Bilious emesis has a green color due to the presence of a large amount of bile in the stomach. The color helps distinguish it from gastric contents, which often appear clear to yellow and may or may not contain food contents. Bilious emesis in a neonate is a sign of intestinal obstruction and is a surgical emergency. The presence of bile in the emesis often indicates an obstruction present distal to the ampulla of Vater, such as malrotation with volvulus. Delay in recognition or treatment could lead to significant bowel necrosis necessitating a bowel resection, which could lead to further complications such as short gut. True bilious emesis can be a sign of a life-threatening emergency and needs to be addressed immediately.