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

Impact of a collaborative small bowel obstruction imaging and care protocol with the general surgery service on radiology workflow and resource utilization: a pilot study

PURPOSE

Small bowel obstruction (SBO) is a common indication for diagnostic imaging, hospital admission, and surgical consultation. At our institution, patients with SBO identified on an initial CT scan without enteric contrast often underwent a second CT with enteric contrast. A new protocol was implemented in a collaboration between the department of surgery to eliminate this second CT, instead utilizing enteric water-soluble contrast (WSC) and serial abdominal radiographs for further assessment of SBO in clinically stable patients. This study aims to assess the impact of this protocol on radiation exposure and resource utilization.

METHODS

A retrospective cohort study was conducted on patients with SBO diagnosed on initial abdominopelvic CT for whom the general surgery service was consulted. The control group included patients prior to protocol implementation who underwent two abdominopelvic CT scans within 24 h-one with and one without enteric contrast. The experimental group included patients managed under the new protocol. Ionizing radiation exposure, contrast media utilization, and CT technologist time were recorded for both groups.

RESULTS

Eighteen patients were included in the experimental group and 38 patients were included in the control group. Total effective dose (mSv) and CT technologist time were significantly less with the new protocol (p = 0.02 and p < 0.001, respectively). Although the use of intravenous contrast was lower in the experimental group, this did not reach statistical significance (p = 0.06).

CONCLUSION

The implementation of a collaborative SBO imaging and care algorithm between general surgery and radiology resulted in reduced radiation exposure to patients and decreased CT technologist time. This highlights the value of multidisciplinary approaches in improving the efficiency of imaging strategies for SBO.

The diagnostic and therapeutic value of Gastrografin in small bowel obstructions

Purpose

Small bowel obstructions represent a major cause of hospitalization, morbidity and mortality in surgical emergency departments. The Gastrografin protocol could be an effective tool in facilitating its evaluation and treatment.

Methods

A prospective observational study was conducted on patients admitted to the emergency department with a diagnosis of small bowel obstruction treated with the Gastrografin challenge to analyze risk factors related to the outcome.

Results

55 patients were included. In 38 patients (69.09%) the resolution of the occlusive condition was obtained. The progression of Gastrografin in the colon at x-ray was correlated to the positive outcome (p = 0.001). Older (>75 years old) and frailer patients were related to protocol failure and submitted more to surgery (p = 0.043; p = 0.022). Air-fluid levels at x-ray was related to negative outcome (P = 0.027). Higher doses of Gastrografin (100 ml vs. 50 ml) seems unrelated to obstruction resolution. At the two-year follow-up, among the 38 patients who tested positive, 8 patients (21.05%) had further access to the emergency department due to intestinal obstruction and were re-treated conservatively.

Conclusions

The standardized diagnostic-therapeutic protocol with Gastrografin is a valid tool in the non-operative management of small bowel obstructions offering a resolution of the obstructive condition in 70% of patients.

How to successfully administer palliative treatment with a stent for malignant gastric outlet obstruction?

Although endoscopic stenting (ES) has been widely used as a less-invasive palliation method for malignant gastric outlet obstruction (GOO), recent reports have highlighted issues related to the procedure. For successful treatment, various aspects must be assessed before considering the practices. First, it is necessary to eliminate cases with contraindications such as coexistence of distal small-bowel obstruction or perforation. Other factors potentially related to clinical failure (i.e., peritoneal carcinomatosis) may require consideration but remain controversial. ES has better short-term outcomes than surgical gastrojejunostomy (GJ). GJ has recently been considered preferable in cases with longer life expectancy because of superior sustainability. Various types of stents are now commercially available, but their ideal structure and mechanical properties have not yet been clarified. Covered metal stent may reduce stent obstruction but is prone to increase stent migration, and its significance remains uncertain. Subsequent chemotherapy after stenting should be considered, as it is expected to prolong patient survival without increasing the risk of adverse events. Furthermore, it may be helpful in preventing tumor ingrowth. In cases with GOO combined with biliary obstruction, biliary intervention is often difficult. Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been widely used as an alternative procedure for endoscopic transpapillary biliary drainage (ETBD). Despite the lack of consensus as to whether ETBD or EUS-BD is preferred, EUS-BD is useful as a salvage technique for cases where ETBD is difficult. To perform stent placement successfully, it is important to pay attention to the above points; however, many remaining issues need to be clarified in the future.