Gastrografin Protocol for Adhesive Small Bowel Obstruction (SBO)

My name is Mira Kodgali and I'm one of the pediatric surgeons here at Cincinnati Children's Hospital. Today we're going to be talking about the use of Gastrografin, a water-soluble oral contrast agent in the management of adhesive small bowel obstructions. The use of Gastrografin to manage adhesive small bowel obstructions began in the adult population probably about 10 years ago. The idea behind it is that it's both diagnostic and therapeutic. Because Gastrografin can be seen on X-rays, you can follow its progress through the bowel and tell whether or not the obstruction has resolved. But the thought is that also as a hyperosmolar agent, it draws water from the bowel edema into the lumen of the bowel, helping to resolve the obstruction. Given the data supporting its use, we wanted to develop a guideline for the use of Gastrografin in the management of adhesive small bowel obstructions here at Cincinnati Children's. There were some great papers from the adult literature, including a meta-analysis by Branco at all and a prospective observational trial by Zelinsky at all. And we used those papers in addition to the protocol published by Lindon at all from Comer Children's in Chicago to design our own guideline. So here it is. So the first question is, who is this guideline appropriate for? Gastrografin should only be used in the management of adhesive small bowel obstructions, which is to say it's not appropriate for patients who have never had an operation. Additionally, it's not for use in patients with concern for strangulation or those with peritonitis. Those patients should be considered for an immediate operative intervention. We also excluded patients with an active malignancy from our protocol. Once you have your patient and they're suspected to have an adhesive small bowel obstruction, they undergo imaging with a two view abdominal x-ray or a CT to confirm the small bowel obstruction. As long as they don't have signs of strangulation or peritonitis, they get nasogastric decompression for at least an hour, or longer if the NG continues to drain bilious fluid. We confirm that the tip of the NG tube is in the stomach and then we administer gastrografin. The dose for gastrografin is age-based and it's diluted in water to be a 50% solution. The NG is then clamped for 8 to 10 hours, although it can be unclammped at any time if the patient is nauseated or vomiting. The patient gets a portable plain film at 10 hours, and if the contrast is in the cecum or past the cecum, then their NG tube is removed and their diet can be advanced at an appropriate rate. If it has not yet made it to the cecum, we get another X-ray at 24 hours. If it has reached the cecum by then, again, the NG tube can be removed and the diet can be advanced. If it has not yet reached the cecum, strong consideration is given to an operative exploration at that time. It's important to note that throughout this period of time, the patient requires serial abdominal exams every four hours to ensure that they have not progressed to peritonitis or that they don't have an indication for a more urgent operative intervention. So far, we've had great success using Gastrografin for the management of adhesive small bowel obstructions in children, and we thank our colleagues at Comer Children's for leading the way with their protocol.