What is the appropriate management for a patient presenting with bile emesis, possibly accompanied by abdominal pain, nausea, and vomiting, and who may have a history of gastrointestinal disorders or surgery?

Management of Bile Emesis

Bile emesis is a medical emergency requiring immediate evaluation for bowel obstruction, with abdominal radiography as the first-line imaging study, followed by urgent upper GI contrast series if obstruction is suspected, regardless of initial radiograph findings. 1, 2

Immediate Clinical Assessment

The presence of bile in vomitus indicates obstruction distal to the ampulla of Vater and demands urgent investigation. 2 Key clinical features to assess include:

• Age of presentation: In neonates within 72 hours of birth, 20% of bilious vomiting cases represent midgut volvulus—a surgical emergency that can cause intestinal necrosis within hours. 1, 2
• Associated symptoms: Abdominal distension with bilious vomiting strongly suggests proximal bowel obstruction. 1, 2
• Fever and jaundice: These suggest biliary infection (cholangitis) rather than mechanical obstruction. 1, 3
• Post-surgical context: After laparoscopic cholecystectomy, bile emesis with fever, abdominal pain, and jaundice indicates possible bile duct injury. 1

Diagnostic Algorithm

Step 1: Obtain Abdominal Radiograph Immediately

Plain abdominal radiography is the mandatory first imaging study for all patients with bile emesis. 1, 2 Look for:

• "Double bubble" sign: Indicates duodenal obstruction (most commonly duodenal atresia in neonates). 1
• "Triple bubble" sign: Suggests jejunal atresia. 1, 2
• Multiple dilated bowel loops with absent distal gas: Indicates more distal obstruction. 2

Critical pitfall: Normal radiographs do NOT exclude malrotation or volvulus—clinical suspicion based on bilious vomiting alone mandates proceeding to upper GI study. 2

Step 2: Urgent Upper GI Contrast Series

If bowel obstruction is suspected clinically (regardless of radiograph findings), proceed immediately to upper GI contrast series—this is the definitive diagnostic study with 96% sensitivity for malrotation. 2 This study identifies:

• Abnormal position of the duodenojejunal junction (malrotation)
• Presence of midgut volvulus requiring immediate surgery
• Specific level and cause of obstruction

Do not delay this study based on normal initial radiographs, as up to 7% false-negatives can occur with plain films alone. 2

Step 3: Laboratory Evaluation

Obtain liver function tests including direct and indirect bilirubin, AST, ALT, ALP, GGT, and albumin to differentiate obstructive from infectious causes. 1 In critically ill patients, add CRP, procalcitonin, and lactate to assess sepsis severity. 1

Step 4: Advanced Imaging for Specific Scenarios

For post-surgical patients or when bile duct injury is suspected: Abdominal triphasic CT is the first-line study to detect fluid collections and ductal dilation, complemented by contrast-enhanced MRCP for exact visualization and classification of bile duct injury. 1

For suspected cholangitis: Abdominal ultrasound initially (80-90% sensitivity), followed by CT with IV contrast if equivocal (90-95% sensitivity), then MRCP for definitive biliary anatomy if diagnosis remains uncertain (95-100% sensitivity). 3

Management Based on Etiology

Mechanical Bowel Obstruction (Neonates/Children)

Confirmed malrotation with volvulus requires immediate surgical intervention—proceed directly to surgery without delay. 2 The pathophysiology involves twisting of the mesentery around the superior mesenteric artery, causing venous congestion, arterial compromise, and transmural intestinal ischemia that can progress to necrosis within hours. 2

For confirmed intestinal atresia (duodenal, jejunal, or ileal), surgical repair is definitive treatment. 1, 2

Acute Cholangitis

Initiate broad-spectrum antibiotics within 1 hour of diagnosis using piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem. 1, 3 Continue for 5-7 days. 3

Biliary drainage strategy depends on severity: 1, 3

• Severe (Grade III) cholangitis: Emergency biliary decompression immediately via ERCP with sphincterotomy (preferred method with 90-95% success rate). 1, 3
• Moderate (Grade II) cholangitis: Urgent drainage within 24-48 hours if no improvement despite antibiotics. 3
• Percutaneous transhepatic biliary drainage (PTBD): Reserved for ERCP failures or inaccessible papilla. 1

Bile Duct Injury (Post-Cholecystectomy)

For patients not recovering after laparoscopic cholecystectomy with alarm symptoms (fever, abdominal pain, distention, jaundice, nausea, vomiting), investigate promptly. 1

Management depends on timing and severity: 1

• Minor injuries (Strasberg A-D) with drain in place: Observe initially; if no improvement, proceed to ERCP with sphincterotomy and stent placement. 1
• Major injuries (Strasberg E1-E2) diagnosed within 72 hours: Refer to hepatopancreatobiliary (HPB) center for urgent surgical repair with Roux-en-Y hepaticojejunostomy. 1
• Major injuries diagnosed 72 hours to 3 weeks post-op: Percutaneous drainage of collections, targeted antibiotics, nutritional support, then delayed surgical repair after minimum 3 weeks. 1

Antibiotic regimen for bile peritonitis: Use piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem, with amikacin added for shock and fluconazole for delayed diagnosis. 1 Continue for 5-7 days for biloma and generalized peritonitis. 1

Age-Specific Differential Diagnoses

Neonates (first 72 hours): Intestinal atresia, midgut volvulus, annular pancreas, meconium ileus, Hirschsprung disease. 1, 2

Older infants/children: Intussusception, internal hernia (especially post-gastric bypass), foreign body ingestion. 2, 4

Adults: Cholangitis, bile duct injury, superior mesenteric artery syndrome, internal hernia. 1, 3

Critical Pitfalls to Avoid

• Never dismiss bilious vomiting as benign at any age—it is pathologic until proven otherwise and requires immediate investigation. 5, 6
• Do not rely solely on normal abdominal radiographs to exclude malrotation or volvulus; proceed to upper GI series based on clinical suspicion. 2
• Avoid delaying surgical consultation in neonates with bilious vomiting, as midgut volvulus can cause irreversible bowel necrosis within hours. 2
• Do not perform contrast enema or ultrasound as initial studies before plain radiography in suspected bowel obstruction. 1
• In post-cholecystectomy patients, do not attribute symptoms to routine post-operative changes without investigating for bile duct injury. 1