Value of gastrografin in adhesive small bowel obstruction

Bedside Small Bowel Follow-Through: The Role in the Management of Adhesive Small Bowel Obstruction

BACKGROUND

 Adhesive small bowel obstruction (ASBO) accounts for the majority of hospitalizations related to SBO following abdominal surgery. Delays in the management of ASBO are associated with longer hospital stays and increased mortality rates, making it imperative to establish an efficient way of determining which patients need surgical intervention.

PURPOSE

To evaluate the contribution of bedside small bowel follow-through (BSBFT) in the management of suspected ASBO.

MATERIALS AND METHODS

A single-site analysis of 320 patients who underwent BSBFT from August 2015 to 2019 was retrospectively performed. The presence of contrast in the colon on abdominal radiographs obtained at eight and 24 hours after administration and subsequent management (conservative versus surgical) was recorded.

RESULTS

Of the 320 BSBFT exams, 235 cases had colonic contrast present at eight hours. Twelve of those cases received surgical treatment, while the remaining 223 were managed conservatively. Forty-three cases showed colonic contrast at 24 hours despite not showing contrast at eight hours. Of these cases, 29 patients were managed conservatively, while 14 patients underwent surgery. Forty-two cases had no contrast at 24 hours, and 33 patients of those patients subsequently received surgical intervention, while nine were managed conservatively. Patients who had contrast on radiographs and underwent surgical interventions had either high clinical concern for postoperative complications or stagnant clinical progression.

CONCLUSION

BSBFT helps determine the management for suspected ASBO. ​Patients with colonic contrast on eight- or 24-hour abdominal images were more likely to be managed conservatively. However, the clinical context is important, since clinical factors may overrule the results of the BSBFT.

Feasibility of Gastrografin Use for Adhesive Small Bowel Obstruction in Low-Income Countries

INTRODUCTION

Small bowel obstruction (SBO) is one of the most common causes for hospital admission in Ethiopia. The use of water-soluble contrast agents (WSCAs) such as Gastrografin to manage adhesive SBO can predict nonoperative resolution of SBO and reduce decision time to surgery and length of hospital stay. However, nothing is known about practice patterns and Gastrografin use in low-income settings. We sought to characterize current management practices, including use of WSCAs, as well as outcomes for patients with SBO in Addis Ababa, Ethiopia.

METHODS

We conducted a mixed-methods study consisting of a survey of surgeons throughout Ethiopia and a retrospective record review at five public, tertiary care-level teaching hospitals in Addis Ababa.

RESULTS

Of the 76 surgeons who completed the survey, 63% had heard of the use of WSCAs for SBO and only 11% used oral agents for its management. Chart review of 149 patients admitted with SBO showed the most common etiology was adhesion (39.6% of admissions), followed by small bowel volvulus (20.8%). Most patients (83.2%) underwent surgery during their admission. The most common diagnosis in patients who did not require surgery was also adhesion (68.0%), as well as for those who had surgery (33.9%), followed by small bowel volvulus (24.2%).

CONCLUSIONS

The etiology of SBO in Ethiopia may be changing, with postoperative adhesions becoming more common than other historically more prevalent causes. Although a Gastrografin protocol as a diagnostic and potentially therapeutic aid for SBO is feasible in this population and setting, challenges can be anticipated, and future studies of protocol implementation and effectiveness are needed to further inform its utility in Ethiopia and other low-income and middle-income countries.

The Effect of Hyperosmolar Water-Soluble Contrast for the Management of Adhesive Small Bowel Obstruction: A Systematic Review and Meta-Analysis

OBJECTIVE

To better understand the efficacy of water-soluble contrast (WSC) in the treatment of adhesive small bowel obstruction (SBO).

BACKGROUND

Guidelines recommend using WSC to treat adhesive SBO nonoperatively by acting as a cathartic agent. The evidence supporting this practice is mixed.

METHODS

A systematic review and meta-analysis of published articles describing the effect of WSC compared with control treatments was performed for the period of January 1, 1990 to November 1, 2021. Study quality was assessed using the Cochrane risk-of-bias and the Newcastle-Ottawa tools. The therapeutic effect of WSC was assessed by operative rates and hospital length of stay (HLOS) in nonsurgical patients.

RESULTS

The initial search yielded 4879 articles, of which, 28 were selected for full text review. We identified 11 eligible randomized controlled trials (RCTs) which included 817 patients and 9 observational studies of 3944 patients. HLOS in nonsurgical patients decreased by 1.95 days (95% confidence interval: 0.56-3.3) in the RCTs and could not be assessed in the observational studies. WSC did not significantly affect operative rates in the RCTs (19.8% vs. 21.4%) but did reduce rates in the observational studies (11% vs. 16%, risk ratio: 0.56, 95% confidence interval: 0.39-0.82).

