Feasibility of Gastrografin Use for Adhesive Small Bowel Obstruction in Low-Income Countries

INTRODUCTION

Small bowel obstruction (SBO) is one of the most common causes for hospital admission in Ethiopia. The use of water-soluble contrast agents (WSCAs) such as Gastrografin to manage adhesive SBO can predict nonoperative resolution of SBO and reduce decision time to surgery and length of hospital stay. However, nothing is known about practice patterns and Gastrografin use in low-income settings. We sought to characterize current management practices, including use of WSCAs, as well as outcomes for patients with SBO in Addis Ababa, Ethiopia.

METHODS

We conducted a mixed-methods study consisting of a survey of surgeons throughout Ethiopia and a retrospective record review at five public, tertiary care-level teaching hospitals in Addis Ababa.

RESULTS

Of the 76 surgeons who completed the survey, 63% had heard of the use of WSCAs for SBO and only 11% used oral agents for its management. Chart review of 149 patients admitted with SBO showed the most common etiology was adhesion (39.6% of admissions), followed by small bowel volvulus (20.8%). Most patients (83.2%) underwent surgery during their admission. The most common diagnosis in patients who did not require surgery was also adhesion (68.0%), as well as for those who had surgery (33.9%), followed by small bowel volvulus (24.2%).

CONCLUSIONS

The etiology of SBO in Ethiopia may be changing, with postoperative adhesions becoming more common than other historically more prevalent causes. Although a Gastrografin protocol as a diagnostic and potentially therapeutic aid for SBO is feasible in this population and setting, challenges can be anticipated, and future studies of protocol implementation and effectiveness are needed to further inform its utility in Ethiopia and other low-income and middle-income countries.

THE WATER-SOLUBLE CONTRAST FOR ADHESIVE SMALL BOWEL OBSTRUCTION: ARE THERE ADVANTAGES?

BACKGROUND

Adhesive small bowel obstruction is one of the most common causes of surgical emergencies, representing about 15% of hospital admissions. Defining the need and timing of surgical intervention still remains a challenge.

AIMS

To report the experience of using meglumine-based water-soluble contrast in a tertiary hospital in southern Brazil, comparing with the world literature.

METHODS

Patients suspected of having adhesive small bowel obstruction, according to their clinical conditions, underwent an established protocol, consisting of the administration of water-soluble contrast, followed by plain abdominal radiograph within 12 hours and by a new clinical evaluation. The protocol was initiated after starting conservative management, including fasting and placement of a nasogastric tube, as well as intravenous fluid reposition.

RESULTS

A total of 126 patients were submitted to the protocol. The water-soluble contrast test sensitivity and specificity after the first radiograph were 94.6 and 91.0%, respectively; after the second radiograph, these values were 92.3 and 100%. The general test values for sensitivity and specificity were 91.9 and 100%, respectively.

CONCLUSIONS

The measure parameters evaluated in this study were similar to those found in the literature, contributing to endorse the importance of this test in the evaluation of patients with adhesive small bowel obstruction. The particular relevance of this study was the similar results that were found using a different type of meglumine-based contrast, which is available in Brazil.

A Double-Blinded Randomized Clinical Study on the Therapeutic Effect of Gastrografin in Prolonged Postoperative Ileus After Elective Colorectal Surgery

BACKGROUND

Postoperative ileus is a common problem with significant clinical and economic consequences. We hypothesized that Gastrografin may have therapeutic utility by accelerating the recovery of postoperative ileus after colorectal surgery. The aim of this trial was to study the impact of oral Gastrografin administration on postoperative prolonged ileus (PPI) after elective colorectal surgery.

METHODS

The main endpoint of this randomized, double-blinded, controlled trial was time of resolution of PPI. The secondary endpoints were overall hospital length of stay, time to start oral intake, time to first passage of flatus or stools, time of need of nasogastric tube, and need of parenteral nutrition. Included criteria were patients older than 18 years, operated for colonic neoplasia, inflammatory bowel disease, or diverticular disease. There were two treatments: Gastrografin administration and placebo. The sample size was calculated taking into account the average length of postoperative ileus after colorectal resection until tolerance to oral intake. Statistical analysis showed that 29 subjects in each group were needed.

RESULTS

Twenty-nine patients per group were randomized. Groups were comparable for age, gender, ASA Physical Status Classification System, stoma construction, and surgical technique. No statistical differences were observed in mean time to resolution between the two groups, 9.1 days (CI 95%, 6.51-11.68) in Gastrografin group versus 10.3 days (CI 6.96-10.29) in Placebo group (P = 0.878). Even if not statistically significant, time of resolution of PPI, overall length of stay, time of need of nasogastric tube, and time to tolerance of oral intake were shorter in the G group.

