Bilious vomiting

Liver forms bile. This bile is carried to the intestine by bile duct. Bile duct open in the small intestine in the duodenum. If this bile rather than going to the intestine, comes to the stomach and is seen in vomiting as green or yellowish contents in vomiting, it is called as bilious vomiting.

We will discuss bilious vomiting today.

What is bile?

As we discussed earlier, the liver forms the bile that is carried to the intestinal lumen. This bile is used by the intestine to digest food, especially the fats that are lipids in the food.

There is a lot of chemistry and biology involved in this process. We will try to make it simple for you. Bile looks greenish or yellowish in colour.

After doing its work a major part of bile is absorbed back in blood with digested food and carried back to the liver. Liver recycles it and sends it back to the intestine.

Some part of it is escaped into the stool or carried to the kidneys and excreted in the urine.

Why bilious vomiting?

When due to some conditions this bile comes to the stomach and is vomited, the vomit looks greenish or yellowish. It is called bilious vomiting.

For this bile to come to the stomach there should be a blockade to its flow in the intestine or may be the motion that carries intestinal content to the distal intestine is working in the wrong way.

What are the causes of bilious vomiting?

Depending on age causes of bilious vomiting may differ. 

In neonates and infancy

In neonates and infancy bilious vomiting may be because of incorrect intestinal movements or may be because of congenital defects in intestinal tract.

Though sometimes bilious vomiting can occur in normal neonates too, when there is bilious vomiting always consider congenital intestinal defect unless proven otherwise.

Some of these congenital defects include:

  • Duodenal atresia: It is a condition in which the duodenal part of the small intestine is not developed properly. This condition needs surgical treatment.
  • Malrotation of the gut with volvulus: In this condition, the small or large intestine is not placed correctly in the abdomen and it may lead to obstruction in the intestinal lumen. This condition needs surgical treatment.
  • Jejunal atresia: In this condition, the intestinal part further distal to the duodenum is malformed and the intestinal lumen is obstructed.
  • Meconium ileus: In this condition, the meconium is excessively hard and thick and it obstructs the intestinal lumen. It may occur with cystic fibrosis. It may need surgical correction.
  • Necrotizing enterocolitis: This is a serious intestinal infection in which the neonate cannot tolerate food, the abdomen is distended and the neonate looks toxic. The neonate may die of this condition because of sepsis.

In children

In children, causes of bilious vomiting can be mild to very serious. They are:

  • Gastroenteritis: This condition is because of the infection of the intestinal tract. Patients usually have vomiting, nausea, and loose motion. Some patients may also have abdominal cramps. The child may look dehydrated because of loss of water due to ongoing conditions.
  • Intestinal obstruction: Like neonates, children may also get intestinal obstruction. The causes are different than neonates and may or may not need surgical correction.
  • Constipation: Severe constipation as occurs in patients of cerebral palsy or cystic fibrosis may cause intestinal obstruction and can lead to bilious vomiting.

 In adults

In adults the causes of bilious vomiting are somewhat different than in children.

  • Drinking: Alcohol binge may induce excessive vomiting. Alcohol irritates the intestine and the intestine tries to throw it away. In such cases, patients may get bilious vomiting when then there are vigorous attempts of vomiting.
  • Intestinal obstruction: Intestinal obstruction in children may be an important cause of bilious vomiting in adults too. Usually intestinal obstruction the cramps are severe in the abdomen.
  • Motion sickness: Conditions like motion sickness may cause severe vomiting. If the journey is continued in such a condition and the stomach is empty the back regurgitation from the small intestine may come in vomit and you may experience bilious vomiting.
  • Vigorous vomiting: In vigorous vomiting along with contents of stomach contents of small intestine and bile may be seen.
  • Gastroenteritis: Like in children in adults too gastroenteritis may cause bilious vomiting.

What to do if bilious vomiting?

You should visit your doctor or pediatrician depending on your age if you experience bilious vomiting. Your doctor will examine you and suggest you some tests if needed. 

What tests are usually needed?

The additional lab tests help to confirm the primary diagnosis made on history and physical examination of the patients. If the intestinal obstruction is suspected further tests are needed they are as follows:

USG abdomen

USG abdomen may help to diagnose the intestinal obstruction or malrotation and detect some congenital anomalies.

It may also help to detect NEC in toxic neonates.

X-ray abdomen

X-ray abdomen is helpful to diagnose the condition like intestinal obstruction or volvulus or NEC in neonates.

Blood tests

Blood tests are not themselves helpful to diagnose the underlying condition but they are valuable to assess the effects of dehydration like electrolyte imbalance and acute kidney failure. 

Blood tests may be needed to assess the patients before surgical intervention.

What treatment is needed?

Treatment of bilious vomiting depends upon multiple factors. Some of them are as listed below.

  • Age of the patient
  • Underlying cause of the bilious vomiting
  • Hydration status of the patient
  • Other associated symptoms if any.

In neonates all the bilious vomiting cases are intestinal malformation and obstruction unless proven otherwise. Patients should be thoroughly investigated and treated depending on cause.

In case of NEC patients need to stop feeding and start TPN and treat with antibiotics in NICU. The prognosis may be guarded in such cases even with adequate treatment.

In malrotation and intestinal obstruction also oral feeding is stopped and the patient is provided with total parenteral nutrition. The surgery is planned and an anomaly is corrected. Patient needs surgical treatment with NICU support.

For children and adults for intestinal obstruction oral food intake is stopped and the patient is hydrated with IV fluids and the obstruction or volvulus is treated with surgical intervention.

In cases of severe dehydration and contraindication or inability to take oral fluids need hydration and maintenance of the hydration with IV fluids till underlying condition is treated and patient is able to take food orally.

Summery

Bilious vomiting is a condition which is itself just a symptom of the underlying disease process. Depending on age of the patient and underlying condition of the patients the treatment and investigations may be needed. 

The prognosis and outcome of the treatment depend on age, underlying cause, and associated morbidities of the patients.




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