301 - Defining Action Thresholds for Neonatal Bilious Emesis: A Survey of Pediatric Surgeons

Poster Number: 301
Publication Number: 301.441

Katelyn H. Roberts, University of Michigan Medical School, ann Arbor, MI, United States; Erin E. Perrone, University of Michigan Medical School, Ann Arbor, MI, United States; Gary M. Weiner, University of Michigan Medical School, Ann Arbor, MI, United States

Background: Bilious emesis is a sign of intestinal obstruction requiring prompt investigation; however, there is wide variation in the color that providers in the neonatal ICU describe as bilious. Over identification of bile may lead to unnecessary interventions. Under recognition may result in delayed diagnosis of malrotation with volvulus leading to catastrophic bowel injury.

Objective: 1. Determine the threshold color that pediatric surgeons define as bilious gastric aspirate/emesis. 2. Determine whether the threshold color for transfer to a referral center, if necessary, and an upper gastrointestinal (UGI) varies with clinical context.

Design/Methods: Electronic surveys (Qualtrics, Provo, Utah) were sent by email to the AAP Section on Surgery (~ 600 members). Participants were shown a color block with 8 standardized RGB color gradations in order from light yellow to dark green and asked to identify all colors representing bile (Figure 1). Participants were then presented with 6 newborn scenarios and asked to select which color(s) would lead to a recommendation for transfer to a referral center, if necessary, and UGI. Scenarios included: (1) term with only emesis; (2) term with emesis, distended abdomen, and bloody stool; (3) term with a gastric aspirate and distended abdomen; (4) term with aspirate after gastroschisis repair; (5) extremely preterm with gastric aspirate; (6) extremely preterm with emesis and abdominal distention. For analysis, the respondent’s threshold color was defined as the lowest color number selected for each question. Responses were summarized using the median with interquartile range (IQR). Median thresholds were compared between scenarios using the Kruskal-Wallis test (GraphPad, Prism 9).

Results: Responses were received from 160 surgeons, but number of responses for each question varied (Table 1). The median (IQR) color representing bile was #4 (3,5), but every color was selected at least once (Figure 2). The threshold in five scenarios was #4, but every color was selected at least once. The threshold was slightly lower (#3, (2,4)) in the term infant with emesis and abdominal symptoms. In the preterm scenarios (5 & 6), none of the above was chosen by 44% and 15% of respondents.Conclusion(s): Using a standardized color block, pediatric surgeons selected color #4 as the threshold for describing bilious aspirate/emesis and the threshold for action in most scenarios. Even among surgeons, there is wide variation in the colors considered bilious but little variation based on clinical context. Use of a standardized color block to describe bile may improve interdisciplinary communication.
Standardized Color Block
Distribution of Thresholds for Bile