What is the management and treatment for bilious vomiting?

Management of Bilious Vomiting

Bilious vomiting requires immediate gastric decompression with nasogastric tube placement and urgent evaluation to exclude life-threatening intestinal obstruction, particularly malrotation with midgut volvulus. 1, 2

Immediate Initial Actions

• Place a naso- or orogastric tube immediately to decompress the stomach in any patient presenting with bilious vomiting 2
• Assess for alarm symptoms including fever, abdominal pain, distention, jaundice, and altered mental status 3
• Stop all oral intake until surgical causes are excluded 1

Diagnostic Evaluation

Laboratory Assessment

• Obtain liver function tests including direct and indirect bilirubin, AST, ALT, ALP, GGT, and albumin 3
• In critically ill patients, add CRP, procalcitonin, and lactate to evaluate severity of inflammation and sepsis 3
• Check serum electrolytes, blood gases, and renal function in any patient with dehydration or concerning features 1

Imaging Strategy

First-line imaging depends on patient age and clinical context:

For Neonates and Infants

• Upper GI contrast series is the reference standard for evaluating malrotation and should be performed urgently 3, 4, 2
• The UGI series has 96% sensitivity for malrotation, though false-positives (10-15%) and false-negatives (2-4%) can occur due to redundant duodenum or bowel distension 3
• Ultrasound can identify midgut volvulus via the "whirlpool sign" (clockwise wrapping of SMV and mesentery around SMA), which is highly specific 3, 5
• When ultrasound makes a certain diagnosis, its accuracy eliminates need for further testing (PPV 100%), but inconclusive studies require contrast radiography 5

For Post-Cholecystectomy Patients

• Abdominal triphasic CT is first-line imaging to detect intra-abdominal fluid collections and ductal dilation 3, 6
• Add contrast-enhanced MRCP for exact visualization, localization, and classification of bile duct injury 3, 6

Management Based on Underlying Cause

Surgical Emergencies (Neonates/Infants)

Most common causes requiring urgent surgery: 2

• Malrotation with midgut volvulus (medical emergency)
• Duodenal atresia
• Jejunoileal atresia
• Meconium ileus
• Necrotizing enterocolitis
• Intussusception

Surgical consultation should be immediate when imaging confirms obstruction 2

Bile Duct Injury (Post-Cholecystectomy)

Minor Injuries (Strasberg A-D)

• If drain is present and bile leak noted, observation with nonoperative management is an option initially 3
• If no improvement or worsening occurs, ERCP with biliary sphincterotomy and stent placement becomes mandatory 3, 6

Major Injuries (Strasberg E1-E2)

• Refer immediately to hepatopancreatobiliary center if local expertise unavailable 3, 6
• Urgent surgical repair with Roux-en-Y hepaticojejunostomy may be performed if diagnosed within 72 hours 3
• For injuries diagnosed between 72 hours and 3 weeks: percutaneous drainage of collections, targeted antibiotics, nutritional support, then delayed surgical repair after minimum 3 weeks 3

Antibiotic Therapy

Indications for antibiotics in bilious vomiting context: 3

• Evidence of cholangitis or infected fluid collections
• Biliary peritonitis or biloma
• Sepsis or severe systemic infection

Antibiotic regimens: 3

• For biliary peritonitis: piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem 3
• Add amikacin if shock is present 3
• Add fluconazole in fragile patients or delayed diagnosis 3
• Start within 1 hour if severe sepsis or shock present 3

Duration: 3

• 4 days after source control for cholangitis
• 5-7 days for biloma and generalized peritonitis
• 2 weeks if Enterococcus or Streptococcus isolated (to prevent endocarditis)

Critical Pitfalls to Avoid

• Never assume normal abdominal radiographs exclude malrotation - only 44% of surgical cases had definitively positive plain films 3
• Normal SMV/SMA relationship on ultrasound does not preclude malrotation (21% false-positive, 2-3% false-negative rates) 3
• Meticulous UGI technique is essential as redundant duodenum and bowel distension cause interpretation errors 3
• In neonates with bilious vomiting and normal UGI studies, consider non-surgical causes including sepsis, polycythemia, neurologic abnormalities, and metabolic disorders 4