Surgical care of children: a free MRCS Part A question

Bilious vomiting in a neonate is malrotation with volvulus until proven otherwise, even in a well baby with a soft abdomen — the bowel can infarct within hours. The pathway is to decompress the stomach, start intravenous fluids and discuss with and transfer to a paediatric surgical centre the same day for an upper gastrointestinal contrast study to define the position of the duodenojejunal flexure. Pyloric stenosis causes non-bilious vomiting at a few weeks of age. A formula change and overnight review lose the window to save the midgut. A normal plain film does not exclude volvulus, so it cannot justify observation. Hirschsprung's disease is suggested by delayed meconium and distension, which are absent here. Reference: Bailey & Love 28e.