Enhancement of a small bowel obstruction model using the gastrografin® challenge test

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.

Survey of Diagnostic and Management Practices in Small Bowel Obstruction: Individual and Generational Variation Despite Practice Guidelines

Background: Small bowel obstruction (SBO) is a common disorder managed by surgeons. Despite extensive publications and management guidelines, there is no universally accepted approach to its diagnosis and management. We conducted a survey of acute care surgeons to elucidate their SBO practice patterns.Methods: A self-report survey of SBO diagnosis and management practices was designed and distributed by email to AAST surgeons who cared for adult SBO patients. Responses were analyzed with descriptive statistics and Chi-square test of independence at α = .05.Results: There were 201 useable surveys: 53% ≥ 50 years, 77% male, 77% at level I trauma centers. Only 35.8% reported formal hospital SBO management guidelines. Computed tomography (CT) scan was the only diagnostic exam listed as "essential" by the majority of respondents (82.6%). Following NG decompression, 153 (76.1%) would "always/frequently" administer a water-soluble contrast challenge (GC). There were notable age differences in approach. Compared to those ≥50 years, younger surgeons were less likely to deem plain abdominal films as "essential" (16.0% vs 40.2%; P < .01) but more likely to require CT scan (88.3% vs 77.6%; P = .045) for diagnosis and to "always/frequently" administer GC (84.0% vs 69.2%; P < .01). Younger surgeons used laparoscopy "frequently" more often than older surgeons (34.0% vs 21.5%, P = .05).Discussion: There is significant variation in diagnosis and management of SBO among respondents in this convenience sample, despite existing PMGs. Novel age differences in responses were observed, which prompts further evaluation. Additional research is needed to determine whether variation in practice patterns is widespread and affects outcomes.

Current Management of Adhesive Small Bowel Obstructions in Children

Adhesive small bowel obstructions are a common cause of morbidity in children who underwent prior abdominal surgery. The concept of partial versus complete bowel obstruction is outdated and lacks precision to be clinically useful. Identifying patients with indications for immediate operative intervention is critical and must be recognized to limit morbidity. Clinical protocols and contrast challenge algorithms have attempted to identify patients that will resolve their bowel obstruction nonoperatively; there has been slow uptake in the pediatric patient population versus adults until recently. Incorporating predictive models and standardized contrast challenge protocols will help reduce interpractitioner variability and improve clinical outcomes.

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.

Evaluating suspected small bowel obstruction with the water-soluble contrast challenge

With optimized technique, the water-soluble contrast challenge is effective at triaging patients for operative vs non-operative management of suspected small bowel obstruction. Standardized study structure and interpretation guidelines aid in clinical efficacy and ease of use. Many tips and tricks exist regarding technique and interpretation, and their understanding may assist the interpreting radiologist. In the future, a CT-based water-soluble contrast challenge, utilizing oral contrast given as part of the initial CT examination, might allow for a more streamlined algorithm and provide more rapid results.

Water-Soluble Contrast Challenge for Suspected Small Bowel Obstruction: Technical Success Rate, Accuracy, and Clinical Outcomes

Among 109 iohexol-based water-soluble contrast challenges performed for suspected small bowel obstruction, 105 were technically adequate. Among technically-adequate studies, colonic contrast (i.e., successful challenge) was seen in 66 on 8-hour, and 86 on 24-hour, radiograph. Fourteen patients underwent operative magnement; 91 underwent non-operative management (NOM). Successful challenge had sensitivity 91.2%, specificity 78.5%, PPV 96.5%, NPV 57.8%, and odds ratio 38.0 (95% CI, 8.7-165.2) for NOM. Three of 86 patients with successful challenge underwent operative management.

Use of the Water-Soluble Contrast Medium Gastrografin in Treatment of Adhesive Small Bowel Obstruction in Patients with and Without Chronic Radiation Enteropathy: A Single-Center Retrospective Study

Background

This retrospective cohort study from a single center aimed to compare patient outcomes following the use of the water-soluble contrast medium Gastrografin in the treatment of adhesive small bowel obstruction (ASBO) in patients with and without a history of chronic radiation enteropathy (CRE).

