A 3-Day-Old Boy With Bilious Emesis

Jamie Shalkow, MD


April 14, 2016

Physical Examination and Workup

The physical examination reveals a full-term baby boy who is small for his gestational age and in poor general condition. He is awake but hypotonic and hyporeactive. His temperature is 96.6° F (35.9°C), heart rate is 175 beats/min, respiratory rate is 48 breaths/min, and blood pressure is 75/40 mm Hg. He has a generalized grayish coloration, with acrocyanosis, and appears to be dehydrated. The head is normocephalic, with a depressed anterior fontanel, and the mucous membranes are dry.

No congenital anomalies are noted. The trachea is in a central position and there is no jugular venous distension. On chest examination, the respiratory movements are fast and shallow. Both lungs are clear to auscultation. Although tachycardic, the heart rate is regular and no murmurs are heard. The upper abdomen is grossly distended, whereas the lower abdomen appears scaphoid. There is a mild bluish discoloration of the abdominal skin, which also appears shiny and thin. Subcutaneous veins are easily seen. The baby retracts his legs upwards and cries while the abdomen is being palpated. No hepatosplenomegaly or masses are palpated, and no bowel sounds are noted. No rebound tenderness is observed. On rectal examination with a thermometer, bloody mucus is seen. The external genitalia are normal for the patient's age and gender. The extremities are thin and there is skin tenting. The capillary refill time is documented at 4 seconds.

Initially, oxygen is administered by nasal cannula at 1 L/min, and a 20 cc/kg bolus of Ringer lactate solution is given. An orogastric tube is passed, and 35 cc of bilious material is evacuated. A Foley catheter is inserted but no urine is initially obtained. After resuscitative measures are started, the patient is taken to the radiology department for a plain abdominal radiograph followed by an upper gastrointestinal contrast study.


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