Background: Bilious vomiting in the neonate is an important presenting sign of intestinal obstruction. We conducted a review of the presentation and management of term neonates admitted with bilious vomiting (BV) to determine the incidence of a surgical pathology in our population.  Design: Retrospective cohort study using a prospectively maintained database.  Participants: All term infants admitted to NICU with BV at the Royal Women’s Hospital Melbourne during a 5-calendar year period.  Results: All 153 babies had at least one imaging study. 128 (83.7%) had plain abdominal radiographs. 127 (83%) underwent upper gastrointestinal contrast scan (UGI) and 103 (67.3%) had both. 6 (3.9%) UGI studies were abnormal, with 3 babies (1.9%) subsequently having surgical pathology (2 volvulus, 1 Hirschsprung disease). Only 6 (3.9%) babies in our cohort had a surgical pathology identified (4 Hirschsprung disease, 2 malrotation). Babies with surgical pathology were more likely to present later (median 40 hours versus 23 hours). Abdominal distension was highly sensitive for surgical pathology.  Conclusion: The incidence of surgical pathology in this cohort was low compared to other studies. It is more likely in infants presenting with BV after 24 hours.