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Bilious Emesis in the Neonate

Taryn M. Edwards, MSN CRNP NNP-BC

Intestinal obstructions are the most common surgical diagnoses in the neonatal period (Godbole & Stringer, 2002; Vinocur, Lee, & Eisenberg, 2012). It is imperative that an early and accurate diagnosis is made to ensure prompt patient management. In a neonate, bilious emesis can be the presenting sign of an intestinal obstruction, and if not managed in a timely manner, some of these obstructions may result in intestinal compromise. An observational study found that neonates with bilious emesis were later diagnosed with an intestinal obstruction when abdominal distention, abdominal tenderness, and abnormal X-ray findings were present at the same time (Mohinuddin et al., 2015).

In addition to abdominal radiographs, ultrasonography can play an important role in evaluating gastrointestinal (GI) disorders. Utilizing ultrasonography can diagnose or exclude midgut volvulus, a surgical emergency, by determining the location of the mesenteric vessels at their origin and following their course in the mesenteric root (Veyrac, Baud, Prodhomme, Saquintaah, & Couture, 2012). Although ultrasonography can be used in this situation, an upper GI series remains the study of choice to diagnose malrotation with or without volvulus (Carroll, Kavanagh, Leidhin, Lavelle, & Malone, 2016). Upon evaluation, contrast will leave the stomach and enter the duodenum. The duodenum will be to the right of the spine, the small intestine will all be on the right side of the abdomen, and the colon will be on the left. In a neonate with a volvulus, a “corkscrew” or ‘beaking” appearance of the duodenum and proximal jejunum is seen (Applegate, Anderson, & Klatte, 2006; Mattei, 2011).

Neonatal intestinal obstructions can be divided into high and low obstructions. The outline below delineates these diagnoses (Vinocur et al., 2012).

1. High intestinal obstruction
   1. Gastric atresia
      1. Duodenal atresia
      2. Duodenal stenosis with annular pancreas
   2. Duodenal web
   3. Malrotation
   4. Jejunal atresia
   5. Jejunal stenosis
2. Low intestinal obstruction
   1. Ileal atresia
   2. Meconium ileus
   3. Functional immaturity of the colon
   4. Hirschsprung disease
   5. Colonic atresia
   6. Anal atresia and anorectal malformations

General preoperative nursing considerations that should guide nursing care include GI decompression, fluid and electrolyte balance, thermoregulation, prevention of infection, and nutrition.

Gastric Decompression
Gastric decompression is achieved via a nasal or oral gastric decompression tube that is connected to low continuous suction. Decompression is important to prevent aspiration, respiratory decompensation due to abdominal distention, and gastric perforation (Kenner, & Lott, 2003). Therefore, tube patency is essential to ensure decompression is maintained.

Fluid and Electrolyte Balance
The goal of nursing management in an infant with intestinal obstruction is to maintain fluid and electrolyte balance (Kenner & Lott, 2003). It is critically important for strict and adequate intake and output measurements. The amount of gastric output needs to be measured every 4 hours to prevent fluid volume deficit and electrolyte derangement. Depending on the volume of gastric output, the volume may need to be replaced or the total fluid limit may need to be increased (Kenner & Lott, 2003).

Metabolic alkalosis may occur with high intestinal obstructions because of the loss of acidic gastric secretions. In obstructions that occur in the distal segment of the small intestine, there are larger volumes of alkaline secretions lost; as a result, metabolic acidosis occurs (Kenner & Lott, 2003). When the obstruction is below the proximal colon, acid-base balance usually is maintained because GI fluids are absorbed before reaching the intestinal obstruction (Kenner & Lott, 2003). Laboratory monitoring is essential to prevent acid-base imbalance and electrolyte derangements.

Thermoregulation
For any neonate, thermoregulation is vitally important. However, for the stressed or ill neonate, thermoregulation is even more critical. Cold stress dramatically increases oxygen consumption, predisposing the neonate to hypoglycemia and metabolic acidosis (Karlsen, 2013; Kenner & Lott, 2003). Nursing interventions include external heat source, head covering, and temperature monitoring.

Prevention of Infection
Surgical infants have an increased risk for infection; therefore, broad-spectrum antibiotics should be administered immediately (Kenner, & Lott, 2003). Postoperative antibiotics also should be administered. Laboratory monitoring of complete blood count with differential in the preoperative and postoperative period should occur.

Nutrition
Caloric and metabolic demands of an infant with GI dysfunction can be challenging. Since enteral feeding will be delayed, parenteral hyperalimentation and fat emulsion will be used to provide nutrition and prevent catabolism while nil per os (Kenner & Lott, 2003).  When the infant is ready for enteral feedings, a slow feeding advance will ensue. Advancement of feeding is followed closely to ensure tolerance. Intolerance includes diarrhea, vomiting, and abdominal distention.

General Postoperative Management
Hydration, maintenance of electrolyte balance, gastric decompression, and fluid-loss replacement are continued in the postoperative period. Pain is assessed at least every 4 hours using the appropriate pain assessment tool. Postoperative antibiotics will be administered; duration depends on surgical findings. Meticulous care is needed to maintain skin integrity because of possible limited positioning changes, opioid administration for pain management resulting in decreased active range of motion, and possible surgical drain placement (Kenner & Lott, 2003).

References

Applegate, K. E., Anderson, J. M., & Klatte, E. C. (2006). Intestinal malrotation in children: A problem-solving approach to the upper gastrointestinal series. Radiographics, 26(5), 1485–1500.

Carroll, A. G., Kavanagh, R. G., Leidhin, C. N., Lavelle, L. P., & Malone, D. E. (2016). Comparative effectiveness of imaging modalities for the diagnosis of intestinal obstruction in neonates and infants. Academic Radiology, 23(5), 559–568.

Godbole. P., & Stringer, M. D. (2002). Bilious vomiting in the newborn: How often is it pathologic? Journal of Pediatric Surgery, 37(6), 909–911.

Karlsen, K. (2013). The S.T.A.B.L.E. program (6th ed.). American Academy of Pediatrics.

Kenner, C., & Lott, J. W. (2003). Comprehensive neonatal nursing: A physiologic perspective (3rd ed.). St. Louis, MO: Saunders.

Mattei, P. (Ed.). (2011). Fundamentals of pediatric surgery. New York, NY: Springer Science+Business Media, LLC.

Mohinuddin, S., Sakhuja, P., Bermundo, B., Ratnavel, N., Kempley, S., Ward, H. C., & Sinha, A. (2015). Outcomes of full-term infants with bilious vomiting: Observational study of a retrieved cohort. Archives of Disease in Childhood, 100(1), 14–17.

Veyrac, C., Baud, C., Prodhomme, O., Saquintaah, M., & Couture, A. (2012). US assessment of neonatal bowel (necrotizing enterocolitis excluded). Pediatric Radiology, 42(S1), S107–S114.

Vinocur, D. N., Lee, E. Y., & Eisenberg, R. L. (2012). Neonatal intestinal obstruction. American Journal of Roentgenology, 198(1), W1–W10.

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