Management of Bilious Vomiting

Diagnostic Evaluation

Assess for alarm symptoms including fever, abdominal pain, distention, jaundice, and altered mental status in patients with bilious vomiting, as recommended by the World Journal of Emergency Surgery 1, 2
Obtain liver function tests including direct and indirect bilirubin, AST, ALT, ALP, GGT, and albumin in patients with bilious vomiting, as recommended by the World Journal of Emergency Surgery 2, 3
In critically ill patients, add CRP, procalcitonin, and lactate to evaluate severity of inflammation and sepsis, as recommended by the World Journal of Emergency Surgery 2, 3

The American College of Radiology recommends upper GI contrast series as the reference standard for evaluating malrotation in neonates and infants, with 96% sensitivity, though false-positives (10-15%) and false-negatives (2-4%) can occur due to redundant duodenum or bowel distension 4
Ultrasound can identify midgut volvulus via the "whirlpool sign" (clockwise wrapping of SMV and mesentery around SMA), which is highly specific, as recommended by the American College of Radiology 4
Abdominal triphasic CT is first-line imaging to detect intra-abdominal fluid collections and ductal dilation in post-cholecystectomy patients, as recommended by the World Journal of Emergency Surgery 2, 3, 5

The World Journal of Emergency Surgery recommends nonoperative management with observation as an initial option for minor bile duct injuries (Strasberg A-D) if a drain is present and bile leak is noted 1
ERCP with biliary sphincterotomy and stent placement is mandatory if no improvement or worsening occurs in minor bile duct injuries (Strasberg A-D), as recommended by the World Journal of Emergency Surgery 1, 5
Refer immediately to a hepatopancreatobiliary center if local expertise is unavailable for major bile duct injuries (Strasberg E1-E2), as recommended by the World Journal of Emergency Surgery 1, 5

The World Journal of Emergency Surgery recommends antibiotic therapy in patients with bilious vomiting who have evidence of cholangitis or infected fluid collections, biliary peritonitis or biloma, or sepsis or severe systemic infection 6, 7
Piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem are recommended antibiotic regimens for biliary peritonitis, as recommended by the World Journal of Emergency Surgery 6, 2, 7
Start antibiotic therapy within 1 hour if severe sepsis or shock is present, as recommended by the World Journal of Emergency Surgery 7

Never assume normal abdominal radiographs exclude malrotation, as only 44% of surgical cases had definitively positive plain films, as recommended by the American College of Radiology 4
Normal SMV/SMA relationship on ultrasound does not preclude malrotation, with 21% false-positive and 2-3% false-negative rates, as recommended by the American College of Radiology 4