Material/Methods

Fifty-nine patients with CRE-induced small bowel obstruction (SBO) and 53 patients with ASBO at Jinling Hospital between April 2014 and February 2018 were enrolled. The patients were given 100 ml Gastrografin through a naso-jejunal tube, and erect abdominal X-rays were taken. Risk factors were found to be correlated with successful non-operative management (SNM) through statistical analyses.

Results

The success rate of conservative treatment was higher in the Gastrografin group than in the control group (P<0.05). The Gastrografin challenge test is predictive of need for surgery in CRE-induced SBO and ASBO (AUC=0.860 and 0.749, respectively). The predictors associated with SNM in the CRE-induced SBO group were the total dose of radiotherapy, the Gastrografin challenge test, and previous operations for SBO. In the ASBO group, the predictors were the Gastrografin challenge test and previous operations for SBO. The operation rate of SBO patients with Gastrografin treatment was significantly lower than that in the control group (P<0.05).

Conclusions

The findings from this study showed that the use of Gastrografin effectively resolved ASBO in patients with and without a history of CRE, but a long-term requirement for surgery could not be avoided. The Gastrografin challenge may be a useful test to predict surgical outcomes.

Small Bowel Obstruction: the Sun Also Rises?

Small bowel obstruction (SBO) remains a common reason for emergency/unplanned admissions, and remains a significant burden to SBO patients and the healthcare system alike. The management of SBO has undergone a significant paradigm shift over the years, shifting far from the tenet to "never let the sun rise on a bowel obstruction." Not only has the timing to surgery changed, but there is also an increased utilization of diagnostic tools to aid clinical decision-making. Furthermore, the surgical management is beginning to favor a less invasive approach. This review will serve to provide an up-to-date review of the evaluation and management of SBO, based on the most recent available evidence and our experience with the methods described.

Short-Term Clinical Outcomes after Using Novel Deeper Intubation Technique (DIT) of Ileus Tube for Acute Bowel Obstruction Patients

Background

The ileus tube has been widely used for the treatment of acute small bowel obstruction. However, it is difficult to get the tube sufficiently adjacent to the obstruction site due to various reasons.

Methods

We developed a novel intubation technique, named Deeper Intubation Technique (DIT), by using the Zebra Urological Guidewire and digital gastrointestinal fluoroscopy, where we deepened the catheter intubation, and further compared the effects of DIT with the Traditional Intubation Technique (TIT) on the short-term clinical outcomes of 183 patients.

Results

The average intubation depth of DIT apparently exceeds that of TIT (213.89 ± 31.11 vs. 134.67 ± 18.22 cm, P < 0.001). Compared with patients in the TIT group, patients in the DIT group got a lower pain score (P < 0.001), shorter recovery time for anal exhaust defecation (2.87 ± 1.50 vs. 3.37 ± 1.52 d, P = 0.040), higher recovery rate in anal exhaust defecation (24 h, 16.8% vs. 5.7%, P = 0.021; 48 h, 46.3% vs. 27.3%, P = 0.009), better symptomatic remission rate and imaging relief rate (P < 0.05), and increased drainage volume (1006.88 ± 583.45 vs. 821.02 ± 358.73 ml, P = 0.009). Importantly, the emergency surgery rate in the DIT group was lower than that in the TIT group (3.2% vs. 13.6%, P = 0.014). In addition, the DIT procedure was effective for patients with adhesive obstruction but not for cancerous and stercoral bowel obstruction.

Conclusion

Compared to TIT, DIT produced better short-term clinical outcomes, indicating that DIT is a safe and feasible technique for the treatment of adhesive intestinal obstruction.