CONCLUSION

WSC studies may reduce HLOS for patients who have SBO and do not require surgery. However, the current literature is heterogenous with considerable design limitations. High-quality RCTs are needed using standardized protocols to determine the full benefit of WSC for the management of SBO.

Prognostic Value of Water-Soluble Contrast Challenge for Nonadhesive Small Bowel Obstruction

BACKGROUND

There is little evidence supporting the use of a water-soluble contrast challenge (WSCC) for conservative management of nonadhesive small bowel obstruction (NASBO). Our objective was to evaluate the prognostic value of the WSCC in a diverse group of patients with NASBO in comparison with patients with adhesive small bowel obstruction (ASBO).

STUDY DESIGN

Retrospective chart review of patients with ASBO or NASBO who underwent a WSCC during a 4-year time period was performed. The primary study endpoint was any intervention for small bowel obstruction during the initial admission or within 30 days of discharge.

RESULTS

A total of 106 patients were included, 53 with ASBO (mean age 64 ± 13 years [SD]; 55% women) and 53 with NASBO (mean age 59 ± 13 years [SD]; 57% women). A higher rate of interventions during admission or within 30 days of discharge was seen in patients with NASBO compared with ASBO (24/53 [45%] vs 12/53 [23%]; p = 0.01), including those with colonic transit times of less than 36 hours (14/41 [34%] vs 5/43 [12%]; p = 0.01). Using multivariate analysis, transit time greater than 36 hours remained an independent predictor of an intervention during admission or within 30 days of discharge (p < 0.001, odds ratio 19.0), after controlling for the type of small bowel obstruction.

CONCLUSIONS

A majority of patients with NASBO were successfully managed conservatively during a 30-day period, supporting the use of WSCC in patients with NASBO; however, patients with NASBO had a higher rate of interventions during admission or within 30 days of discharge.

Variations in use of "water soluble contrast challenge" for small bowel obstruction among academic radiologists: results of a national survey

OBJECTIVE

To assess the frequency and indications for use of oral water-soluble contrast challenge as a diagnostic test for small bowel obstruction in four regions of the USA.

MATERIALS AND METHODS

We distributed a 9-question web-based survey to the abdominal section heads of academic radiology departments throughout the USA (N = 97). The questions pertained to use of water-soluble contrast for management of small bowel obstruction. Descriptive statistics and Fisher's exact tests were used for data analysis.

RESULTS

The overall response rate was 46%. Eighty percent of the responding hospitals had more than 500 beds in operation. Water-soluble contrast challenge was considered standard of care for management of non-operative small bowel obstruction in 60% of the responding radiology departments. The majority of the responding departments (41%) performed 2-8 contrast challenge studies per month on average. The most frequent indication for the study was distinguishing partial vs complete bowel obstruction. Eighty percent of the responding radiologists believed that the contrast challenge is useful for management of small bowel obstruction. Overall, there was no statistically significant difference in frequency and indication for use of water-soluble contrast challenge based on geographic location.

CONCLUSION

The water-soluble contrast challenge was considered standard of care for non-operative management of small bowel obstruction in majority of the academic radiology departments represented in this survey. Surgeons were referring clinicians in every case. The most common clinical indication for the study was distinguishing partial versus complete small bowel obstruction.

Therapeutic Role of Water-Soluble Contrast Media in Adhesive Small Bowel Obstruction: a Systematic Review and Meta-Analysis

BACKGROUND

Adhesive small bowel obstruction (ASBO) is a common post-operative cause of hospitalisation. Water-soluble contrast media (WSCM) has become a popular non-surgical approach to treatment. However, previous reviews have concluded with conflicting results. This meta-analysis of randomised controlled trials (RCTs) re-evaluated the therapeutic value of WSCM in the management of ASBO.

METHODS

A comprehensive search of PubMed, Embase, and Cochrane databases was undertaken to identify RCTs from January 2000 to November 2018. The primary outcomes of length of stay and secondary outcomes of time to resolution, need for surgery, and mortality were extracted from the included studies. Quantitative pooling of the data was based on the random effects model.

RESULTS

Eight hundred and seventy-nine patients from the nine studies were included in the analysis. The administration of oral WSCM reduced the length of hospital stay (weighted mean difference - 0.15 days, P < 0.0001). However, WSCM does not reduce the need for surgery (relative risk 0.84, P < 0.009) and makes no difference to mortality rate (RR 0.99, P < 1.000). The definition of time to resolution of ASBO differed between the studies, ranging from time to passing flatus, to cessation of abdominal pain, and time to initiating oral intake. The significant differences in definition precluded meaningful quantitative pooling of this outcome.

