Whole-gut lavage in children using an iso-osmolar solution containing polyethelene glycol (Golytely)

Professionals' experiences with paediatric colonoscopy: an interview study

Background

Colonoscopy plays a crucial role in the diagnosis of paediatric inflammatory bowel disease (IBD), adolescents comprise 25% of all cases of IBD. Several studies have found that a safe, informative, and effective colonoscopy, performed in a child-friendly atmosphere with minimal distress to the child, is difficult to achieve.

The aim of this study was to describe nurse’s experiences of the pre-colonoscopy procedure prior in children.

Methods

A qualitative design with a thematic content analysis approach was used. Fifteen nurses at a children’s hospital participated in interviews regarding their experiences of the bowel cleansing procedure with PEG in children.

Results

Four key themes were extracted from the nurses’ experiences; lack of knowledge, challenges surrounding information, responsibility without control and assembly line- like procedure..

Conclusions

This study shows that nurses feel that they need more time and education opportunities before involved in paediatric colonoscopies.

Parents' experiences when their child is undergoing an elective colonoscopy

PURPOSE

The purpose was to illuminate parents' experiences when their children are undergoing an elective colonoscopy performed using polyethylene glycol-based regimes for bowel preparation.

DESIGN AND METHODS

Individual interviews with 12 parents were performed and analysed using content analysis.

RESULTS

The parents' experiences were structured into one theme: "Charged with conflicting emotions" with three categories: "Being forced to force," "Losing one's sense of being a parent" and "Standing without guidance."

PRACTICE IMPLICATIONS

Understanding parents' experiences can help healthcare staff guide parents in helping their children undergo a colonoscopy.

[Safety and efficacy of polyethylene glycol 3350 plus electrolytes for the treatment of functional constipation in children]

INTRODUCTION

Polyethylene glycol 3350 plus electrolytes (PEG+E) efficacy has been validated in some studies, but not many have evaluated its safety in children. The aim of our study was to evaluate the safety; renal, malabsorption or excessive production of gas and efficacy of PEG+E treatment in our paediatric population.

PATIENTS AND METHODS

Fifteen patients who suffered functional constipation (Rome III criteria) were evaluated. Median age was 6.2 years (r 2-9). All patients had normal renal function. PEG+E were administered for 4 weeks (4WP). The mean dose was 0.44 g/kg/day, titrated according to age, weight and response. Urine screens (sodium and osmolality) were performed at the beginning and 4WP. Stool sample NIRA (near-infrared reflectance analysis) and hydrogen breath test analysis samples were performed at 4WP. To analyse the efficacy of the treatment, the number of stools per week and stool form type (Bristol stool scale) were recorded.

RESULTS

The number of stools per week was higher after 4 weeks (2.46 ± 0.71 vs 5.29 ± 1.68, P<.001), as well as the stool form score (2.47 ± 1.24 vs 4.5 ± 0.91, P<.001). No statistical differences were obtained between urine sodium and urine osmolality values at the beginning and 4WP. After 4WP the NIRA median values were normal in all patients [fat 4.45% (range (r) 3.6-7.09); nitrogen 0.78% (r 0.4-1); sugars 1.4% (r 0.47-2.35) and water 68% (r 59-74)]. Median breath hydrogen test was 7 ppm (r 2-18).

CONCLUSIONS

No adverse effects on biochemistry values or gastrointestinal disturbances were observed. PEG+E can be recommended for the treatment of functional constipation in children.