CONCLUSIONS

Gastrografin does not accelerate significantly the recovery of prolonged postoperative ileus after elective colorectal resection when compared with placebo. However, it seems to clinically improve all the analyzed variables.

[THE METHOD OF TREATMENT OF LYMPHORRHEA AFTER RECONSTRUCTION OF THE LOWER EXTREMITIES ARTERIES]

Lymphorrhea have had occur after performance of 1381 reconstructive operative interventions on arteries of the lower extremities in 42 (3.04%) of patients. While application of 76% solution of triombrast and further elastic compression in 83.3% observations a good result was achieved, in 16.7%--satisfactory.

[Role of the small intestinal decompression tube and Gastrografin in the treatment of early postoperative inflammatory small bowel obstruction]

OBJECTIVE

To evaluate the role of the small intestinal decompression tube (SIDT) and Gastrografin in the treatment of early postoperative inflammatory small bowel obstruction (EPISBO).

METHODS

Twelve patients presented EPISBO after abdominal surgery in our department from April 2011 to July 2012. Initially, nasogastric tube decompression and other conventional conservative treatment were administrated. After 14 days, obstruction symptom improvement was not obvious, then the SIDT was used. At the same time, Gastrografin was injected into the small bowel through the SIDT in order to demonstrate the site of obstruction of small bowel and its efficacy.

RESULTS

In 11 patients after this management, obstruction symptoms disappeared, bowel function recovered within 3 weeks, and oral feeding occurred gradually. Another patient did not pass flatus after 4 weeks and was reoperated. After postoperative follow-up of 6 months, no case relapsed with intestinal obstruction.

CONCLUSION

For severe and long course of early postoperative inflammatory intestinal obstruction, intestinal decompression tube plus Gastrografin is safe and effective, and can avoid unnecessary reoperation.

Long-term Taenia saginata infection successfully treated with meglumine/diatrizoate sodium

A 46-year-old Japanese man visited our hospital for chronic abdominal pain, persistent diarrhea and discharge of proglottids for 7 years. He had been living in Lao People's Democratic Republic. Ileography using meglumine/diatrizoate sodium (Gastrografin) revealed a long tapeworm. A Taenia saginata including the scolex was excreted through the intestinal tract by the administration of total 780 ml of Gastrografin. Taeniasis is an important disease in the differential diagnosis of imported diseases in Japan. Parasite infection should be suspected in patients with chronic abdominal pain or persistent diarrhea regardless of the findings for small bowel obstruction when there is a history of overseas travel.

Comparison of Urografin Versus Standard Therapy in Postoperative Small Bowel Obstruction

Water-soluble contrast media (Urografin) cause redistribution of intravascular and extracellular fluid into intestinal lumen due to their hyperosmolarity. As a consequence, these media decrease intestinal wall edema and act as a direct stimulant to intestinal peristalsis. In this prospective study, we aimed to examine objectively the therapeutic role and ability of Urografin in patients with postoperative small bowel obstruction for whom failed to respond to conservative treatment. Three hundred and seventeen patients with postoperative small bowel obstruction due to intraperitoneal adhesions were included prospectively in this study. In the Urografin group, 40 mL Urografin diluted in 40 mL distilled water was administered through the nasogastric tube. No contrast media were administered in the control group, but the patients were decompressed via a nasogastric tube continuously. The number of obstruction episode in 317 patients was 338. In total, 199 patients were in the Urografin group, and 118 patients were in the control group. In the Urografin group, 178 (89.4%) patients responded successfully to the treatment, but 21 (11.6%) patients underwent surgical operation. Intensive intraabdominal adhesions and obstructing fibrous bands were observed and repaired in 15 (71.4%) patients at the operation, while 6 patients underwent segmental small intestine resection in control group, conventional management was successful in only 89 (75.4%) patients, and the remaining 29 (24.6%) patients underwent surgical intervention. In conclusion, it was suggested that in patients with intestinal obstruction due to postoperative intra-abdominal adhesion, water-soluble contrast media such as Urografin may be safely administered via a nasogastric tube or oral route and may decrease the need for surgical operation; furthermore, they may help the physician to operate the patients who needs surgery as early as possible.