ACR Appropriateness Criteria® Suspected Small-Bowel Obstruction

Small-bowel obstruction is a common cause of abdominal pain and accounts for a significant proportion of hospital admissions. Radiologic imaging plays the key role in the diagnosis and management of small-bowel obstruction as neither patient presentation, the clinical examination, nor laboratory testing are sufficiently sensitive or specific enough to diagnose or guide management. This document focuses on the imaging evaluation of the two most commonly encountered clinical scenarios related to small-bowel obstruction: the acute presentation and the more indolent, low-grade, or intermittent presentation. This document hopes to clarify the appropriate utilization of the many imaging procedures that are available and commonly employed in these clinical settings. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Outcomes of a low-osmolar water-soluble contrast pathway in small bowel obstruction

BACKGROUND

Adhesive small-bowel obstruction (SBO) is a common surgical condition accounting for a significant proportion of acute surgical admissions and surgeries. The implementation of a high-osmolar water-soluble contrast challenge has repeatedly been shown to reduce hospital length of stay and possibly the need for surgery in SBO patients. The effect of low-osmolar water-soluble contrast challenge however, is unclear. The aim of this study is to evaluate the outcomes of an SBO pathway including a low-osmolar water-soluble contrast challenge.

METHODS

A prospective cohort of patients admitted for SBO were placed on an evidence-based SBO pathway including low-osmolar water-soluble contrast between January 2017 and October 2018 and were compared with a historical cohort of patients prior to the implementation of the pathway from September 2013 through December 2014. The primary outcome was length of stay less than 4 days with a secondary outcome of failure of nonoperative management.

RESULTS

There were 140 patients enrolled in the SBO pathway during the study period and 101 historic controls. The SBO pathway was independently associated with a length of stay less than 4 days (odds ratio, 1.76; 95% confidence interval, 1.03-3.00). Median length of stay for patients that were successfully managed nonoperatively was lower in the SBO pathway cohort compared with controls (3 days vs. 4 days, p = 0.04). Rates of readmission, surgery, and bowel resection were not significantly different between the two cohorts.

CONCLUSION

Implementation of an SBO pathway using a low-osmolarity contrast is associated with decreased hospital length of stay. Rates of readmission, surgery, and need for bowel resection for those undergoing surgery were unchanged. An SBO pathway utilizing low-osmolarity water-soluble contrast is safe and effective in reducing length of stay in the nonoperative management of adhesive small-bowel obstructions.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

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.

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.

Use of gastrografin in the management of faecal impaction in patients with severe chronic constipation: a randomized clinical trial

BACKGROUND/AIM

Faecal impaction (FI) is a common cause of lower gastrointestinal tract obstruction. Gastrografin is a water-soluble radiologic contrast agent that may be orally or rectally administered, with proved therapeutic benefits in adhesive small bowel obstruction. Enemas have long been advocated as the best treatment for FI. The purpose of this study was to demonstrate that enteral administration of gastrografin might be more effective than enema in FI treatment inducing intestinal obstruction.

METHODS

A double-blinded, controlled and randomized trial was conducted. Participants received 100 mL of gastrografin (gastrografin group) through nasointestinal tube or enemas (enema group) once daily for six consecutive days. Successful faecal disimpaction, FI time to resolution, Bristol Stool Scale, constipation severity, symptom assessment and adverse events were evaluated.

RESULTS

A total of 124 patients were eligible, but only 83 were enrolled to this trial (mean age: 44 ± 15.8 years). Forty-two patients received enemas, and 41 patients received gastrografin, with six dropouts in each group. Successful disimpaction was achieved with enemas (69.44%) and gastrografin (88.57%; P = 0.034), mean duration of impaction was strikingly different between the two groups (67.13 versus 31.67, respectively; P < 0.01). Constipation severity and symptom assessment were significantly reduced in the gastrografin group.

CONCLUSION

Gastrografin given through nasointestinal tube was more effective than enema in the treatment of FI inducing colon obstruction. Gastrografin might be taken into consideration as an effective and safe therapeutic option for FI.

Small Bowel Obstruction

Identifying patients with small bowel obstruction who need operative intervention and those who will fail nonoperative management is a challenge. Without indications for urgent intervention, a computed tomography scan with/without intravenous contrast should be obtained to identify location, grade, and etiology of the obstruction. Most small bowel obstructions resolve with nonoperative management. Open and laparoscopic operative management are acceptable approaches. Malnutrition needs to be identified early and managed, especially if the patient is to undergo operative management. Confounding conditions include age greater than 65, post Roux-en-Y gastric bypass, inflammatory bowel disease, malignancy, virgin abdomen, pregnancy, hernia, and early postoperative state.