Anterior sagittal anorectoplasty for anovestibular fistula

Anterior sagittal anorectoplasty (ASARP) was used for the definitive correction in 107 cases of anovestibular fistula (AVF) between 1996 and 2005. These cases were subjected to three different types of treatment regimes during the same period. Majority of the cases (78) were operated in one stage where postoperatively an early oral feed was started (A). Cases were discharged in 2-4 days. In the second group (B), there were ten cases who were also operated in one stage but with prolonged fasting of 9-10 days postoperatively. Nineteen cases (C) were operated under cover of colostomy during the same period. In the immediate postoperative period, among the group A, one case had a major wound disruption requiring a colostomy and a redo surgery. Three cases had subcutaneous leak. In seven cases there was premature dehiscence of mucocutaneous or skin sutures. In groups B and C, there were no significant complications in the immediate postoperative period. In the follow-up period, out of 107 cases, 63 (58.8%) had constipation at the end of 3 months. However, at the end of one year, only 24.3% (26 cases) cases had constipation. Regarding fecal continence, 86 cases (90.5%) were totally continent. Seven had history of occasional soiling and in two cases, soiling was more frequent. As far as repair or correction of AVF or vestibular anus is concerned, we feel that anterior sagittal approach is more suitable as it requires less pelvic dissection. Separation of posterior vaginal wall from rectum, which is considered, is the most important step of the operation, takes place under direct vision. We also feel that AVF can be repaired in one stage with an early postoperative oral feed, provided we are meticulous in pre and postoperative bowel management. It reduces hospital stay and the cost of treatment. This provides a good option to cases who are not able to afford prolonged hospitalization (fasting) or are not willing for a colostomy.

Comparison of three solutions for total gut irrigation in pediatric patients

Total gut irrigation (TGI) is a safe method of bowel preparation in children. Many solutions are used but none is ideal. This study has been done to compare household common salt solution prepared by dissolving 10 g of pure NaCl salt (Active Reagent Quality) in 1 l of tap water, polyethylene glycol with electrolytes (PEG) and ringers lactate for TGI in children. We prospectively evaluated the three solutions in terms of efficacy, safety, rapidity, tolerability and cost effectiveness in patients undergoing a variety of colorectal procedures. Patients (126) were randomly assigned into one of the three groups; Group I, household common salt solution, 40; Group II, Peglec, 55; Group III, Ringer lactate, 31. TGI with PEG is the most rapid method of bowel preparation but is least tolerable. Household common salt solution is inexpensive and most tolerable of the three preparations. All three are similar in safety and effectiveness in bowel preparation. Household common salt solution is effective, safe, cost effective and the most tolerable method of bowel preparation.

An experimental study of choleretic effect and histopathologic alterations in the gastrointestinal system after whole-bowel irrigation

BACKGROUND/PURPOSE

Whole-bowel irrigation (WBI) has been used for different purposes. It has been the preferred method of bowel cleansing before large bowel surgery and colonoscopy. There are some studies about histopathologic alterations in the gastrointestinal system caused by WBI. It was reported that large quantities of bile-stained intraluminal fluid were seen after WBI with lactated Ringer's solution. In light of all these studies, the authors have decided to inspect whether WBI is choleretic and whether the histopathologic findings in the gastrointestinal system are caused by this choleretic effect.

METHODS

During the experimental procedures, animals at first were divided into 2 major groups of A and B; A consisted of the animals whose bile was not collected, and B consisted of animals whose bile was collected. Later, these 2 groups were divided into 4 subgroups consisting of 6 animals each. Sham operations were performed on the animals in group SH-A and SH-B. The animals in group saline-A and saline-B were given 0.9% of sodium chloride (isotonic sodium chloride). The animals in group LR-A and LR-B received lactated Ringer's solution. The last group (PEG-A and PEG-B) underwent WBI by using polyethylene glycol solution (PEG). After completing WBI, animals were rested for 4 hours, and at the end of resting time, laparotomy was performed to take biopsy specimens from stomach, small bowel, and large bowel. All of the specimens were evaluated and graded for congestion, edema, and inflammation by the individual blinded pathologist.

RESULTS

According to the results, WBI has been shown to affect biliary secretion and to have a choleretic effect (P <.05, Tuckey-Kramer). The choleretic effect has also been shown to be responsible for histopathologic alterations in some groups (P <.05, Tuckey-Kramer). The most severe changes of congestion, edema, and inflammation have been detected in isotonic sodium chloride solutions in all groups. The least alterations have been seen in lactated Ringer's and PEG solutions.

