Colour of Bile

Colour of Bile

Introduction

Classic teaching in paediatric surgery is that vomiting of bile in the newborn should be attributed to intestinal obstruction until proved otherwise. Reported series have confirmed the requirement for further investigation in this group, with a need for surgical intervention in 30-40%.1 2 To “avoid errors in judgment” these studies included only babies with green vomit and excluded babies with yellow vomit. Together with other neonatal surgeons we advocate prompt and thorough investigation of any infant with green vomit to specifically exclude mechanical obstruction. In several infants referred to our unit with reported bile vomiting, however, a detailed history reveals only yellow vomiting, though we are aware that a proportion of such babies are found to have intestinal obstruction. We determined what colour was perceived by different observer groups to represent bile in a baby's vomit.

Discussion

Because bile enters the intestine in the second part of the duodenum, intestinal obstruction below this level can result in bile in the vomit or gastric aspirate (fig 2). In the newborn this can be associated with surgical conditions including intestinal atresia, intestinal malrotation, and Hirschsprung's disease.1 These conditions are associated with considerable morbidity, particularly intestinal malrotation, in which rapid diagnosis is essential to prevent catastrophic ischaemia resulting from small bowel volvulus. In cases of small bowel volvulus, bile vomiting may be the only early sign4 and failure to act at this stage will result in avoidable delay. The presence of bile in the vomit is an independent sign of severity of disease and is rarely seen in well infants.

The specialist nurses on the baby unit would be expected to have the highest exposure to bile vomiting in the newborn, and nearly all respondents indicated a green colour when any box could be ticked. It was surprising that nearly a ...