Bilious Vomiting in an 11‑Month‑Old with Fever: Immediate Action Required
An 11‑month‑old infant with fever who transitions from non‑bilious to bilious (yellow/green) vomiting requires immediate surgical evaluation, because bilious vomiting at any age is a surgical emergency until proven otherwise—midgut volvulus can cause intestinal necrosis within hours. 1, 2
Immediate Red‑Flag Recognition
- Bilious vomiting indicates obstruction distal to the ampulla of Vater and mandates urgent assessment by a pediatric surgical team. 1, 2, 3
- Midgut volvulus accounts for 20% of bilious vomiting cases in the first 72 hours of life but can present at any age, including 11 months, and requires immediate surgical consultation to prevent bowel necrosis. 1, 2
- The combination of fever and bilious vomiting raises concern for both surgical pathology (malrotation with volvulus, intussusception) and infectious causes (sepsis, meningitis, urinary tract infection). 1, 2, 4
Immediate Stabilization Steps
1. Place the infant nil per os (NPO) immediately
2. Insert a nasogastric or orogastric tube for gastric decompression
3. Assess hydration status and initiate IV access
- Evaluate for signs of severe dehydration (≥10% fluid deficit): prolonged skin tenting >2 seconds, cool extremities, decreased capillary refill, lethargy. 2
- Establish intravenous access and begin fluid resuscitation with isotonic crystalloid (normal saline or lactated Ringer's) if dehydration is present. 2
4. Obtain immediate surgical consultation
- Contact pediatric surgery before completing the imaging workup, because bilious vomiting is a surgical emergency. 1, 2, 3
Diagnostic Imaging Pathway
First‑Line Imaging: Plain Abdominal Radiographs
- Obtain supine and cross‑table lateral (or left lateral decubitus) abdominal X‑rays as the initial imaging study. 1, 2, 5
- Look for:
- "Double bubble" sign (duodenal obstruction, most commonly duodenal atresia or malrotation with volvulus). 1, 2
- "Triple bubble" sign with absent distal gas (jejunal atresia). 1, 2
- Dilated bowel loops, air‑fluid levels, or pneumatosis intestinalis (suggesting obstruction or necrotizing enterocolitis). 5, 3
Second‑Line Imaging: Upper GI Series
- If plain films show non‑classic findings or only a few distended loops, proceed immediately to an upper GI series with water‑soluble contrast to rule out malrotation with volvulus. 1, 2
- Plain radiographs miss up to 7% of malrotation cases, so a normal X‑ray does not exclude malrotation. 2
- The upper GI series will demonstrate abnormal positioning of the duodenojejunal junction and a "corkscrew" appearance of the proximal small bowel if volvulus is present. 1
Ultrasound Consideration
- If clinical features suggest intussusception (intermittent crampy pain, "currant‑jelly" stools, palpable abdominal mass), ultrasound is the initial imaging modality of choice. 2
- However, intussusception typically presents with intermittent non‑bilious vomiting initially, and the transition to bilious vomiting suggests progression or an alternative diagnosis. 2, 6
Laboratory Evaluation
- Obtain a complete blood count, electrolytes, blood gas, and blood culture to assess for sepsis, metabolic derangements, and dehydration severity. 1, 4
- Check for metabolic alkalosis (hypochloremic, hypokalemic), which would suggest pyloric stenosis, though this is less likely at 11 months and with bilious vomiting. 5
- Urinalysis and urine culture are indicated in febrile infants ≤3 months but remain important in an 11‑month‑old with fever and vomiting to exclude urinary tract infection. 1
Management Priorities
Fluid Resuscitation
- Administer 20 mL/kg boluses of isotonic crystalloid (normal saline or lactated Ringer's) for signs of moderate to severe dehydration or shock. 2
- Reassess perfusion, capillary refill, and mental status after each bolus. 2
Antibiotic Consideration
- If the infant appears toxic (lethargy, poor perfusion, altered mental status), initiate empiric broad‑spectrum antibiotics (e.g., ceftriaxone 50 mg/kg IV) after obtaining blood and urine cultures, to cover for sepsis, meningitis, or urinary tract infection. 1, 4
- Do not delay surgical consultation or imaging to administer antibiotics unless the infant is in septic shock. 1
Antiemetic Use
- Antiemetics are contraindicated in this scenario because they may mask clinical deterioration and delay recognition of surgical pathology. 5, 4
- Ondansetron is reserved for persistent vomiting in non‑surgical conditions (e.g., viral gastroenteritis) and should not be used when bilious vomiting is present. 4
Critical Pitfalls to Avoid
- Never dismiss bilious vomiting as "just gastroenteritis." Even if fever and prior non‑bilious vomiting suggest a viral illness, the transition to bilious emesis changes the differential diagnosis entirely. 2, 7
- Do not wait for imaging results to contact surgery. Midgut volvulus can cause irreversible bowel ischemia within hours, and surgical exploration may be required even if imaging is equivocal. 1, 2, 3
- Do not rely on the absence of abdominal distension to rule out obstruction. Early or high obstructions (e.g., malrotation with volvulus) may present with bilious vomiting before significant distension develops. 1, 3
- Avoid antidiarrheal or antimotility agents. These are ineffective, shift focus away from appropriate fluid therapy, and can cause serious complications including ileus and abdominal distention. 2
Disposition
- Admit to the hospital for surgical evaluation, IV hydration, and close monitoring. 4, 3
- If malrotation with volvulus is confirmed or strongly suspected, the infant requires emergent laparotomy to prevent bowel necrosis. 1, 2, 3
- If imaging excludes surgical pathology and the infant remains febrile, continue evaluation for infectious causes (sepsis, meningitis, urinary tract infection, pneumonia) and manage accordingly. 1, 4