A 13‑month‑old infant is vomiting yellow‑green (biliary) fluid; what is the appropriate emergency management?

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Emergency Management of Bilious Vomiting in a 13-Month-Old

Bilious vomiting in a 13-month-old infant is a surgical emergency until proven otherwise and requires immediate gastric decompression with a nasogastric tube, urgent abdominal radiograph, and immediate pediatric surgical consultation. 1, 2

Immediate Actions (Within Minutes)

1. Gastric Decompression

  • Insert a nasogastric or orogastric tube immediately to decompress the stomach and prevent aspiration 3, 4
  • Keep the infant NPO (nothing by mouth) 3

2. Assess for Life-Threatening Instability

  • Check vital signs for signs of shock (tachycardia >140 bpm increases odds of time-critical diagnosis, cool extremities, prolonged capillary refill) 2, 5
  • Evaluate hydration status: severe dehydration (≥10% fluid deficit) presents with prolonged skin tenting >2 seconds, lethargy, and decreased capillary refill and requires immediate IV fluid resuscitation 2
  • Critical pitfall: Normal vital signs do NOT exclude life-threatening volvulus—three neonates with normal vital signs at referral subsequently died in one study 5

3. Obtain Immediate Imaging

  • Order an abdominal radiograph immediately as the first imaging study to identify obstruction patterns (dilated bowel loops, air-fluid levels, "double bubble" or "triple bubble" signs) 1, 2, 6
  • Do not delay surgical consultation waiting for imaging results 1

Critical Diagnostic Considerations

Why This Is Urgent

  • Bilious vomiting indicates obstruction distal to the ampulla of Vater, suggesting potentially catastrophic conditions 1, 6
  • Midgut volvulus can cause intestinal necrosis within hours due to twisting around the superior mesenteric artery, leading to venous congestion, arterial compromise, transmural ischemia, and death or short gut syndrome 6
  • At 13 months, the differential includes malrotation with volvulus (possible at any age), intussusception (peak incidence 6-18 months), and less commonly intestinal obstruction from other causes 1, 6

Imaging Algorithm

  • Plain abdominal radiograph first: Look for dilated loops, air-fluid levels, or classic signs like "double bubble" (duodenal obstruction) 1, 2, 6
  • Normal radiograph does NOT exclude malrotation or volvulus—up to 7% of malrotation cases have normal plain films 2, 6
  • If obstruction is confirmed or clinical suspicion remains high despite normal radiograph, proceed urgently to upper GI contrast series (96% sensitivity for malrotation) to evaluate the position of the duodenojejunal junction 1, 6
  • Ultrasound is NOT the appropriate initial study for bilious vomiting—it is reserved for suspected intussusception when clinical features include intermittent crampy pain, "currant-jelly" stools, or palpable mass 1, 2

Surgical Consultation

  • Contact pediatric surgery immediately upon presentation—do not wait for imaging confirmation 1
  • Thirteen urgent transfers are required to preserve bowel integrity and save one life in neonates with bilious vomiting 5
  • If upper GI series confirms malrotation/volvulus, proceed directly to emergency surgery 6

Supportive Management

Fluid Resuscitation

  • Establish IV access and begin fluid resuscitation if any signs of dehydration are present 2
  • Monitor electrolytes and correct abnormalities, especially in severe dehydration 3

What NOT to Do

  • Do not attempt oral rehydration therapy—bilious vomiting requires NPO status and surgical evaluation 3
  • Do not give antidiarrheal agents (contraindicated and potentially dangerous) 2
  • Do not dismiss this as viral gastroenteritis—bilious vomiting is never a feature of uncomplicated gastroenteritis 2
  • Do not perform contrast enema as initial imaging—it is reserved for distal bowel obstruction and has a 20% false-negative rate for malrotation 6

Key Clinical Pitfalls

  • Assuming normal vital signs exclude serious pathology: Infants with life-threatening volvulus can appear well initially 5
  • Relying solely on plain radiograph: Normal films miss up to 7% of malrotation cases 2, 6
  • Confusing this with pyloric stenosis: Pyloric stenosis presents with non-bilious projectile vomiting at 3-6 weeks of age, not bilious vomiting at 13 months 1, 2
  • Delaying surgical consultation: The window to prevent bowel necrosis is measured in hours, not days 6

References

1
Guideline

Intussusception Diagnosis and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Guideline

Guideline Summary for Evaluation and Management of Vomiting in Children

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Research

Management of a child with vomiting.

Indian journal of pediatrics, 2013

6
Guideline

Bilious Vomit Characteristics and Clinical Significance

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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