CONCLUSIONS

In light of these findings, it might be concluded that the use of WBI can cause different degrees of histopathologic changes in gastrointestinal system depending on the type of solutions. WBI has been shown to have choleretic effect, and it was found that there is a connection between histopathologic changes in gastrointestinal system and choleretic effect of WBI.

High-molecular-weight polyethylene glycol prevents lethal sepsis due to intestinal Pseudomonas aeruginosa

BACKGROUND & AIMS

During stress, erosion of protective intestinal mucus occurs in association with adherence to and disruption of the intestinal epithelial barrier by invading opportunistic microbial pathogens. The aims of this study were to test the ability of a high-molecular-weight polyethylene glycol compound, polyethylene glycol 15-20, to protect the intestinal epithelium against microbial invasion during stress.

METHODS

The ability of polyethylene glycol 15-20 to protect the intestinal epithelium against the opportunistic pathogen Pseudomonas aeruginosa was tested in cultured Caco-2 cells. Bacterial virulence gene expression, bacterial adherence, and transepithelial electrical resistance were examined in response to apical inoculation of P. aeruginosa onto Caco-2 cells. Complementary in vivo studies were performed in a murine model of lethal sepsis due to intestinal P. aeruginosa in which surgical stress (30% hepatectomy) was combined with direct inoculation of P. aeruginosa into the cecum.

RESULTS

High-molecular-weight polyethylene glycol (polyethylene glycol 15-20) conferred complete protection against the barrier-dysregulating effects of P. aeruginosa in Caco-2 cells. Intestinal application of polyethylene glycol 15-20 in stressed mice protected against the lethal effects of intestinal P. aeruginosa. Mechanisms of this effect seem to involve the ability of polyethylene glycol 15-20 to distance P. aeruginosa from the intestinal epithelium and render it completely insensate to key environmental stimuli that activate its virulence.

CONCLUSIONS

High-molecular-weight polyethylene glycol has the potential to function as a surrogate mucin within the intestinal tract of a stressed host by inhibiting key interactive events between colonizing microbes and their epithelial cell targets.

A comparative histopathologic evaluation of the effects of three different solutions used for whole bowel irrigation: an experimental study

PURPOSE

Although whole bowel irrigation (WBI) is a widely used method of bowel preparation in daily surgical practice, almost nothing is known about the histopathologic alterations caused by WBI and whether these differences have any detrimental effect on the outcome of gastrointestinal surgical procedures. Therefore, an experimental study has been conducted to evaluate and compare the effects of WBI with various solutions on the histology of gastrointestinal tract.

METHODS

During the experimental procedures animals were divided into 4 groups consisting of 8 animals each as follows: group A, WBI performed by using isotonic saline solution; group B, WBI performed by using an isoosmolar solution containing polyethylene glycol (PEG); group C, WBI performed by using Lactated Ringer's solution; group D, Animals that were not irrigated but sham operations that were performed served as controls. Four hours after WBI the animals underwent laparotomy and a segment of transverse colon with intact vascular peduncle was prepared. After waiting for 30 minutes, specimens from duodenum, small intestine, large bowel, colonic segment, and liver were obtained from each animal. Histopathologically, all of the specimens were evaluated and graded by 3 parameters including congestion, edema, and inflammation.

RESULTS

Although varying degrees of congestion, edema, and inflammation were encountered from all of the specimens of group A, B, and C, only slight congestion was noted in all specimens of group D. The difference between group D and other groups was statistically very significant (P < .001). When the sections from duodenums of groups were evaluated, the degree of congestion, edema, and inflammation were found to be moderate in group B, mild-moderate in group A, and mild in group C. Histopathologic examinations of specimens of the small, large bowel, and isolated colonic segment showed severe congestion, edema, and inflammation in group A, moderate-mild in group B, and mild in group C. The difference between A and B, A and C, and A and D was statistically significant (P < .01). Although severe congestion was encountered in liver specimens of group A, only mild congestion was encountered in groups B and C (P= .0001). The matched durations of irrigations and total volume of irrigation solutions were found to be not related with the difference in histopathologic findings.