Radiographic reduction of intussusception in patients with cystic fibrosis

Cystic fibrosis (CF) is a genetic disorder affecting approximately one in 2,500 births in the United States. Nearly 1% of patients with CF will develop intussusception, which is commonly ileocecal and felt to be secondary to inspissated feces. These patients generally present before the age of ten. Once the diagnosis of intussusception is confirmed on ultrasound or CT, surgery has been the mainstay of treatment in this patient group. We propose the use of air and contrast enemas as effective and beneficial non-operative approach in these patients. Clinical and imaging findings in four children with known CF who presented with intestinal intussusception, average age 13.25 +/- 5.3 years (range 8-18 years) were reviewed. Patients were diagnosed using ultrasound (n = 3) or abdominal CT (n = 1). All patients suffered from an ileocolic intussusception. Air and Gastrografin(R) enemas were used in an attempt to reduce the intussusception. There were six separate successful intussusception reductions in four patients. Three patients required multiple attempts (2.3 +/- 0.6). Air enemas were used initially in all cases. Gastrografin(R) was used successfully following the failure of air enema in one patient. One patient suffered three separate intussusceptions over a period of 18 months, which were all successfully reduced using air. There were no complications and the patients tolerated the procedure well. Intussusception is an uncommon but serious complication in children with CF. While surgical reduction has been the mainstay of treatment for these patients, we demonstrated that reduction of an intussusception using air or contrast can be accomplished safely, without anesthesia, and should be the initial treatment option.

Gastrograffin use in distal intestinal obstruction syndrome of cystic fibrosis

BACKGROUND

Meconium ileus equivalent or the Distal Intestinal Obstruction Syndrome (DIOS) is an entity that is frequently seen in patients with cystic fibrosis (CF). In the gastrointestinal tract cystic fibrosis may produces symptoms of malabsorption and constipation. The latter may be associated with complications such as impaction and intestinal perforation. Meconium ileus and DIOS are an emergency and requires to be treated aggressively to ensure that consequences such as perforation do not occur.

METHOD

Traditional modes of management of DIOS have included the use of laxatives, Acetylcysteine and Gastrograffin enemas. We are describing the use of oral gastrograffin in our patient seen at the Aga Khan University Hospital where small bowel obstruction was refractory to treatment. Oral gastrograffin was used once diluted in 4 times the volume of water or fruit juice with half doses given on day 2 and 3.

RESULTS

Oral gastrograffin use was followed by relief of obstruction in this patient.

CONCLUSION

Gastrograffin use orally or rectally may be helpful in the treatment of refractions distal intestinal obstruction syndrome in cystic fibrosis.

Peroperative Gastrograffin bowel lavage in gastroschisis

AIMS

The aim of the study was to evaluate potential benefits in the use of peroperative bowel lavage with Gastrograffin in neonates with gastroschisis.

METHODS

A retrospective analysis of newborns with gastroschisis was performed over a 10-year period in 2 centers in the United Kingdom. Two groups were studied wherein one had peroperative bowel lavage with Gastrograffin and the other did not.

RESULTS

Data were collected on 116 patients of whom 93 were suitable for analysis. There were no statistically significant differences in primary closure rate, duration of ventilation, parenteral nutrition, or hospital stay. Intestinal obstruction occurred more frequently in the nonlavage group.

CONCLUSION

Gastrograffin lavage peroperatively in gastroschisis offers no potential advantage in reducing ventilatory requirements, parenteral nutrition, and hospital stay. It also does not achieve greater primary closure rates, but may reduce the incidence of intestinal obstruction.

Clinical outcome of cystic fibrosis presenting with or without meconium ileus: a matched cohort study

OBJECTIVE

This matched case-control study compared the nutritional and the pulmonary long-term outcomes of cystic fibrosis (CF) patients presenting a history of meconium ileus (MI) with early-diagnosed symptomatic CF without MI (non-MI).

MATERIAL AND METHOD

Twenty-six patients with CF treated for MI between 1980 and 1997 have been matched for sex, birth date, and earliest CF symptomatic diagnosis for the children with non-MI CF. Clinical characteristics, genotype and complications were evaluated as well as the progression of the CF disease from infancy to 15 years old by nutritional status (z score weight, z score height), pulmonary function tests (PFTs) (FVC and FEV1), and Pseudomonas aeruginosa acquisition.

RESULTS

Median duration of the follow-up was 12.5 years (range, 10-17 years). Genotype identification showed no significant difference. Further on, the rate of complications and the occurrence of chronic P. aeruginosa colonization did not differ. At age of 15 years (n = 13), nutritional status and PFTs did not demonstrate any significant difference.

