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 SBO
Guideline · Aug 2019 · 1 min read
In brief
In brief
Use of water-soluble contrast agent (Gastrografin) in the diagnostic and therapeutic management of small bowel obstruction, including indications and clinical outcomes.
Written by the GCMD Library team from the guideline.
Patient Selection and Exclusion Criteria
Protocol applies to pediatric patients with suspected adhesive small bowel obstruction confirmed by imaging (2-view AXR or CT). Exclusion criteria include clinical or radiographic signs of strangulation, peritonitis, active malignancy, non-adhesive SBO, or no prior abdominal surgery. Surgical/medical team retains final decision-making authority for protocol eligibility.
Initial Management and NGT Placement
Nasogastric tube decompression must be established for at least 1 hour using age-appropriate tube sizing (5-8 Fr for infants up to 12-18 Fr for adults). The surgical team places the NGT if not already present at time of consultation. NGT tip position in the stomach must be confirmed before proceeding with contrast administration.
Gastrografin Administration Protocol
Water-soluble contrast (diatrizoate meglumine) is diluted and administered via NGT: 100 mL gastrografin + 100 mL water (200 mL total) for patients ≥8 years, or 50 mL gastrografin + 50 mL water (100 mL total) for patients <8 years. The NGT is clamped for 8-10 hours following administration to allow contrast transit through the bowel.
10-Hour Imaging Assessment
A plain non-portable abdominal radiograph is obtained at 10 hours post-contrast administration. If contrast has reached or passed the cecum, the NGT is discontinued and diet is advanced at an appropriate rate, indicating successful non-operative resolution.
24-Hour Imaging Assessment and Decision Point
If contrast has not reached the cecum at 10 hours, a repeat plain AXR is obtained at 24 hours. Contrast reaching the cecum at 24 hours allows for NGT removal and diet advancement. Failure of contrast to reach the cecum by 24 hours suggests failed non-operative management.
Management of Protocol Failure
If the patient develops nausea or vomiting during the observation period, the NGT is unclamped and returned to suction. Serial examinations every 4 hours should be performed by the surgical team to monitor for signs of clinical deterioration or need for operative intervention.
Statements in this guideline
Nasogastric tube decompression should be performed with an appropriate size tube for at least 1 hour before administering Gastrografin.
Patients with signs of strangulation, peritonitis, known active malignancy, or non-adhesive small bowel obstruction should proceed to the operating room and not receive Gastrografin.
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.
After administering Gastrografin, the nasogastric tube 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 nasogastric tube 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 nasogastric tube should be discontinued and diet advanced at an appropriate rate.
If contrast is not in or past the cecum at 24 hours, the nasogastric tube should be unclamped and placed back to suction.
Serial examinations every 4 hours should be performed by the surgical team.
Exclusion criteria include clinical or radiographic suspicion of strangulation, non-adhesive small bowel obstruction, no prior abdominal surgery, peritonitis, active malignancy, or surgical/medical team decision.
For newborns and infants weighing 3 to 9 kg, the suggested nasogastric tube size is 5 to 8 French.
For toddlers weighing 10 to 11 kg, the suggested nasogastric tube size is 8 to 10 French.
For small children weighing 12 to 14 kg, the suggested nasogastric tube size is 10 French.
For children weighing 15 to 18 kg, the suggested nasogastric tube size is 10 to 12 French.
For children weighing 19 to 23 kg, the suggested nasogastric tube size is 12 to 14 French.
For large children and adults weighing more than 24 kg, the suggested nasogastric tube size is 12 to 18 French.