Managing Adhesive Small Bowel Obstruction with Water-Soluble Contrast Should Be Protocolized: A Retrospective Analysis

Aim  Current literature emphasizes the effectiveness of computed tomography (CT) and water-soluble contrast agent, Gastrografin, in the investigation of adhesive small bowel obstruction (ASBO). As there is no management protocol for ASBO at our institution, the aim of this study was to determine the effect of imaging methods—CT, Gastrografin challenge (GC), or plain-film X-ray—on patient outcomes in a clinical setting.

Methods  All 163 emergency presentations of ASBO during the study period between December 2010 and September 2012 were collected retrospectively. Cases were divided into three groups: CT with oral contrast, GC, or plain-film X-ray only. The primary outcome was time to theater.

Results  Patients investigated with X-ray only were significantly less likely to require surgery (6% in plain-film X-ray vs. 35% and 20% in CT and GC, respectively; p  = 0.003). In cases requiring surgery, GC was associated with a 24-hour longer time to imaging than CT ( p  < 0.001). The time to theater was 71:25 hours for GC versus 46:39 for CT ( p  = 0.039). There was no significant difference in bowel resection or complication rates.

Conclusion  Patients undergoing water-soluble contrast studies were subjected to unnecessary delays in their clinical course. These delays are costly and avoidable. The development and implementation of an evidence-based protocol for the management of small bowel obstruction is strongly recommended. The lack of a protocol likely caused significant delays in Gastrografin administration, reducing its known benefits for clinical decision-making and length of stay.

Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group

Background

Adhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are typically the footprints of previous abdominal surgical procedures. The present paper presents a revised version of the Bologna guidelines to evidence-based diagnosis and treatment of ASBO. The working group has added paragraphs on prevention of ASBO and special patient groups.

Methods

The guideline was written under the auspices of the World Society of Emergency Surgery by the ASBO working group. A systematic literature search was performed prior to the update of the guidelines to identify relevant new papers on epidemiology, diagnosis, and treatment of ASBO. Literature was critically appraised according to an evidence-based guideline development method. Final recommendations were approved by the workgroup, taking into account the level of evidence of the conclusion.

Recommendations

Adhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive etiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are nil per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO.Younger patients have a higher lifetime risk for recurrent ASBO and might therefore benefit from application of adhesion barriers as both primary and secondary prevention.

Discussion

This guideline presents recommendations that can be used by surgeons who treat patients with ASBO. Scientific evidence for some aspects of ASBO management is scarce, in particular aspects relating to special patient groups. Results of a randomized trial of laparoscopic versus open surgery for ASBO are awaited.

Current management of adhesive small bowel obstruction

Small bowel obstruction is a common and significant surgical presentation. Approximately 30% of presentations will require surgery during admission. The great challenge of adhesive small bowel obstruction (ASBO) management is the early detection of silent intestinal ischaemia in patients initially deemed suitable for conservative therapy. Recent literature emphasizes the effectiveness of computed tomography enterography and water-soluble contrast studies in the management of ASBO. Low-volume undiluted water-soluble contrast has been shown to have both triage and therapeutic value in the management of ASBO. Their use has been demonstrated to reduce the need for surgery to below 20%. There has also been growing interest in clinicoradiological algorithms which aim to predict ischaemia early in the course of presentation. The aim of this review is to summarize the latest evidence and clarify previous uncertainties, specifically regarding the duration of conservative treatment, timing of contrast studies and the reliability of predictive algorithms. Based on this latest evidence, we have formulated a management protocol which aims to integrate these latest developments and formalize a strategy for best management in ASBO.