CONCLUSION

These results suggest that adequate initial nutritional and medical management of MI allows further similar nutritional status and PFTs compared with other early-diagnosed symptomatic CF patients. In this study, MI did not represent an additional risk factor for the patient's life.

Prospective Evaluation of Oral Gastrografin in Postoperative Small Bowel Obstruction

BACKGROUND

Orally administered gastrografin has been used for early resolution of postoperative small bowel obstruction (POSBO) and to reduce the need for surgery in various studies. However the studies have reported conflicting results as patients with complete obstruction and equivocal diagnosis of bowel strangulation were also included.

PATIENTS AND METHODS

We carried out a prospective study to evaluate the efficacy of gastrografin in patients with partial adhesive small bowel obstruction. Patients with suspected strangulation, complete obstruction, obstructed hernia, bowel malignancy, and radiation enteritis were excluded. Sixty-two patients with partial adhesive small bowel obstruction were given an initial trial of conservative management of 48 h. Thirty-eight patients improved within 48 h and the other 24 were given 100 ml of undiluted gastrografin through the nasogastric tube. In 22 patients the contrast reached the colon within 24 h. In the remaining two patients the contrast failed to reach the colon and these underwent surgery.

RESULTS

The use of gastrografin avoided surgical intervention in 91.3% (22 of 24) patients who failed conservative management of POSBO. Gastrografin also decreased the overall requirement for surgical management of POSBO from the reported rate of 25 to 30% to 3.2% (2 of 62).

CONCLUSION

Use of gastrografin in patients with partial POSBO helps in resolution of symptoms and avoids the need for surgical management in the majority of patients.

Experience with management of anterior abdominal wall defects using bovine pericard

During 5 years from 1999 until 2003, our experience with 29 (100%) neonates managed for anterior abdominal wall defects is presented. Twenty-one (72%) neonates presented with gastroschisis and 8 (28%) neonates with giant omphaloceles. The male:female ratio was almost equal in gastroschisis (1:1) while a male predominance was observed in omphaloceles (6:1). A primary closure of the defect was possible in 5 (17%) cases and a single patch along with skin closure was achieved in a further 9 (31%) cases. In 15 (52%) neonates the defect was large and two patches were employed to sufficiently cover the defect. All patients (97%), except one (mortality due to extreme prematurity), were managed successfully. Depending upon the size of the defect and the metabolic condition of the neonate, the defect closure was completed after a mean of 85.7 days. Special protocols were created to manage the bovine pericard patches, which behaved differently to lyophilized dura patches previously used at our center. Integration of the patches was successful in 28 (97%) neonates; however, one neonate with gastroschisis presented significant challenges in the management. Bovine pericard patches are optimal biomaterials for the closure of anterior abdominal wall defects in gastroschisis and omphaloceles.

Randomized controlled trial of Gastrografin in adhesive small bowel obstruction

BACKGROUND

Several previous studies have shown that Gastrografin can be utilized to triage patients with adhesive small bowel obstruction (ASBO) to an operative or a non-operative course. Previous studies assessing the therapeutic effect of Gastrografin have been confounded by post-administration radiology alerting the physician to the treatment group of the patient. Therefore the aim of the present paper was to test the hypothesis that Gastrografin hastens the non-operative resolution of (ASBO).

METHODS

Patients, diagnosed with ASBO on clinical and radiological grounds, were randomized to receive Gastrografin or placebo in a double-blinded fashion. Patients did not undergo further radiological investigation. If the patient required subsequent radiological intervention or surgical intervention they were excluded from the study. End-points were passage of time to resolution of ASBO (flatus and bowel motion), length of hospital stay and complications.

RESULTS

Forty-five patients with ASBO were randomized to receive either Gastrografin or placebo. Two patients were excluded due to protocol violations. Four patients in each group required surgery. Eighteen of the remaining patients received Gastrografin and 17 received placebo. Patients who received Gastrografin had complete resolution of their ASBO significantly earlier than placebo patients (12 vs 21 h, P = 0.009) and this translated into a median of a 1-day saving in time in hospital (3 vs 4 days, P = 0.03).

CONCLUSIONS

Gastrografin accelerates resolution of ASBO by a specific therapeutic effect.

[Estimation of cardiac output from dynamic contrast multispiral tomographic data]

OBJECTIVE

To describe and apply a method for programmatically calculating central hemodynamic parameters from the data of dynamic contrast X-ray computed tomography (CT).

