What causes vomiting of bile?

What Causes Vomiting of Bile

Vomiting bile occurs when intestinal contents containing bile reflux backward into the stomach and are expelled, most commonly indicating intestinal obstruction (especially in infants and children), but also occurring with gut stasis from dysmotility, post-surgical bile reflux, or severe prolonged vomiting that empties the stomach.

Bilious Vomiting as a Red Flag for Obstruction

• Bilious vomiting at any age is a sign of intestinal obstruction until proven otherwise and requires immediate attention 1
• In infants, bilious vomiting indicates obstruction distal to the ampulla of Vater, suggesting a potentially serious surgical condition requiring urgent evaluation 2
• The bile-stained (green) appearance distinguishes this from non-bilious vomiting and dramatically changes the urgency of management 3

Common Obstructive Causes in Infants/Newborns:

• Malrotation with midgut volvulus can present at any age and is a surgical emergency 2, 3
• Duodenal atresia, jejunoileal atresia, and meconium ileus are common neonatal causes 4
• Intussusception presents with progression from initial vomiting to bilious emesis, indicating worsening obstruction 2
• Hirschsprung's disease can manifest with bilious vomiting 5

Gut Stasis and Dysmotility

• In severe chronic intestinal dysmotility, failure of forward propulsion causes gut stasis with accumulation of oral intake and normal gut secretions 6
• Large volume vomiting may be faeculent and contain food debris from several days previously, along with bile 6
• The impaired migrating myoelectric complex (MMC) prevents the small bowel from being cleared of debris, predisposing to stasis 6

Post-Surgical Bile Reflux Gastritis

• Bile reflux gastritis is a postgastrectomy condition characterized by abdominal pain, bilious vomiting, and weight loss 7
• The syndrome is caused by free enterogastric reflux of bile and other proximal small bowel constituents into the stomach 7
• This occurs when surgical anatomy allows bile to flow backward from the duodenum into the gastric remnant 7

Severe Prolonged Vomiting (Any Cause)

• In hyperemesis gravidarum, persistent vomiting can eventually lead to bile-stained vomitus once the stomach is emptied of food contents 6
• Any condition causing severe, protracted vomiting may eventually produce bile-tinged vomitus as the stomach empties and duodenal contents reflux 6

Post-Operative Bile Duct Injury

• After laparoscopic cholecystectomy, bile duct injury can present with nausea and vomiting (though typically not the primary symptom) 6
• The most frequent complaints are persistent abdominal pain, abdominal distension, nausea/vomiting, fever, and jaundice 6

Critical Pitfall to Avoid

• Never dismiss bilious vomiting as simple gastroenteritis or reflux without excluding obstruction, particularly in infants where malrotation with volvulus can compromise intestinal vascularization and lead to necrosis within hours 2
• Plain abdominal radiograph should be obtained immediately as the first imaging study to identify signs of obstruction 2, 4
• A nasogastric tube should be placed immediately to decompress the stomach in cases of suspected obstruction 4