What are the treatment options for a patient experiencing vomiting bile?

Management of Bilious Vomiting

Bilious vomiting requires immediate evaluation to exclude life-threatening intestinal obstruction, particularly midgut volvulus, which can cause bowel necrosis within hours if untreated. 1, 2

Immediate Initial Actions

• Place a nasogastric or orogastric tube immediately to decompress the stomach and prevent aspiration 3
• Obtain intravenous access and initiate fluid resuscitation to correct dehydration and electrolyte abnormalities 4, 1
• Bilious vomiting at any age represents intestinal obstruction until proven otherwise and demands urgent surgical consultation 2, 3

Diagnostic Evaluation

Laboratory Assessment

• Obtain comprehensive liver function tests including AST, ALT, alkaline phosphatase, GGT, direct and indirect bilirubin, and albumin 1
• In critically ill patients, add CRP, procalcitonin, and lactate to assess for sepsis severity 1
• Check complete blood count and basic metabolic panel to evaluate for infection and electrolyte disturbances 1

Imaging Strategy

The imaging approach depends on patient age and clinical presentation:

For Neonates and Infants (Priority: Exclude Malrotation/Volvulus)

• Obtain plain abdominal radiographs immediately looking for the "double bubble" sign (duodenal obstruction), dilated bowel loops with air-fluid levels, or decreased distal gas 5, 3
• Critical caveat: Normal abdominal radiographs do NOT exclude malrotation or volvulus - only 44% of surgical cases show definitively positive plain films 1, 5
• Proceed urgently to upper GI contrast series regardless of radiograph findings if clinical suspicion exists, as this is the reference standard with 96% sensitivity for malrotation 1, 5
• Upper GI series identifies abnormal duodenojejunal junction position and presence of midgut volvulus requiring immediate surgery 5
• Ultrasound has limited utility as a primary modality with 21% false-positive and 2-3% false-negative rates for malrotation, though the "whirlpool sign" (clockwise wrapping of superior mesenteric vein around superior mesenteric artery) is highly specific for volvulus 1, 5

For Post-Surgical Patients (Post-Cholecystectomy or Gastric Bypass)

• Abdominal triphasic CT is first-line imaging to detect bile duct injuries, intra-abdominal fluid collections, ductal dilation, or internal hernias 1
• MRCP provides superior biliary anatomy visualization when diagnosis remains uncertain after CT 6

Age-Specific Differential Diagnosis

Neonates (First 72 Hours of Life)

20% of neonatal bilious vomiting represents midgut volvulus - the most critical diagnosis to exclude 5

Other causes include:

• Intestinal atresia (duodenal, jejunal, ileal) - look for "triple bubble" sign on radiographs for jejunal atresia 5
• Annular pancreas 5
• Meconium ileus 5
• Hirschsprung disease 5
• Necrotizing enterocolitis 3

Older Infants and Children

• Intussusception 5
• Internal hernia (particularly after gastric bypass surgery) 5
• Jejunal stricture from non-specific jejunoileitis (common in developing countries) 7

Non-Surgical Causes (All Ages)

• Sepsis or meningitis 5
• Increased intracranial pressure 5
• Metabolic disorders 5
• Small intestinal bacterial overgrowth (post-resection patients) - presents with bloating, diarrhea, nausea, vomiting, weight loss 4

Specific Management Based on Etiology

Confirmed Malrotation/Volvulus

• Proceed directly to emergency surgery - delay can result in massive bowel necrosis, short gut syndrome, or death 5

Bile Duct Injury (Post-Cholecystectomy)

• Minor injuries (Strasberg A-D): Initial nonoperative management with observation if drain is present and bile leak noted 1
• If no improvement or worsening: ERCP with biliary sphincterotomy and stent placement is mandatory 1
• Major injuries (Strasberg E1-E2): Immediate referral to hepatopancreatobiliary center 1

Acute Cholangitis (Fever, Jaundice, Bilious Vomiting)

• Initiate broad-spectrum antibiotics within 1 hour: piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem 1, 6
• Continue antibiotics for 5-7 days 6
• Severe (Grade III) cholangitis: Emergency biliary decompression immediately 6
• Moderate (Grade II) cholangitis: Urgent ERCP with sphincterotomy if no improvement within 24-48 hours 6
• ERCP with stone extraction for choledocholithiasis has 90-95% success rate 6

Hyperemesis Gravidarum (Pregnancy-Related)

• Treatment is supportive: rehydration, correction of electrolyte abnormalities, thiamine supplementation to prevent Wernicke's encephalopathy, and antiemetic therapy 4
• Safe antiemetic options include ondansetron, metoclopramide, and promethazine 4
• Liver chemistry abnormalities (seen in ~50% of cases) typically resolve with hydration and resolution of vomiting 4
• If liver abnormalities persist despite symptom resolution, investigate alternative etiologies 4

Bile Salt Malabsorption (Post-Ileal Resection)

• Therapeutic trial of bile acid sequestrants (colestyramine, colesevelam, or colestipol) is appropriate, particularly if fecal calprotectin is not significantly elevated 4
• Loperamide can also be used 4
• SeHCAT scan should only be requested when diagnosis is uncertain 4

Small Intestinal Bacterial Overgrowth

• Empirical treatment with broad-spectrum antibiotics such as rifaximin is recommended if diagnosis is likely 4
• Recurrent courses may be required 4

Bile Reflux Gastritis (Post-Gastrectomy)

• Medical therapy with chelating agents or prokinetic drugs has disappointing results 8
• Roux-en-Y diversion is the treatment of choice for persistent symptoms, with 85% pain relief rate 8

Critical Pitfalls to Avoid

• Never assume normal abdominal radiographs exclude malrotation - proceed to upper GI series based on clinical suspicion alone 1, 5
• Normal superior mesenteric vessel relationship on ultrasound does not preclude malrotation 1
• Do not delay imaging or surgical consultation in neonates with bilious vomiting within first 72 hours of life 5
• Bilious vomiting is not always a GI disorder - consider sepsis, neurologic causes, and metabolic disorders if no GI disease identified 2
• Meticulous technique is essential for upper GI interpretation to avoid false results from redundant duodenum or bowel distension 5