CONCLUSIONS

WBI has induced varying degrees of histopathologic alterations from mild to severe in the rat gastrointestinal tract. Lactated Ringer's solution and PEG solution have induced the least alterations. Therefore, WBI with Lactated Ringer's solution and PEG solution seem to be safe alternatives of mechanical bowel preparation before elective large bowel surgery. Because saline solution has caused detrimental alterations in distal gastrointestinal tract histology, WBI with saline solution seems to be unadvisable.

Constipation in epidermolysis bullosa: successful treatment with a liquid fiber-containing formula

In epidermolysis bullosa (EB), chronic constipation, painful defecation, and fecal impaction frequently contribute to malnutrition and growth failure. Standard treatments for constipation, such as increased intake of conventional dietary fiber and fluids and/or the use of laxatives and stool softeners, are largely unsuccessful. We evaluated by questionnaire the use of a fiber-containing liquid formula (Enrich) in 20 chronically constipated children with dystrophic EB. All derived substantial improvement in constipation when taking 250 to 750 ml Enrich per day. We recommend that such a fiber-containing food be prescribed for chronic constipation in EB. In cases of fecal impaction, this should be preceded by bowel cleansing.

Small volume isosmotic polyethylene glycol electrolyte balanced solution (PMF-100) in treatment of chronic nonorganic constipation

The present multicenter double-blind placebo-controlled trial evaluates the therapeutic effectiveness of small-volume daily doses of an isosmotic polyethylene glycol (PEG) electrolyte solution in the treatment of chronic nonorganic constipation. After a complete diagnostic investigation, patients still constipated at the end of a four-week placebo-treatment run-in period were enrolled and randomized to receive either placebo or PEG solution 250 ml twice a day for the following eight weeks. Patients were assessed at four and eight weeks of treatment, and they reported frequency and modality of evacuation, use of laxatives, and relevant symptoms daily on a diary card. Oroanal and segmental large-bowel transit times were assessed with radiopaque markers during the fourth week of the run-in period and the last week of the treatment period. During the study period, dietary fiber and liquids were standardized and laxatives were allowed only after five consecutive days without a bowel movement. Of the 55 patients enrolled, five dropped out, three because of adverse events and two for reasons unrelated to therapy; another two were excluded from the efficacy analysis because of protocol violation. Of the remaining 48 patients (37 women, age 42 +/- 15 years, mean +/- SD), 23 were assigned to placebo and 25 to PEG treatment. In comparison to placebo, PEG solution induced a statistically significant increase in weekly bowel frequency at four weeks and at the end of the study (PEG: 4.8 +/- 2.3 vs placebo: 2.8 +/- 1.6; P < 0.002) and a significant decrease in straining at defecation (P < 0.01), stool consistency (P < 0.02), and use of laxatives (P < 0.03). Oroanal, left colon, and rectal transit times were significantly shortened by PEG treatment. There was no difference between controls and PEG-treated patients as far as abdominal symptoms and side effects were concerned. In conclusion, PEG solution at 250 ml twice a day is effective in increasing bowel frequency, accelerating colorectal transit times, and improving difficult evacuation in patients with chronic nonorganic constipation and is devoid of significant side effects.

Internal sphincterotomy in post-pull-through Hirschsprung's disease

Despite proper technique, pull-through operations for Hirschsprung's disease sometimes fail to deliver normal or effective bowel evacuation. Ten patients, described herein, had had a pull-through procedures. The procedures had been performed by various pediatric surgeons. Five cases had been diagnosed in the newborn period and had undergone colostomies. The remainder had been diagnosed later (at 2 months to 2 years of age). They too had undergone colostomy initially, and all had an elective pull-through procedure. The techniques varied; two had Soave procedures, seven had Duhamel procedures, and one had a Kimura-Soave procedure (the only case of total colonic Hirschsprung's disease in the series). All the patients had manifested difficulty in passing stools after the pull-throughs. The problem was described as "severe constipation," "obstipation," or "fecal retention." Four patients had been treated with many laxatives, suppositories, enema routines, and diet regimens for years, with no success. All had been examined radiographically to detect megarectum or megacolon. All had additional biopsies to confirm the presence of ganglia in the pulled-through segments. At 21 months to 12 years of age, these patients underwent full posterior internal sphincterotomies. Nine of the 10 had a good or excellent outcome, with resolution of the megarectum or megacolon. Three patients still require small doses of senna compound, which are being decreased continuously. Therapy failed for a patient with Down's syndrome and a, Duhamel pull-through, and a stoma was required.