Oral water soluble contrast for malignant bowel obstruction

BACKGROUND

Malignant bowel obstruction (MBO) is a common problem in patients with intra-abdominal cancer. Oral water soluble contrast (OWSC) has been shown to be useful in the management of adhesive small bowel obstruction in identifying patients who will recover with conservative management alone and also in reducing the length of hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in patients with MBO.

OBJECTIVES

To determine the reliability of OWSC media and follow-up abdominal radiographs in predicting the success of conservative treatment in resolving inoperable MBO with conservative management.To determine the efficacy and safety of OWSC media in reducing the duration of obstruction and reducing hospital stay in people with MBO.

SEARCH METHODS

We identified studies from searching Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in Process, Embase, CINAHL, Science Citation Index (Web of Science) and Conference Proceedings Citation Index - Science (Web of Science). We also searched registries of clinical trials and the CareSearch Grey Literature database. The date of the search was the 6 June 2017.

SELECTION CRITERIA

Randomised controlled trials (RCTs), or prospective controlled studies, that evaluated the diagnostic potential of OWSC in predicting which malignant bowel obstructions will resolve with conservative treatment.RCTs, or prospective controlled studies, that assessed the therapeutic potential of OWSC in managing MBO at any level compared with placebo, no intervention or usual treatment or supportive care.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We assessed risk of bias and assessed the evidence using GRADE and created a 'Summary of findings' table.

MAIN RESULTS

We found only one RCT meeting the selection criteria for the second objective (therapeutic potential) of this review. This study recruited nine participants. It compared the use of gastrografin versus placebo in adult patients with MBO with no indication for further intervention (surgery, endoscopy) apart from standardised conservative management.The overall risk of bias for the study was high due to issues with low numbers of participants, selective reporting of outcomes and a high attrition rate for the intervention arm.Primary outcomesThe included trial was a pilot study whose primary outcome was to test the feasibility for a large study. The authors reported specifically on the number of patients screened, the number recruited and reasons for exclusion; this was not the focus of our review.Due to the low number of participants, the authors of the study decided not to report on our primary outcome of assessing the ability of OWSC to predict the likelihood of malignant small bowel obstruction resolving with conservative treatment alone (diagnostic effect). It also did not report on our primary outcome of rate of resolution of MBO in patients receiving OWSC compared with those not receiving it (therapeutic effect).The study reported that no issues regarding safety or tolerability of either gastrografin or placebo were identified. The overall quality of the evidence for the incidence of adverse events with OWSC was very low, downgraded twice for serious limitations to study quality (high risk of selective reporting and attrition bias) and downgraded once for imprecision (sparse data).Secondary outcomesThe study planned to report on this review's secondary outcome measures of length of hospital stay and time from administration of OWSC to resolution of MBO. However the authors of the study decided not to do so due to the low numbers of patients recruited. The study did not report on our secondary outcome measure of survival times from onset of inoperable MBO until death.

AUTHORS' CONCLUSIONS

There is insufficient evidence from RCTs to determine the place of OWSC in predicting which patients with inoperable MBO will respond with conservative treatment alone. There is also insufficient evidence from RCTs to determine the therapeutic effects and safety of OWSC in patients with malignant small bowel obstruction.

Value of gastrografin in adhesive small bowel obstruction

BACKGROUND

Small bowel obstruction (SBO) from adhesive disease presents great burden for the healthcare system. Some groups have reported water soluble contrast agents (WSCA) protocols, but published studies are underpowered. This study introduces a WSCA protocol to improve outcomes and streamline patient care.

STUDY DESIGN

The study ran July 1, 2013-June 30, 2015, at Kaiser Permanente San Diego; protocol started July 1, 2014. Data was collected prospectively, on an intention to treat basis. We excluded patients whose SBO were not due to adhesive disease. Protocol included nasogastric tube, intravenous resuscitation, liquid docusate, and gastrografin study if symptoms persisted at 24 h. Colon contrast determined resolution vs operative consideration. Primary outcomes were operative rates and hospital length of stay (LOS).