MATERIAL AND METHODS

A procedure is proposed to calculate cardiac output (CO) on the basis of the tracer dilution method as a ratio of the injected dose of a contrast agent (Urografin, Shering AG, Austria) to the area under the concentration-time curve derived for one of the cardiac chambers: [see text]. The blood concentration of the agent was estimated from the blood iodine (I) concentration-X-ray density (XD) regression dependence: [XD] = 0.49+22.07 x [I]. Thirty-three patients were studied on a multispiral X-ray Somatom Sensation 4 computed tomograph (Siemens), by injecting 15-20 ml of Urografin. The calculating method was realized as a software package for processing dynamic contrast CT data.

RESULTS

The proposed method could exactly determine the values of cardiac output: the correlation with the results of the reference technique (Doppler echo measurement) was highly significant (r = 0.95; p < 0.001) in the whole range of values. Moreover, the data on XD could accurately determine the blood concentration of both iodine (I): [XD] = 0.49+22.07 x [I] and gadolinium as a component of the contrast paramagnetic Gd-DTPA for which the solution concentration-XR dependence was as follows: XD 1.2+33.6 x [Gd].

CONCLUSIONS

Thus, dynamic spiral CT may be also used for the estimation of cardiac output by the tracer dilution method.

Value of gastrografin in adhesive small bowel obstruction after unsuccessful conservative treatment: A prospective evaluation

AIM: Gastrografin is a hyperosmolar water-soluble contrast medium. Besides its predictive value for the need for operative treatment, a potential therapeutic role of this agent in adhesive small bowel obstruction has been suggested. This study aimed at evaluating the effectiveness of gastrografin in adhesive small bowel obstruction when conservative treatment failed.

METHODS: Patients with adhesive small bowel obstruction were given trial conservative treatment unless there was fear of bowel strangulation. Those responded in the initial 48 h had conservative treatment continued. Patients who showed no improvement in the initial 48 h were given 100 mL of gastrografin through nasogastric tube followed by serial abdominal radiographs. Patients with the contrast appeared in large bowel within 24 h were regarded as having partial obstruction and conservative treatment was continued. Patients in which the contrast failed to reach large bowel within 24 h were considered to have complete obstruction and laparotomy was performed.

RESULTS: Two hundred and twelve patients with 245 episodes of adhesive obstruction were included. Fifteen patients were operated on soon after admission due to fear of strangulation. One hundred and eighty-six episodes of obstruction showed improvement in the initial 48 h and conservative treatment was continued. Two patients had subsequent operations because of persistent obstruction. Forty-four episodes of obstruction showed no improvement within 48 h and gastrografin was administered. Seven patients underwent complete obstruction surgery. Partial obstruction was demonstrated in 37 other cases, obstruction resolved subsequently in all of them except one patient who required laparotomy because of persistent obstruction. The overall operative rate in this study was 10%. There was no complication that could be attributed to the use of gastrografin.

CONCLUSION: The use of gastrografin in adhesive small bowel obstruction after unsuccessful conservative treatment is safe and reduces the need for surgical intervention.

Oral contrast medium in PET/CT: should you or shouldn’t you?

PURPOSE

It has been suggested that the use of computed tomography (CT) positive contrast agents has led to attenuation-induced artefacts on 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT) systems. Consequently, centres may withhold the use of such agents. Whilst there is theoretical evidence to support the aforementioned claim, the clinical relevance of the induced artefacts has not been widely established. Moreover, the potential benefits of bowel enhancement on PET/CT have yet to be formally evaluated. We therefore prospectively examined PET/CT studies to assess whether the use of oral contrast medium induces clinically relevant artefacts and whether the use of these agents is diagnostically helpful.

METHODS

Over a 2-month period, 18F-FDG PET/CT images were prospectively reviewed from 200 patients following Gastrografin administration 2 h prior to examination. Both a radiologist and a nuclear medicine physician reviewed the images for contrast medium-mediated clinically relevant artefacts. Artefacts were sought on the CT attenuation-corrected images and were compared with the appearance on non-attenuated-corrected images. The number of examinations in which the oral contrast aided image interpretation was also noted.

RESULTS

There were no oral contrast medium-induced clinically significant artefacts. In 38 of the 200 patients, oral contrast aided image interpretation (owing to differentiation of mass/node from bowel, discrimination of intestinal wall from lumen or definition of the anatomy of a relevant site). In 33 of these 38 patients, the anatomical site of interest was the abdomen/pelvis.

