A retrospective analysis of 163 term infants who had bilious emesis in the first week of life found that 14% had a surgical condition that required immediate management. Overall, approximately half of these infants had a surgical condition. Abnormal abdominal radiograph, abdominal distention and abdominal tenderness (but not consistency of the abdomen) were findings associated with a surgical abdominal condition. However no clear clinical or radiographic signs differentiated the infants who required emergency surgery from those who did not. The authors suggest that all term infants with bilious emesis be referred urgently for surgical evaluation.