RESULTS

Seven hundred fifteen were patients admitted with SBO; after exclusions there were 261 pre-protocol and 243 protocol patients. One hundred sixty patients resolved within 24 h; 96% of remaining patients stayed on protocol (n = 154). After WSCA protocol began, 15.6% required an operation, compared to 19.8% of pre-protocol patients (NS). The WSCA protocol significantly decreased the time to surgery (2.8 vs 4.88 days, p = 0.03), and the LOS of operated patients (9.51 vs 15.78 days, p = 0.02).

CONCLUSIONS

A standardized SBO protocol using WSCA significantly decreased time to operation and hospital LOS. This approach improves utilization of resources and may improve outcomes. More work should be done to investigate the positive effects of WSCA protocol for patients with SBO.

Failure of conservative treatment with Gastrografin® for adhesive small bowel obstruction after colorectal surgery

PURPOSE

The aim of this study was to identify risk factors related with failure of conservative management of adhesive small bowel obstruction (ASBO) in patients with previous colorectal surgery.

METHODS

Patients admitted with the diagnosis of ASBO after previous colorectal resection, were included. All patients underwent administration of Gastrografin®. Abdominal radiography was done after 24 h, to confirm the presence of contrast in colon (incomplete obstruction) or not (complete obstruction). Several factors were investigated to study their relationship with the failure of conservative management. Failure of conservative management was considered when emergency operation was needed to solve ASBO.

RESULTS

Incomplete obstruction was observed in 174 episodes (93.0%) while in 13 (7.0%) was complete. One hundred seventy-one ASBO episodes (91.4%) responded successfully to nonoperative treatment and 16 (8.6%) required emergency surgery. Five patients needed bowel resection. Results on the diagnostic test with Gastrografin® showed a sensitivity of 75%, specificity of 99%, positive predictive value 92%, and negative predictive value 98%. Age over 75 years was the only predictive factor for failure of conservative management. The median waiting time from the radiologic confirmation of complete obstruction to surgery was higher in patients requiring bowel resection when compared to those who did not need resection.

CONCLUSIONS

The use of Gastrografin® in ASBO after colorectal resection is a safe and useful tool for the indication of conservative management. Age over 75 years is a predictive factor for need of surgery. Surgery should be performed no later than the following 24 h of confirmed complete obstruction.

Defining the Need for Surgery in Small-Bowel Obstruction

BACKGROUND

Small-bowel obstruction is a frequent disorder in emergency medicine and represents a major burden for patients and health care systems worldwide. Within the past years, progress has been made regarding the management of small-bowel obstructions, including the use of contrast agent swallow as a tool in the decision-making process.

OBJECTIVES

This is a prospective controlled study investigating the central role of contrast agent swallow in the diagnostic and treatment algorithm for small-bowel obstruction at a university department of surgery. Endpoints were the correct identification of patients who needed operative treatment and the accuracy of a conservative treatment decision including the analysis of dropout from this routine algorithm.

METHODS

We performed a single-center analysis of 181 consecutive patients diagnosed with a small-bowel obstruction based on clinical, radiologic, and sonographic findings. Patients with clinical signs of strangulation or peritonitis underwent immediate surgery (group 1). Patients without signs of peritonitis and incomplete stop in the initial abdominal plain film were considered eligible for Gastrografin® challenge (group 2).

RESULTS

Seventy-six of the 181 patients (42.0%) underwent immediate surgery. A Gastrografin® challenge was initialized in 105 of the 181 patients (58.0%). Twenty of these 105 patients (19.1%) with persisting or progressive symptoms and absence of contrast agent in the colon after 12 and 24 h subsequently underwent surgery. Here, a segmental bowel resection was necessary in 6 of these 20 patients (30.0%). In 16 out of 20 patients (80.0%) who failed the Gastrografin® challenge, a corresponding correlate in terms of a strangulation was detected intraoperatively. The Gastrografin® challenge had a specificity of 96% and a sensitivity of 100%; accuracy to predict the need for exploration was 96%.

CONCLUSION

A straightforward algorithm based mainly on contrast agent swallow for patients with small-bowel obstructions enabled a timely and very accurate differentiation between patients qualifying for conservative and operative treatment.

