Updated 8/2019 v3.0 Sources:•Grant HW et al. Adhesions after abdominal surgery in children. JPS2008;43(1):152-156. •Branco BC et al. Systematic review and meta-analysis of the diagnostic and therapeutic role of water-soluble contrast agent in adhesive small bowel obstruction. BJS2010;97(4):470-478. •Lee CY et al. Evaluation of a water-soluble contrast agent for conservative management of adhesive small bowel obstruction in pediatric patients. JPS2015;50(4):581-585. •Linden et al. Evaluation of a water-soluble contrast protocol for non-operative management of pediatric adhesive small bowel obstruction. JPS2019;54(1):184-188.•ZeilinskiMD et al. Multi-institutional, prospective, observational study comparing the Gastrograffinchallenge versus standard treatment in adhesive small bowel obstruction. J Traumand ACS 2017;83(1):47-54. **GastrografinDose by age:•Age ≥8 years: 100 cc gastrografin+ 100 cc water (total 200 cc)•Age <8 years: 50 cc gastrografin+ 50 cc water (total 100 cc)Orderplaced in EPIC by surgery team, gastrografinobtained from fluorotech, and diluted by surgical team and administered GastrografinProtocol for AdhesiveSmall Bowel Obstruction (SBO)Patient with suspected adhesiveSBO 2V AXR or CT confirming SBO NGT decompression with appropriate size tube* for at least1 hourTube should be placed by surgical team if not yet in place at time of consultationSigns of strangulation, peritonitis, known active malignancy, non-adhesive SBOYesTo OR as indicated No Confirm NGT tip is in stomach Administer gastrografin(diatrizoate meglumine)** and clamp NGT for 8-10 hours Plain non-portable AXR at 10 hours Contrast in or past cecum?NoPlain AXR at 24 hoursContrast in or past cecum?YesD/C NGT and advance diet at appropriate rate YesD/C NGT and advance diet at appropriate rate No *Appropriate NGT tube size by age:Exclusion Criteria:•Clinical or radiographic suspicion of strangulation•Non-adhesive SBO•No prior abdominal surgery•Peritonitis•Active malignancy•Surgical/medical team decision Wt(kg)NGT Size (Fr)SuggestedNewborn/Infant3 -95 -88Toddler10 -118 -1010Small Child12 -141012Child15 -1810 -1214Child19 -2312 -1416Large Child/Adult>2412 -1818 Unclamp NGT , place back to suctionPatient nauseated or vomitingSerial exams q4 hours should be performed by surgical team
Gastrografin for Adhesive Small Bowel Obstruction (SBO)
Guideline · Sep 2019 · 1 min read
In brief
In brief
Evidence-based protocol from Cincinnati Children's Hospital for using water-soluble contrast (Gastrografin) in the conservative management of adhesive small bowel obstruction in pediatric patients. Guidelines synthesize findings from multiple studies demonstrating diagnostic and therapeutic benefits of contrast administration.
- Gastrografin protocol requires NGT decompression for ≥1 hour before administration, then clamping for 8-10 hours post-dose.
- Dosing: ≥8 years gets 100cc gastrografin + 100cc water; <8 years gets 50cc gastrografin + 50cc water.
- Contrast reaching cecum by 10 hours predicts successful non-operative management; reassess at 24 hours if negative.
- Exclude patients with strangulation signs, peritonitis, active malignancy, or non-adhesive SBO from protocol.
- Serial q4h exams mandatory; unclamp NGT to suction if patient becomes nauseated or vomits during observation period.
Written by the GCMD Library team from the guideline.
Evidence Base and Gastrografin Dosing
Protocol based on systematic reviews and pediatric studies demonstrating efficacy of water-soluble contrast in adhesive small bowel obstruction management. Gastrografin dosing is age-stratified: 200cc total (100cc gastrografin + 100cc water) for patients ≥8 years, and 100cc total (50cc gastrografin + 50cc water) for patients <8 years. Contrast is obtained from fluorotech, diluted by surgical team, and administered per protocol.
Patient Selection and Exclusion Criteria
Protocol applies to patients with suspected adhesive SBO confirmed by 2-view abdominal X-ray or CT scan. Exclusion criteria include clinical or radiographic signs of strangulation, peritonitis, active malignancy, non-adhesive SBO, no prior abdominal surgery, or surgical/medical team discretion. Patients must have appropriate nasogastric tube decompression for at least 1 hour before contrast administration.
Nasogastric Tube Placement Guidelines
Weight-based NGT sizing provided from neonates (5-8 Fr for 3-9kg) through adults (12-18 Fr for >24kg). Surgical team places NGT if not already present at time of consultation. Tube tip position must be confirmed in stomach before gastrografin administration.
Contrast Administration Protocol
After confirming NGT tip location in stomach, diluted gastrografin is administered and NGT is clamped for 8-10 hours. Non-portable plain abdominal X-ray obtained at 10 hours to assess contrast progression. Serial examinations every 4 hours performed by surgical team during observation period.
10-Hour Assessment and Management
If contrast reaches or passes cecum on 10-hour X-ray, NGT is discontinued and diet advanced at appropriate rate. If contrast has not reached cecum, NGT is unclamped and placed back to suction if patient is nauseated or vomiting. Second assessment performed at 24 hours if 10-hour film negative.
24-Hour Assessment and Operative Decision
Plain abdominal X-ray repeated at 24 hours if contrast not in cecum at 10 hours. If contrast reaches or passes cecum at 24 hours, NGT discontinued and diet advanced. Failure of contrast to reach cecum by 24 hours indicates need for operative intervention.
Statements in this guideline
For patients age 8 years or older, the Gastrografin dose is 100 cc Gastrografin plus 100 cc water for a total of 200 cc.
For patients younger than 8 years, the Gastrografin dose is 50 cc Gastrografin plus 50 cc water for a total of 100 cc.
NGT decompression with appropriate size tube should be performed for at least 1 hour before Gastrografin administration.
The NGT tube should be placed by the surgical team if not yet in place at time of consultation.
Patients with signs of strangulation, peritonitis, known active malignancy, or non-adhesive SBO should proceed to the OR as indicated.
After Gastrografin administration, the NGT should be clamped for 8 to 10 hours.
A plain non-portable abdominal X-ray should be obtained at 10 hours after Gastrografin administration.
If contrast is in or past the cecum at 10 hours, the NGT should be discontinued and diet advanced at an appropriate rate.
If contrast is not in or past the cecum at 10 hours, a plain abdominal X-ray should be obtained at 24 hours.
If contrast is in or past the cecum at 24 hours, the NGT should be discontinued and diet advanced at an appropriate rate.
If the patient is nauseated or vomiting, the NGT should be unclamped and placed back to suction.
Serial exams every 4 hours should be performed by the surgical team.
Exclusion criteria include clinical or radiographic suspicion of strangulation.
Exclusion criteria include non-adhesive SBO.
Exclusion criteria include no prior abdominal surgery.
Exclusion criteria include peritonitis.
Exclusion criteria include active malignancy.
For newborns and infants weighing 3 to 9 kg, the suggested NGT size is 5 to 8 French.
For toddlers weighing 10 to 11 kg, the suggested NGT size is 8 to 10 French.
For small children weighing 12 to 14 kg, the suggested NGT size is 10 French.
For children weighing 15 to 18 kg, the suggested NGT size is 10 to 12 French.
For children weighing 19 to 23 kg, the suggested NGT size is 12 to 14 French.
For large children and adults weighing more than 24 kg, the suggested NGT size is 12 to 18 French.