Paul Stephen Cullis1, Emily Mullan2, Allan Jackson3, Gregor Walker4. 1. Department of Surgical Paediatrics, Royal Hospital for Children Glasgow, Glasgow, UK; University of Glasgow, Glasgow, UK. 2. University of Glasgow, Glasgow, UK; Department of Neonatology, Queen Elizabeth University Hospital, Glasgow, UK. 3. University of Glasgow, Glasgow, UK; Department of Neonatology, Princess Royal Maternity Unit, Glasgow, UK; ScotSTAR Paediatric Retrieval Service, Paisley, UK. 4. Department of Surgical Paediatrics, Royal Hospital for Children Glasgow, Glasgow, UK; University of Glasgow, Glasgow, UK. Electronic address: gregor.walker@ggc.scot.nhs.uk.
Abstract
BACKGROUND: Between 20% and 50% neonates with bilious vomiting are diagnosed with surgical pathology. Distinguishing neonates requiring surgery remains challenging. Our aim was to conduct an audit of term neonates with bilious vomiting referred for assessment to identify characteristics of this cohort and management. Secondary aims were to identify factors predictive of surgical pathology. METHODS: Infants <28 days referred for bilious vomiting from 2011 to 2015 were identified through cross-referencing multiple patient databases. Data obtained included clinical features, laboratory, radiological investigations and management. The sensitivity and specificity of tests were calculated and regression analyses were conducted to identify predictors of surgical pathology. RESULTS: 351 eligible neonates were referred [46% female; mean gestation 39 + 6 weeks (SD 9.2 days); mean birthweight 3469 g (SD 558 g)]. Laboratory results were available for 68.7% patients, 88.9% underwent X-ray and 96.6% contrast studies. 11.7% had a surgical diagnosis [malrotation 4.6% (1.7% with volvulus)]. No single test available in peripheral centers could exclude a surgical diagnosis. In regression analyses, age > 72 h, presence of abdominal distension, raised CRP and abnormal X-ray were statistically significant predictors of surgical pathology, while only the former two were predictive of time-critical surgical pathology. CONCLUSION: 11.7% neonates had surgical pathology, fewer than in previous studies. Only contrast fluoroscopy could exclude surgical pathology and therefore prevent transfer. A more sensitive, widely available test would be required to reduce unnecessary neonatal transfers. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level III. Crown
BACKGROUND: Between 20% and 50% neonates with bilious vomiting are diagnosed with surgical pathology. Distinguishing neonates requiring surgery remains challenging. Our aim was to conduct an audit of term neonates with bilious vomiting referred for assessment to identify characteristics of this cohort and management. Secondary aims were to identify factors predictive of surgical pathology. METHODS:Infants <28 days referred for bilious vomiting from 2011 to 2015 were identified through cross-referencing multiple patient databases. Data obtained included clinical features, laboratory, radiological investigations and management. The sensitivity and specificity of tests were calculated and regression analyses were conducted to identify predictors of surgical pathology. RESULTS: 351 eligible neonates were referred [46% female; mean gestation 39 + 6 weeks (SD 9.2 days); mean birthweight 3469 g (SD 558 g)]. Laboratory results were available for 68.7% patients, 88.9% underwent X-ray and 96.6% contrast studies. 11.7% had a surgical diagnosis [malrotation 4.6% (1.7% with volvulus)]. No single test available in peripheral centers could exclude a surgical diagnosis. In regression analyses, age > 72 h, presence of abdominal distension, raised CRP and abnormal X-ray were statistically significant predictors of surgical pathology, while only the former two were predictive of time-critical surgical pathology. CONCLUSION: 11.7% neonates had surgical pathology, fewer than in previous studies. Only contrast fluoroscopy could exclude surgical pathology and therefore prevent transfer. A more sensitive, widely available test would be required to reduce unnecessary neonatal transfers. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level III. Crown