Small bowel obstruction: A practical step-by-step evidence-based approach to evaluation, decision making, and management

The initial goal of evaluating a patient with SBO is to immediately identify strangulation and need for urgent operative intervention, concurrent with rapid resuscitation. This relies on a combination of traditional clinical signs and CT findings. In patients without signs of strangulation, a protocol for administration of Gastrografin immediately in the emergency department efficiently sorts patients into those who will resolve their obstructions and those who will fail nonoperative management.Furthermore, because of the unique ability of Gastrografin to draw water into the bowel lumen, it expedites resolution of partial obstructions, shortening time to removal of nasogastric tube liberalization of diet, and discharge from the hospital. Implementation of such a protocol is a complex, multidisciplinary, and time-consuming endeavor. As such, we cannot over emphasize the importance of clear, open communication with everyone involved.If surgical management is warranted, we encourage an initial laparoscopic approach with open access. Even if this results in immediate conversion to laparotomy after assessment of the intra-abdominal status, we encourage this approach with a goal of 30% conversion rate or higher. This will attest that patients will have been given the highest likelihood of a successful laparoscopic LOA.

Long-term outcomes of gastrografin in small bowel obstruction

BACKGROUND

The gastrografin (GG) challenge is a diagnostic and therapeutic tool used to treat patients with small bowel obstruction (SBO); however, long-term data on SBO recurrence after the GG challenge remain limited. We hypothesized that patients treated with GG would have the same long-term recurrence as those treated before the implementation of the GG challenge protocol.

METHODS

Patients ≥18 years who were treated for SBO between July 2009 and December 2012 were identified. We excluded patients with contraindications to the GG challenge (i.e., signs of strangulation), patients having SBO within 6-wk of previous abdominal or pelvic surgery and patients with malignant SBO. All patients had been followed a minimum of 1 y or until death. Kaplan-Meier method and Cox regression models were used to describe the time-dependent outcomes.

RESULTS

A total of 202 patients were identified of whom 114 (56%) received the challenge. Mean patients age was 66 y (range, 19-99 y) with 110 being female (54%). A total of 184 patients (91%) were followed minimum of 1 year or death (18 patients lost to follow-up). Median follow-up of living patients was 3 y (range, 1-5 y). During follow-up, 50 patients (25%) experienced SBO recurrences, and 24 (12%) had exploration for SBO recurrence. The 3-year cumulative rate of SBO recurrence in patients who received the GG was 30% (95% confidence interval [CI], 21%-42%) compared to 27% (95% CI, 18%-38%) for those who did not (P = 0.4). The 3-year cumulative rate of exploration for SBO recurrence in patients who received the GG was 15% (95% CI, 8%-26%) compared to 12 % (95% CI, 6%-22%) for those who did not (P = 0.6).

CONCLUSIONS

The GG challenge is a clinically useful tool in treating SBO patients with comparable long-term recurrence rates compared to traditional management of SBO.

Review of small-bowel obstruction: the diagnosis and when to worry

This is a review of small-bowel obstruction written primarily for residents. The review focuses on radiography and computed tomography (CT) for diagnosing small-bowel obstruction and CT for determining complications. (©) RSNA, 2015.

A protocol for the management of adhesive small bowel obstruction

BACKGROUND

Differentiating between partial adhesive small bowel obstruction (aSBO) likely to resolve with medical management and complete obstruction requiring operative intervention remains elusive. We implemented a standardized protocol for the management of aSBO and reviewed our experience retrospectively.

METHODS

Patients with symptoms of aSBO were admitted for intravenous fluid resuscitation, bowel rest, nasogastric tube decompression, and abdominal examinations every 4 hours. Laboratory values and a computed tomography scan of the abdomen and pelvis with intravenous contrast were obtained. Patients with peritonitis or computed tomography scan findings suggesting bowel compromise were taken to the operating room for exploration following resuscitation. All other patients received 80 mL of Gastroview (GV) and 40 mL of sterile water via nasogastric tube. Abdominal plain films were obtained at 4, 8, 12, and 24 hours. If contrast did not reach the colon within 24 hours, then operative intervention was performed.

