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Neonatal bilious vomiting; exclusion of intestinal malrotation — MRCEM SBA MCQ

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HardPaediatric emergenciesNeonatal bilious vomiting; exclusion of intestinal malrotationMRCEM SBA

A 12-day-old infant born at 39 weeks presents after two episodes of distinctly green vomiting. He passed meconium on the first day of life and continues to pass stools. He is afebrile and well perfused, with a soft, non-distended abdomen. A nasogastric tube returns green fluid. Blood gas shows a lactate of 1.5 mmol/L, C-reactive protein is 3 mg/L, and an abdominal radiograph shows no obstruction or free gas. Feeds have been withheld; the tube is on free drainage, intravenous maintenance fluids and antibiotics have been started, and a blood culture has been taken. An appropriately experienced radiologist can perform an upper gastrointestinal contrast study locally in eight hours. What is the most appropriate next management plan?

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Correct answer: C — Admit under neonatal care and arrange local upper gastrointestinal contrast imaging.

Distinctly green vomit in a neonate requires assessment for malrotation, even when the infant has passed meconium, continues to pass stools and has an unremarkable abdominal radiograph. An upper gastrointestinal contrast study performed by an appropriately experienced radiologist is the investigation used to exclude it. This infant has no abdominal signs, haemodynamic compromise, acidosis or radiographic evidence of acute obstruction. He therefore needs monitored neonatal care and timely contrast imaging, rather than immediate surgery. Because suitable imaging is available locally within eight hours, it can be performed without emergency transfer. ([neonatalnetworkssoutheast.nhs.uk](https://neonatalnetworkssoutheast.nhs.uk/wp-content/uploads/2025/03/Wessex-Care-Pathway-for-Bilious-Vomiting-for-Exclusion-of-Malrotation_v3-ratified-March-2025.pdf)) **A** would be appropriate to consider if acute abdominal pathology or deterioration made immediate surgical intervention necessary. **B** risks missing malrotation: repeating a plain radiograph does not replace contrast assessment. **D** delays the indicated study by making it contingent on a different test. **E** recognises the need for contrast imaging, but immediate transfer is unnecessary in this stable infant when expert local imaging is available within the recommended timeframe; transfer becomes appropriate if timely local imaging cannot be arranged. ([neonatalnetworkssoutheast.nhs.uk](https://neonatalnetworkssoutheast.nhs.uk/wp-content/uploads/2025/03/Wessex-Care-Pathway-for-Bilious-Vomiting-for-Exclusion-of-Malrotation_v3-ratified-March-2025.pdf))

Reference: Wessex Care Pathway for Neonates Referred with Bilious Vomiting for Exclusion of Malrotation (March 2025) — https://neonatalnetworkssoutheast.nhs.uk/wp-content/uploads/2025/03/Wessex-Care-Pathway-for-Bilious-Vomiting-for-Exclusion-of-Malrotation_v3-ratified-March-2025.pdf Wessex Care Pathway, section 4.0 and initial-management decision tree (March 2025) — https://neonatalnetworkssoutheast.nhs.uk/wp-content/uploads/2025/03/Wessex-Care-Pathway-for-Bilious-Vomiting-for-Exclusion-of-Malrotation_v3-ratified-March-2025.pdf