonly at ileocecal junction. Compromised blood supply-->intermittent abdominal pain often with ??.
Majority of cases occur in ??.
appearance on ultrasound??

proximal bowel segment into distal segment
“currant jelly” stools
children (usually idiopathic; may be associated with recent enteric or respiratory viral infection), Abdominal emergency in early childhood
Unusual in adults (associated with intraluminal mass or tumor that acts as lead point that is pulled into the lumen)
bull’s-eye appearance on US


intussusception imaging ??

-XR: Target sign with small bowel within large bowel
Cresent sign with leading small bowel mass (US and CT are better)
-Air*(better if perforation) or Barium enema is dx and tx: round mass which moves retrograde with increased pressure, try to reduce back


Intussusception age ??
lead points ??

Most cases ages 1-2yo, Slight male predominance
Lead points: viral induced lymphoid hyperplasia, Meckel’s, lymphoma (older child)
Ileocolonic is most common


Intussusception complications

bowel obstruction, bowel edema and congestion. (current jelly stools are from the fluid losses from bowel edema and bleeding)
Episodes of severe pain alternating with lethargy


Intussusception tx

Fluid resuscitation and barium/ or air enema
If not reduced, then surgical intervention
Risk of bowel necrosis
Intussusception (need translation)


Meckel diverticulum

Most typically presents with painless rectal bleed
-Remnant of fetal omphalomesenteric duct and is an outpouching of distal ileum present in 1-2% of population
-Ectopic gastric tissue within diverticulum causes ulceration of mucosa in the adjacent ileum


Meckel diverticulum FA

True diverticulum. Persistence of the vitelline duct. May contain ectopic acid–secreting gastric mucosa and/or pancreatic tissue. Most common congenital anomaly of GI tract. Can cause melena, RLQ pain, intussusception, volvulus, or obstruction near terminal ileum. Contrast with omphalomesenteric cyst = cystic dilation of vitelline duct.
-painless bleeding, leading edge for Intussusception (can happen independently)


rule of 2's for Meckel's diverticulum FA

The five 2’s:
2 inches long.
2 feet from the ileocecal valve.
2% of population.
Commonly presents in first 2 years of life. May have 2 types of epithelia (gastric/


Meckel's Diverticulum dx

Technetium scan (nuclear scan) tagging the acid producing gastric musosa
FA: pertechnetate study for uptake by ectopic gastric mucosa.


You are called to discharge a newborn after 48 hours of life. You note that the child has not stooled (meconium).
On exam the infant has mild abdominal distension

Hirschsprung disease
other ddx:
Meconium plug
Meconium ileus *(cystic fibrosis)*
Ileal atresia
Imperforate anus


Hirschsprung disease FA

Congenital megacolon characterized by lack of ganglion cells/enteric nervous plexuses (Auerbach and Meissner plexuses) in segment of colon. Due to failure of neural crest cell migration. Associated with mutations in the RET gene


Hirschsprung disease FA presentation

Presents with bilious emesis, abdominal distention, and failure to pass meconium
Ž chronic constipation. Normal portion of the colon proximal to the aganglionic segment is dilated, resulting in a “transition zone.” Involves rectum.


Hirschsprung disease FA: association, dx, tx

Think of Hirschsprung as a giant spring that has sprung in the colon. Risk inc. with Down syndrome.
Dx: rectal SUCTION biopsy. Tx: resection


Hirschsprung dx:

Barium may suggest it but need rectal SUCTION biopsy: documentation of *absence of myenteric and submucosal plexus (aganglionic distal bowel segment)*
-Defective craniocaudal migration of vagal neural crest cells 5-12 weeks gestation, Familial 8-10%
-Lack of internal and sphincter relaxation


Hirschsprungs presentation

Untreated can lead to ??

Failure to pass meconium 24-48 hrs, Abdominal distention, *Bilious vomiting*, Constipation since birth
-toxic megacolon, entercolitis, sepsis and death
-surgical resection of affected colon
pics: slide 32: swollen abdomen and stool buildup


A mother brings her 2 week old infant with complaint of vomiting. Upon history, you learn that emesis had a sudden onset two days ago and from how the mother describes it, it could be characterized as bilious vomiting. On physical exam, the afebrile infant is very irritable upon palpation of abdomen and you note significant abdominal distension. What would you suspect?
A. Duodenal atresia
B. Meckel’s diverticulum
C. Volvulus
D. Gastroenteritis

C. Volvulus


A 3.5 kg male is born to a 26 year old primigravid female after an uneventful pregnancy. Through first trimester screening and subsequent confirmatory testing, you are anticipating the child to have Down’s syndrome. After delivery, patient is started on formula feeding. He passes urine shortly after birth no passage of meconium is noted. How can you explain the absence of meconium?
A.Anal atresia
B.Duodenal atresia
C.Meckel’s Diverticulum
D.Hirschsprung’s Disease
E.Pyloric stenosis

B. Duodenal atresia


A 3 day old female infant is brought into the ED because of difficulty breathing and poor feeding. Mother says she chokes and coughs out whatever is fed to her. You suspect that the infant has a tracheoesophageal fistula. Embryologically, where is the malformation for this condition?
A.Failure of tracheoesophageal ridges to fuse
B.Patent thyroglossal duct
C.Incomplete recanalization of larynx
D.Incomplete formation of septum secundum
E.Failure of buccopharyngeal membranes to rupture

A.Failure of tracheoesophageal ridges to fuse


A 1 month old infant is brought in after a week long history of non bilious vomiting. On physical exam a firm, mobile, palpable mass is felt over the epigastrium. What is the embryologic origin of this mass ?



Nurse calls you that newborn has respiratory distress. Polyhydramnios was noted during the third trimester. Physical exam shows an infant in respiratory distress. Strenuous accessory muscle use is noted as well as scaphoid abdomen. On physical exam, you can auscultate bowel sounds in lower left lung fields. What do you suspect?
B.Infantile esophagitis
C.Diaphragmatic hernia
D.Pulmonary atresia
E.Choanal atresia

C.Diaphragmatic hernia


A 26 hour old infant in the NICU presents with vomiting and abdominal distension. Vomiting is of a bilious nature. You review her charts and you note a prenatal ultrasound that showed polyhydramnios. An abdominal radiograph shows air distension in the stomach and proximal duodenum separated by a pyloric valve. What has caused this malformation?
A. Malrotation of the bowel
B. Failure of the duodenum to recanalize
C. Hypertrophy of Pylorus

B. Failure of the duodenum to recanalize


A 18-month old child is brought in by his uncle to the ED because of abdominal pain. The uncle says the infant will lie on the floor with his legs pulled to his chest screaming in pain. Then will have periods of sleepiness. When asked about being able to pass stool, the uncle says that today, the stool looked like mucous mixed with blood. He did have vomiting about two weeks ago. The uncle is babysitting the infant while the parents are on vacation. What do you suspect?
C.Lower GI bleed
D.Meckel’s diverticulum
E.Duodenal ulcer