CONCLUSIONS

This meta-analysis evaluating the therapeutic value of WSCM has shown that it does not reduce the need for operative management in ASBO or impact mortality rates. It shortens hospital stay by 0.15 days (3.6 h) which is not clinically significant.

Evaluation of a water-soluble contrast protocol for small bowel obstruction: A southwestern surgical congress multicenter trial

Differentiation between SBO that will resolve with supportive measures and those requiring surgery remains challenging. WSC administration may be diagnostic and therapeutic. The purpose of this study was to evaluate use of a SBO protocol using WSC challenge. A protocol was implemented at five tertiary care centers. Demographics, prior surgical history, time to operation, complications, and LOS were analyzed. 283 patients were admitted with SBO; 13% underwent immediate laparotomy; these patients had a median LOS of 7.5 days. The remaining 245 were candidates for WSC challenge. Of those, 80% received contrast. 139 (71%) had contrast passage to the colon. LOS in these patients was 4 days. Sixty-five patients (29%) failed contrast passage within 24 h and underwent surgery. LOS was 9 days. 8% of patients in whom contrast passage was observed at 24 h nevertheless subsequently underwent surgery. 4% of patients who failed WSC challenge did not proceed to surgery. Our multicenter trial revealed that implementation of a WSC protocol may facilitate early recognition of partial from complete obstruction.

Outcomes in adhesive small bowel obstruction from a large statewide database: What to expect after nonoperative management

BACKGROUND

Although adhesive small-bowel obstruction (ASBO) is frequently managed nonoperatively, little is known regarding outcomes on readmission following this approach. Using a large population-based dataset, we evaluated risk factors for operative intervention and mortality at readmission in patients with ASBO who were initially managed nonoperatively.

METHODS

The ASBO patients were identified in the California Office of Statewide Health Planning and Development 2007 to 2014 patient discharge database. Patients who were managed operatively at index admission or had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for nonadhesive obstructive small bowel disease were excluded. Associations between risk factors and both operative intervention and death following readmission were evaluated using survival analysis.

RESULTS

Among 15,963 ASBO patients, 3,103 (19.4%) had at least one readmission. The 1,069 (34.5%) who received an operation during their first readmission presented sooner (175 days vs. 316 days, p < 0.001) and were more likely to die during that readmission (5.2% vs. 0.7%, p < 0.001). Operative management at first readmission was associated with younger age, fewer comorbidities, and shorter times to readmission. Patients operatively managed at first readmission had longer times to second readmission compared with nonoperative patients. Stratified analyses using nonoperative patients as the reference over the study period revealed that patients who underwent lysis of adhesions and bowel resection were 5.04 times (95% confidence interval [CI], 2.82-9.00) as likely to die while those who underwent lysis only were 2.09 times (95% CI, 1.14-3.85) as likely to die. Patients with bowel resection only were at an increased risk for subsequent interventions beyond the first readmission (hazard ratio, 1.79; 95% CI, 1.11-2.87).

CONCLUSION

In a large cohort readmitted for ASBO and initially managed nonoperatively, subsequent operative intervention conferred a greater risk of death and a longer time to readmission among survivors. Prospective research is needed to further delineate outcomes associated with initial nonoperative management of ASBO.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Obstruction reduction: Use of water-soluble contrast challenge to differentiate between partial and complete small bowel obstruction

Differentiating SBO that will resolve conservatively from those requiring surgery remains challenging. Water-soluble contrast administration may be diagnostic and therapeutic. Our study evaluated use of a WSC challenge protocol. We hypothesize that protocol use discriminates between surgical SBO and obstructions which can be managed non-operatively. Demographics, prior surgeries, time to operation, complications, and LOS were analyzed. 108 patients were admitted with SBO. 13% underwent immediate laparotomy with concern for bowel compromise; these had a median LOS of 8.5 days. 91 received WSC protocol. Of these, 77% had contrast passage to the colon. Of the 48 in whom contrast passed between 0 and 12 h, LOS was 2 days. Of the 22 patients in whom contrast passed between 12 and 24 h, LOS was 4.5 days. 21 had failure of contrast passage; 18 of those underwent surgery after 24 h as a result. Of the 21 patients who failed WSC challenge, median LOS was 8 days. WSC protocol implementation facilitates early recognition of partial from complete obstruction and may decrease LOS. Our findings warrant further evaluation with a multicenter trial.