Green Vomiting in a Ten-Day-Old - General Surgery clinical simulation case. A 10-day-old male infant, born at 39 weeks via uncomplicated vaginal delivery,...
Age: 10 • Gender: Male • Setting: Emergency Triage
Clinical Presentation & History
A 10-day-old male infant, born at 39 weeks via uncomplicated vaginal delivery, presents to the pediatric emergency department with sudden-onset bilious (green) vomiting, abdominal distension, and progressive lethargy over the past 24 hours. The parents initially attributed poor feeding to colic. The infant is now mottled, dehydrated, and shows visible peristaltic bowel loops across a tense, erythematous abdomen.
Acute Resuscitation Milestones & Priorities
Clinical phases and key interventions encountered in this emergency module:
Phase 2: Disposition — Operating Room vs Further Imaging
Phase 3: Intraoperative Crisis — Midgut Ischemia and Resection Threshold
Phase 4: Postoperative ICU Care and Parent Communication
High-Yield Clinical Pearls
Bilious (green) emesis in a neonate is malrotation with volvulus until proven otherwise; the green color originates from bile refluxed past the ampulla of Vater, indicating obstruction distal to the duodenum.
The Ladd procedure widens the narrow mesenteric root, divides peritoneal bands crossing the duodenum, derotates the volvulus, and places the small bowel on the right and colon on the left.
Neonates tolerate intestinal ischemia poorly — within 60–120 minutes of complete SMA occlusion, transmural infarction occurs. Early laparotomy is diagnostic and therapeutic.
Second-look laparotomy at 24–48 hours is standard for marginal bowel viability; dusky bowel at first look often recovers after detorsion and warming.
Initial IV access, broad-spectrum antibiotics, fluid resuscitation, and correction of hypoglycemia are non-negotiable pre-op steps; ceftriaxone is contraindicated in neonates due to bilirubin displacement.
Honest parent communication in their native language, paired with visible clinical commitment, builds trust even when prognosis is uncertain.
Test Your Clinical Reasoning in Real Time
Step into the active clinician role for this case. Order diagnostic tests, analyze live laboratory panels, and navigate branching clinical decisions with real-time feedback.