Gastrografin for uncomplicated adhesive small bowel obstruction in children

Contrast Challenge Algorithms for Adhesive Small Bowel Obstructions Are Safe in Children: A Multi-Institutional Study

OBJECTIVE

The purpose of this study was to evaluate the safety of a water-soluble contrast challenge as part of a nonoperative management algorithm in children with an adhesive small bowel obstruction (ASBO).

BACKGROUND

Predicting which children will successfully resolve their ASBO with non-operative management at the time of admission remains difficult. Additionally, the safety of a water-soluble contrast challenge for children with ASBO has not been established in the literature.

METHODS

A retrospective review was performed of patients who underwent non-operative management for an ASBO and received a contrast challenge across 5 children's hospitals between 2012 and 2020. Safety was assessed by comparing the complication rate associated with a contrast challenge against a pre-specified maximum acceptable level of 5%. Sensitivity, specificity, negative (NPV) and positive (PPV) predictive values of a contrast challenge to identify successful nonoperative management were calculated.

RESULTS

Of 82 children who received a contrast challenge, 65% were successfully managed nonoperatively. The most common surgical indications were failure of the contrast challenge or failure to progress after initially passing the contrast challenge. There were no complications related to contrast administration (0%; 95% confidence interval: 0-3.6%, P = 0.03). The contrast challenge was highly reliable in determining which patients would require surgery and which could be successfully managed non-operatively (sensitivity 100%, specificity 86%, NPV 100%, PPV 93%).

CONCLUSION

A contrast challenge is safe in children with ASBO and has a high predictive value to assist in clinical decision-making.

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 The concept of partial versus complete bowel obstruction is outdated and lacks precision to be clinically useful.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.

Attitudes Affecting Decision-making for Use of Radiologic Enteral Contrast in the Management of Pediatric Adhesive Small Bowel Obstruction: A Survey Study of Pediatric Surgeons

BACKGROUND

Pediatric surgeons are often asked to treat clinical problems for which little high-quality data exist. For adults with adhesive small bowel obstruction (ASBO), water soluble contrast-based protocols are used to guide management. Little is known about their utility in children. We aimed to better understand key factors in clinical decision-making processes and integration of adult based data in pediatric surgeon's approach to ASBO.

METHODS

We administered a web-based survey to practicing pediatric surgeons at institutions comprising the Western Pediatric Surgery Research Consortium.

RESULTS

The response rate was 69% (78/113). Over half of respondents reported using contrast protocols to guide ASBO management either routinely or occasionally (n = 47, 60%). Common themes regarding the incorporation of adult-based data into clinical practice included the need to adapt protocols for pediatric patients, the dearth of pediatric specific data, and the quality of the published adult evidence.

CONCLUSIONS

Our findings demonstrate that pediatric surgeons use contrast-based protocols for the management of ASBO despite the paucity of pediatric specific data. Furthermore, our survey data help us understand how pediatric surgeons incorporate adult based evidence into their practice.

Paediatric adhesive bowel obstruction: a systematic review

Adhesions following abdominal surgery remain a common cause of bowel obstruction. The incidence is between 1 and 12.6% in children who have had previous abdominal surgery. While conservative management is usually trialled in all patients (including children) suspected of having ASBO, the majority will require surgical intervention. New materials such as Seprafilm^® have been studied in the paediatric population, with promising results of its use in index abdominal surgeries to prevent the formation of adhesions. In this article, we conducted a systematic review to present an overview of the current knowledge on the incidence, aetiology, pathophysiology, clinical presentation, and management of ASBO.

Evaluation of a water-soluble contrast protocol for nonoperative management of pediatric adhesive small bowel obstruction

BACKGROUND/PURPOSE

We examined outcomes before and after implementing an enteral water-soluble contrast protocol for management of pediatric adhesive small bowel obstruction (ASBO).

METHODS

Medical records were reviewed retrospectively for all children admitted with ASBO between November 2010 and June 2017. Those admitted between November 2010 and October 2013 received nasogastric decompression with decision for surgery determined by surgeon judgment (preprotocol). Patients admitted after October 2013 (postprotocol) received water-soluble contrast early after admission, were monitored with serial examinations and radiographs, and underwent surgery if contrast was not visualized in the cecum by 24 h. Group outcomes were compared.

RESULTS

Twenty-six patients experienced 29 admissions preprotocol, and 11 patients experienced 12 admissions postprotocol. Thirteen (45%) patients admitted preprotocol underwent surgery, versus 2 (17%) postprotocol patients (p = 0.04). Contrast study diagnostic sensitivity as a predictor for ASBO resolution was 100%, with 90% specificity. Median overall hospital LOS trended shorter in the postprotocol group, though was not statistically significant (6.2 days (preprotocol) vs 3.6 days (postprotocol) p = 0.12). Pre- vs. postprotocol net operating cost per admission yielded a savings of $8885.42.

CONCLUSIONS

Administration of water-soluble contrast after hospitalization for pediatric ASBO may play a dual diagnostic and therapeutic role in management with decreases in surgical intervention, LOS, and cost.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Use of gastrografin in the management of worm-induced small bowel obstruction in children

OBJECTIVE

Ascaris-induced small bowel obstruction (SBO) is a common sequel of Ascaris lumbricoides (AL) infestation. Most cases respond to conservative treatment practiced in different centers worldwide. We conceived a prospective randomized trial to compare the conservative treatment with gastrografin administered in addition to the conservative treatment.

