Critical Role of Ultrasound for Differentiating Surgical from Non-Surgical Causes of Greenish Vomiting in Neonates

Background: Newborns with green vomiting are usually correlated with lower bowel obstruction, some of whom may require surgical intervention. Objective: This case demonstrates that green vomiting is not always indicative of bowel obstruction.

Case: We report a preterm male infant born at 27 weeks’ gestation (1095 g) via cesy improvement and cyst reduction.

Discussion: Bilious vomiting in neonates does not necessarily indicate a surgical etiology. While Alehossein et al. (2012) demonstrated that identification of 23 neonates with bilious vomiting as surgical candidates by ultrasound led to surgery with a positive predictive value of 100% and sensitivity and specificity reaching 89% and 100%, respectively, for intestinal atresia. Five neonates in their cohort were managed conservatively without surgical intervention.

Low et al. (2024) further demonstrated that adjunctive ultrasound played a decisive role in achieving a preoperative diagnosis of intestinal malrotation in neonates with inconclusive upper gastrointestinal series, confirming its value as an essential complementary tool. Herliczek et al. (2011) proposed sonographic upper gastrointestinal assessment as a practical alternative to fluoroscopic series in the vomiting infant, given that it is non-ionizing, portable, quick, and readily available.

In our case, ultrasound not only excluded intestinal obstruction but also identified two coexisting pathologies, namely a duplication cyst and bilateral hydronephrosis, which directly informed the decision to pursue conservative management, underscoring how early ultrasound assessment neonates presenting with green vomiting can meaningfully guide clinical decision-making.

Conclusion: Prompt and comprehensive ultrasonographic assessment is essential in neonates with green vomiting to accurately identify the underlying etiology and minimize unnecessary surgical intervention. Keywords: bowel obstruction, non-surgical management.