RESULTS

Over 1 year, 91 patients were admitted with aSBO. Sixty-three patients received GV, of whom 51% underwent surgery. Twenty-four patients went directly to the operating room because of clinical or imaging findings suggesting bowel ischemia. Average time to surgery was within 1 day for the no-GV group and 2 days for the GV group. Patients passing GV to the colon within 5 hours of administration had a 90% rate of resolution of obstruction. There was a direct relationship between the duration of time before passing GV to the colon and hospital length of stay (HLOS) (r = 0.459). Patients who received GV and did not require surgery had lower HLOS (3 days vs. 11 days, p < 0.0001).

CONCLUSION

The GV protocol facilitated early recognition of complete obstruction. Administration of GV had diagnostic and therapeutic value and did not increase HLOS, morbidity, or mortality.

LEVEL OF EVIDENCE

Therapeutic study, level V. Epidemiologic study, level V.

Role of gastrografin challenge in early postoperative small bowel obstruction

INTRODUCTION

Early small bowel obstruction following abdominal surgery presents a diagnostic and therapeutic challenge. Abdominal imaging using Gastrografin has been shown to have diagnostic and therapeutic properties when used in the setting of small bowel obstruction outside the early postoperative period (>6 weeks). We hypothesize that a GG challenge will reduce need for re-exploration.

METHODS

Patients with early small bowel obstruction who underwent a Gastrografin challenge between 2010 and 2012 were case controlled, based on age ±5 years, sex, and operative approach to an equal number of patients that did not receive the challenge.

RESULTS

One hundred sixteen patients received a Gastrografin challenge. There were 87 males in each group with an average age of 62 years. A laparoscopic approach in the index operation was done equally between groups (18 vs. 18 %). There was no difference between groups in operative re-exploration rates (14 vs. 10 %); however, hospital duration of stay was greater in patients who received Gastrografin challenge (17 vs. 13 days). Two in hospital deaths occurred, one in each group, both of infectious complications.

CONCLUSION

Use of the Gastrografin challenge in the immediate postoperative period appeared to be safe. There was no difference, however, in the rate of re-exploration between groups.

Efficacy of Gastrografin® Compared with Standard Conservative Treatment in Management of Adhesive Small Bowel Obstruction at Mulago National Referral Hospital

INTRODUCTION

The treatment of adhesive small bowel obstruction is controversial, with both operative and non-operative management practiced in different centers worldwide. Non-operative management is increasingly getting popular, though operative rates still remain high. A study to compare the efficacy of an oral water-soluble medium (Gastrografin®) with standard conservative management, both non-operative methods, in the management of this condition was conducted in a tertiary Sub Saharan hospital.

METHODS

An open randomised controlled clinical trial was conducted between September 2012 and March 2013 at Mulago National Referral and Teaching Hospital, Uganda. Fifty patients of both genders, with adhesive small bowel obstruction, in the hospital's emergency and general surgical wards were included. Randomisation was to Gastrografin® and standard conservative treatment groups. The primary outcomes were: the time interval between admission and relief of obstruction, the length of hospital stay, and the rates of operative surgery.

RESULTS

All 50 recruited patients were followed up and analysed; 25 for each group. In the Gastrografin® group, 22 (88%) patients had relief of obstruction following the intervention, with 3 (12%) requiring surgery. The conservative treatment group had 16 (64%) patients relieved of obstruction conservatively, and 9 (36%) required surgery. The difference in operative rates between the two groups was not statistically significance (P = 0.67). Average time to relief of obstruction was shorter in the Gastrografin® group (72.52 hrs) compared to the conservative treatment group (117.75 hrs), a significant difference (P = 0.023). The average length of hospital stay was shorter in the Gastrografin® group (5.62 days) compared to the conservative treatment group (10.88 days), a significant difference (P = 0.04).

CONCLUSION

The use of Gastrografin® in patients with adhesive small bowel obstruction helps in earlier resolution of obstruction and reduces the length of hospital stay compared with standard conservative management. Its role in reducing the rate of laparotomies remains inconclusive.