STUDY DESIGN

This prospective randomized study was conducted between January 2011 and June 2014 at Department of Paediatric and Neonatal Surgery, a tertiary-care hospital. Patients were divided into two groups, one group received conservative treatment and the other received gastrografin in addition to conservative treatment. Forty patients having uncomplicated AL-induced SBO were included in each group. Gastrografin was administered through nasogastric tube and serial clinical and radiological monitoring was performed. The duration of hospital stay, time between admission and first oral feed, passage of worms/flatus were compared in the two groups. Student's t test was used for comparing these variables.

RESULTS

Average time for passage of flatus or worms and resolution of abdominal signs and was shorter in gastrografin group as compared to the conservative group. This difference was found to be statistically significant. The average duration of hospital stay in gastrografin group was 25.20 ± 8.01 h whereas it was 61.12 ± 14.64 h in the conservative group (P < 0.001). The difference in the operation rate was statistically insignificant (2 in gastrografin group and 3 in the conservative group).No serious adverse reaction was noted after gastrografin administration.

CONCLUSION

Use of gastrografin resulted in faster relief of signs and symptoms of AL-induced SBO, early passage of worms/flatus and return to oral feeds. However, the role of gastrografin role in reducing the likelihood of laparotomy remains inconclusive. Adverse effects of gastrografin can be prevented if it is used in well-hydrated patients.

Evaluation of a water-soluble contrast agent for the conservative management of adhesive small bowel obstruction in pediatric patients

BACKGROUND/PURPOSE

The diagnostic and therapeutic benefits of a commercial water-soluble contrast agent (Gastrografin) in pediatric patients with adhesive small-bowel obstruction (ASBO) are controversial. The aim of this study was to assess the therapeutic value of Gastrografin in the management of ASBO in children after unsuccessful conservative treatment.

METHODS

Medical records from patients with uncomplicated ASBO managed at Cathay General Hospital, Taipei, Taiwan between January 1996 and December 2011 were retrospectively reviewed. All children ≤18 years of age with clinical evidence of ASBO were managed conservative treatment, unless there was suspicion of strangulation. Patients who did not improve after 48 hours of conservative treatment were administered Gastrografin.

RESULTS

Twenty-four patients with 33 episodes of ASBO were analyzed. Of those, there were 19 episodes of ASBO that failed to respond to the initial conservative management, and 16 (84%) responded well to Gastrografin administration thereby abrogating the need for surgical intervention. There were neither complications nor mortality that could be attributed to the use of Gastrografin.

CONCLUSION

This preliminary study suggested that the use of a water-soluble contrast agent in ASBO is safe in children and useful for managing ASBO, particularly in reducing the need for surgery when conservative treatment fails. However, larger prospective studies would be needed to confirm these results.

Adhesive small bowel obstruction--acute management and treatment in children

Adhesive small bowel obstruction is a significant cause of short- and long-term morbidity in infants and children. Unfortunately, the majority of scientific literature relative to adhesive obstructions continues to be dominated by adult studies. In this article, the existing literature for infant and pediatric adhesive obstructions is reviewed, with relevant comparisons to the available adult data. In addition, general guidelines for the management of infant and pediatric adhesive obstructions are recommended, based on the best available evidence.

Conservative treatment of adhesive small bowel obstruction in children: a systematic review

OBJECTIVE

To assess the effectiveness of conservative treatment for adhesive small bowel obstruction (ASBO) in children.

DESIGN

Systematic review of studies involved children with ASBO who received initial conservative/non-operative treatment.

SETTING

The search was performed in April 2013 using PubMed (see online supplementary file 1), current contents, and the Cochrane database.

PARTICIPANTS

Children with ASBO.

INTERVENTIONS

Conservative treatment included nasogastric decompression, parenteral fluids and correction of electrolyte and fluid imbalance.

PRIMARY OUTCOME

Treatment success.

SECONDARY OUTCOMES

Length of hospital stay and the time to first feeding after hospital admission.

RESULTS

7 studies (six retrospective, one prospective), involving 8-109 patients (age: 1 month to 16 years) treated conservatively, were included in the review. The nature of conservative treatment was generally consistent between studies (nasogastric decompression, parenteral fluids and correction of electrolyte and fluid imbalance), although patients in one study also received Gastrografin. The rate of conservative treatment success ranged from 16% to 75% among the five studies, but one trial showed 0% successful rate. The hospital length of stay ranged from 3 to 6.5 days for conservative treatment (vs 10.2-13 days for operative treatment). The time to first feeding ranged from 31 to 84 h for conservative treatment.

CONCLUSIONS

In conclusion, in the majority of cases, conservative treatment is an effective means of managing ASBO in children.

Beyond appendicitis: evaluation and surgical treatment of pediatric acute abdominal pain

PURPOSE OF REVIEW

Evaluation of the child with acute abdominal pain is challenging because of the wide range of potential diagnoses. Presenting symptoms, clinical examination, and laboratory findings can guide selection of diagnostic imaging.

RECENT FINDINGS

Intussusception and intestinal malrotation are potentially serious causes of intestinal obstruction, which are best evaluated by ultrasound and upper gastrointestinal series, respectively. Ultrasound has diagnostic importance in the evaluation of multiple diseases, including appendicitis, by potentially decreasing the need for inpatient observation, cholecystitis and complications of gall stones such as pancreatitis, and ovarian diseases. Pelvic inflammatory disease should be considered in evaluation of a teenage girl with lower abdominal pain. Less common causes of acute abdominal pain include ingested foreign bodies, infected congenital anomalies, and perforated peptic ulcer disease.

SUMMARY

Presenting symptoms and physical examination findings can narrow the number of potential diagnoses in pediatric acute abdominal pain and thereby guide diagnostic imaging selection. Abdominal/pelvic ultrasound, rather than computed tomography scan, is the preferred modality for initial evaluation of many potential causes of pediatric abdominal pain.