What is the appropriate management for an adult presenting with bilious vomiting?

Management of Bilious Vomiting in Adults

Bilious vomiting in adults is a surgical emergency that requires immediate evaluation for intestinal obstruction until proven otherwise, with urgent surgical consultation and imaging studies to determine the cause.

Initial Assessment

When an adult presents with bilious vomiting, consider the following key causes:

• Small bowel obstruction (SBO) - most common cause
• Malrotation with midgut volvulus - surgical emergency
• Jejunal strictures
• Post-surgical complications (especially after gastric bypass)
• Obstruction at the jejuno-jejunostomy after RYGB

Red Flag Symptoms

• Abdominal pain
• Distension
• Inability to pass flatus or stool
• Signs of dehydration or sepsis
• Hemodynamic instability

Diagnostic Approach

1. Abdominal radiographs - First-line imaging to assess for obstruction patterns 1

   • Look for dilated bowel loops, air-fluid levels, and absence of distal gas

2. CT scan with oral contrast - If radiographs are inconclusive or to better characterize obstruction

3. Upper GI series with contrast - To evaluate for malrotation or obstruction location

Management Algorithm

Step 1: Immediate Stabilization

• Insert nasogastric tube for decompression
• Correct fluid and electrolyte imbalances with IV fluids
• NPO (nothing by mouth)
• Administer antiemetics: ondansetron 4-8 mg IV 2

Step 2: Determine Obstruction Location and Cause

If post-RYGB patient with bilious vomiting:

• Suspect obstruction at the jejuno-jejunostomy 1
• Urgent surgical consultation
• Consider early exploratory laparoscopy in hemodynamically stable patients

If non-surgical patient:

• Complete imaging workup
• Surgical consultation for suspected mechanical obstruction

Step 3: Definitive Management

For mechanical obstruction:

• Surgical intervention - The definitive treatment for most cases of bilious vomiting due to obstruction 1
• In hemodynamically stable patients with segmental intestinal ischemia, limited intestinal resection and anastomosis may be appropriate
• For unstable patients with extended intestinal ischemia/peritonitis, damage control surgery with open abdomen approach is recommended 1

For non-mechanical causes:

• Treat underlying condition
• Consider prokinetic agents for motility disorders

Special Considerations

Post-Bariatric Surgery Patients

• After RYGB, bilious vomiting indicates obstruction at the jejuno-jejunostomy or a gastro-gastric fistula 1
• Common causes include internal hernia (53.9%), Roux limb compression (20.5%), and adhesions (13.7%) 1
• Early exploratory laparoscopy is mandatory when internal hernia is suspected 1

Endoscopic Management

• For gastric strictures after sleeve gastrectomy, endoscopic balloon dilation or stent placement has 88-94% success rate 1
• When endoscopic methods fail, conversion to RYGB should be considered 1

Pitfalls to Avoid

1. Delayed diagnosis - Bilious vomiting is a surgical emergency until proven otherwise
2. Inadequate resuscitation - Fluid and electrolyte imbalances must be corrected aggressively
3. Missing malrotation with volvulus - Can lead to bowel necrosis and death if not promptly identified
4. Attributing symptoms to non-surgical causes without adequate investigation

Conclusion

Bilious vomiting in adults represents a surgical emergency until proven otherwise. Prompt evaluation with appropriate imaging and early surgical consultation are essential to prevent morbidity and mortality from intestinal ischemia and necrosis.