What is the management for green vomit?

Management of Green Vomit

Green vomit indicates bilious emesis, which suggests a distal obstruction or bowel pathology and requires immediate evaluation for surgical causes, particularly bowel obstruction, malrotation with volvulus, or gastric outlet obstruction. 1

Immediate Assessment and Stabilization

Stop all oral intake immediately and insert a nasogastric tube for gastric decompression in any patient with bilious (green/yellow) vomiting. 1 This is critical because:

• Green vomit signals bile reflux from the duodenum, indicating either mechanical obstruction distal to the ampulla of Vater or severe dysmotility 1
• A distal obstruction is suggested by feculent vomit, while more proximal obstruction presents with green/yellow vomit 1
• Assess airway, breathing, circulation, and hydration status immediately 2

Diagnostic Priorities

Obtain urgent imaging (CT scan with IV contrast preferred) to identify a transition point between dilated and normal bowel, which confirms mechanical obstruction. 1 Key diagnostic considerations include:

• Look for organic obstruction from adhesions, volvulus, intussusception, or strictures 1
• Radiologic clues include a distinct transition point, though this may not be apparent if obstruction has resolved or bowel is fixed by adhesions 1
• Obtain imaging during an acute pain episode when possible for highest diagnostic yield 1
• Check for impaction, complete obstruction, hypercalcemia, hypokalemia, hypothyroidism, and diabetes mellitus 1

Red Flag Signs Requiring Urgent Intervention

Any patient with bilious vomiting, altered sensorium, toxic/septic appearance, severe dehydration, or bent-over posture requires immediate surgical consultation. 2 These indicate:

• Potential bowel ischemia, perforation, or closed-loop obstruction 2
• Need for laboratory evaluation including electrolytes, blood gases, renal and liver function 2
• Possible need for emergent surgical intervention 1

Medical Management After Exclusion of Surgical Causes

If mechanical obstruction is ruled out and gastric outlet obstruction or severe dysmotility is confirmed:

Initiate corticosteroids for gastric outlet obstruction, with alternative options including endoscopic stenting or decompressing G-tube placement. 1

For functional causes after surgical pathology excluded:

• Start with metoclopramide 10-20 mg PO/IV every 6 hours as first-line dopamine antagonist 3
• Add ondansetron 4-8 mg PO/IV 2-3 times daily if symptoms persist, targeting different receptor pathways 3
• Consider haloperidol 0.5-2 mg PO/IV every 4-6 hours or prochlorperazine 10 mg PO/IV every 6-8 hours as alternatives 3

Route of Administration

Use rectal suppositories, subcutaneous/IV infusions, or sublingual formulations when oral route is not feasible due to active vomiting. 3 Options include:

• Promethazine or prochlorperazine rectal suppositories 1
• Ondansetron sublingual tablets 1
• Continuous IV or subcutaneous antiemetic infusions for refractory cases 3

Critical Pitfalls to Avoid

Never administer antiemetics or prokinetics in suspected mechanical bowel obstruction, as this masks progressive ileus and gastric distension. 3 Additional cautions:

• Do not give metoclopramide if obstruction is not definitively ruled out, as it can worsen pain and precipitate perforation 1
• Avoid repeated endoscopy or imaging unless new symptoms develop 3
• Monitor QTc interval when using ondansetron, especially with other QT-prolonging agents 3
• Watch for extrapyramidal symptoms with dopamine antagonists, particularly in young males 3

Fluid and Electrolyte Management

Replace fluid deficits with IV crystalloids and correct electrolyte abnormalities, as bowel obstruction causes third-spacing and secretory losses. 1 During obstructive episodes:

• The bowel secretes more fluid, and when obstruction resolves, diarrhea or high stomal output follows 1
• Ensure adequate hydration and correct any electrolyte abnormalities before considering antiemetics 1

Special Considerations

In elderly patients, reduce initial antiemetic doses by 25-50% and monitor closely for extrapyramidal side effects. 4 For pediatric patients with bilious vomiting, consider congenital causes including malrotation with volvulus, intestinal atresia, and pyloric stenosis, which are surgical emergencies. 2