Twisting the night away: Malrotation

Case presentation

A 5-day-old male infant presents with decreased feeding and activity for the past 24 hours. The parents report emesis that initially looked like infant formula but over the past 12 hours has become “yellow-green” and the last several episodes have been “green.” The emesis has occurred whenever the child attempts to feed, which was typically every 3 hours, but the parents have been attempting to feed more frequently (every hour or so) because they feel the child is not “keeping anything down.” There has been no fever, cough, congestion, rhinorrhea, or reported/known trauma. The child had initially been fussy and appeared “uncomfortable.”

The child’s physical examination reveals an ill-appearing, afebrile child. His heart rate is 116 beats per minute, respiratory rate is 20 breaths per minute, and oxygen saturations are 96% on room air. He has a sunken anterior fontanelle, dry mucous membranes, and dry skin without lesions. His skin turgor is poor with delayed capillary refill. There is no appreciable heart murmur and his lungs are clear. His abdominal examination demonstrates generalized distention with no obvious hepatosplenomegaly and the abdomen appears to be tense.

Imaging considerations

Emesis in the neonate has causes that range from benign to life-threatening, and history and physical examination can help to determine the need for imaging. Bilious emesis can indicate a surgical emergency and, while imaging is desirable, rapid treatment of the patient and prompt surgical consultation should not be delayed in these patients, especially if they appear ill or are in extremis.