Posterior sagittal rectal myectomy for persistent rectal achalasia after the Soave procedure for Hirschsprung's disease

For the management of persistent rectal achalasia after the Soave endorectal pull-through procedure, we have used posterior sagittal myectomy of the remaining aganglionic rectal muscular cuff, and have had satisfactory outcomes in five patients. Via a posterior sagittal skin incision, the posterior aspect of the rectal muscular cuff is reached. With the striated muscular complex retracted downward, the level of the dentate line is identified on the posterior wall of the rectum with the aid of the surgeon's finger inserted inside the anorectum. Two parallel longitudinal incisions are made on the rectal muscular cuff to create a muscular strip which is elevated and excised; the distal end of the myectomy strip is at the level of the dentate line and includes a part of the internal and sphincter muscle. During the last 4 years, we performed this procedure in 5 patients with remarkable relief of constipation, distension, and enterocolitis. The advantages of this procedure include: (1) less technical difficulty than the transanal approach, (2) avoiding colostomy, and (3) promising results.

Acute pulmonary edema after polyethylene glycol intestinal lavage in a child

OBJECTIVE

To report the case of an eight-year-old girl, without preexisting cardiac or renal disease, who developed acute pulmonary edema and severe respiratory distress after balanced electrolyte with polyethylene glycol (BE-PEG) intestinal lavage.

CASE SUMMARY

During the nasogastric infusion of a one-liter dose of BE-PEG (OCL, Abbott), the patient experienced abdominal discomfort, gagging, vomiting and coughing. After the nasogastric infusion, the patient again had emesis, developed tachypnea, intercostal retractions, and acute respiratory distress. She received oxygen and subsequently required intubation and ventilatory support. Physical examination revealed pulmonary congestion bilaterally but no signs of cardiac failure or sepsis. Chest X-ray revealed bilateral pulmonary edema. Ventilatory support was continued for 36 hours and the patient was extubated after two days.

DISCUSSION

Enteral BE-PEG may have caused acute pulmonary edema secondary to aspiration or systemic fluid overload. Although the exact cause remains unknown, the close temporal onset of pulmonary edema after BE-PEG administration in an otherwise healthy child suggests a causal relationship.

CONCLUSIONS

This case should alter clinicians to the potential for significant morbidity with BE-PEG solutions, particularly if used in outpatient settings. Patients who receive BE-PEG should be closely observed and monitored for potential aspiration, excessive infusion rates, and gastrointestinal symptoms to optimize efficacy and reduce morbidity.

Use of whole bowel irrigation in an infant following iron overdose

An 11-month-old, 11-kg infant presented to the emergency department after ingesting 130 to 150 mg/kg of elemental iron. Emesis was induced twice and the child was lavaged throughout a 4-hour period with some tablet return. An abdominal radiograph after gastrointestinal decontamination showed at least 16 whole iron tablets remaining in the stomach. Serum iron drawn 2 hours postingestion was 46.7 mumol/L. Blood glucose was 7.7 mmol/L and white blood count was 21,800 mm3. Despite a second lavage 8 hours postingestion, a large number of whole tablets were visualized in the stomach per radiograph. Whole bowel irrigation with polyethylene glycol electrolyte lavage solution (Golytely, Braintree Laboratories, Inc, Braintree, MA) was begun via nasogastric tube 14 hours after the ingestion. Serial abdominal radiographs showed tablet movement out of the stomach within 4 hours after initiating whole bowel irrigation. This case demonstrates the safety and efficacy of WBI in an infant when conventional gastrointestinal decontamination has failed.