CONCLUSION

The use of oral contrast medium in 18F-FDG PET studies should not be withheld as it improves image interpretation and does not produce clinically significant artefacts.

Oil-soluble contrast during hysterosalpingography in women with proven tubal patency

To determine if there are therapeutic advantages to oil-soluble contrast medium compared with water-soluble medium during hysterosalpingography.A randomized, controlled trial including 56 infertile patients undergoing hysterosalpingography was performed. After a hysterosalpingogram with water-soluble contrast demonstrated tubal patency, 30 patients were randomized to receive oil-soluble contrast medium (oil group) and 26 patients received no additional contrast medium (control group). The outcome was pregnancy and timing of pregnancy in relation to hysterosalpingography. There were 18 (64%) pregnancies in the oil group and 14 (56%) pregnancies in the control group. Mean time to achieve pregnancy was shorter in the oil group: 3.8 months in the oil group compared with 6.1 months in the control group (P =.06) There was a clinically meaningful improvement in pregnancy rates between the oil group and the control group at 1 month postprocedure (relative risk [RR] 2.1, 95% confidence interval [CI] 0.6, 7.2). However, at 12 months postprocedure, the advantage was diminished. (RR 1.3, CI 0.8, 2.1)Eighteen months after hysterosalpingography, contrast does not appear to influence cumulative pregnancy rates; however, the addition of oil-soluble contrast medium to water-soluble contrast medium may have the potential to reduce the time to conception.

Gastrografin administration in the treatment of postoperative delayed gastric emptying

Five cases of delayed gastric emptying (DGE) are reported. Three patients had pancreatic head carcinoma and underwent a Whipple operation during which truncal vagotomy and gastrectomy were performed. The remaining two patients underwent vagotomy and gastrectomy because of benign peptic ulcer. In one of the pancreatectomy cases, the pylorus was at first preserved, but after DGE developed, a gastrectomy was carried out, which did not result in any improvement. The duration of DGE was 16-72 days, during which time the patients were under total parenteral or enteral nutrition. There were no other major complications. The patients received prokinetic agents (metoclopramide, erythromycin) but without any improvement. Finally, all patients were treated with Gastrografin, 40 ml every two hours, via a nasogastric tube. In all cases, gastric motility was restored within 20-36 hours.

Preoperative bowel preparation with meglumine and sodium diatrizoate (Gastrografin): a prospective randomised comparison

OBJECTIVE

To test the use of meglumine and sodium diatrizoate (Gastrografin) as an agent for preoperative mechanical bowel preparation.

DESIGN

Prospective randomised comparison.

SETTING

County general hospital, Greece.

SUBJECTS

58 patients listed for elective colorectal operations were randomly divided into 2 groups. The first (n = 30) was given Gastrografin 200 ml orally for 2 consecutive days before operation, and the second (n = 28) was given Ringer's solution through a nasogastric tube.

MAIN OUTCOME MEASURES

Tolerability, acceptability, quality of cleansing, and complications.

RESULTS

There were no disturbances in electrolyte concentrations, and other laboratory variables also remained unchanged. Two patients treated with Ringer's solution had appreciable increases in arterial blood pressure, but there were no significant overall changes. About half the patients given Ringer's felt nauseated and a third vomited. Such symptoms were uncommon in patients treated with Gastrografin (p < 0.01). 28/30 and 26/28 (93%) had a clean colonic lumen at operation, whereas in the reminder the lumen was evaluated as containing "slight residue". There were no operation-related complications.

CONCLUSIONS

Gastrografin can be used successfully as an agent for mechanical bowel preparation before elective colorectal surgery, as it gives equally good cleansing results compared with the established method of whole gut irrigation. It also seems to be better tolerated and accepted by patients.

Potential therapeutic effects of contrast materials in hysterosalpingography: a prospective randomized clinical trial. Kaiser Permanente Infertility Work Group

PURPOSE

To evaluate the influence of the contrast material used in hysterosalpingography (HSG) on subsequent reproductive success, independent of other therapeutic interventions.

MATERIALS AND METHODS

In a prospective, multisite, randomized trial, 666 women who had been infertile for more than 1 year and were scheduled to undergo HSG as part of their evaluation were assigned to one of three groups: those receiving water-soluble contrast material (WSCM) (n = 260), those receiving oil-soluble contrast material (OSCM) (n = 273), and those receiving both OSCM and WSCM (n = 133). Possible causes of infertility and therapeutic interventions were abstracted from the medical records. Data on conception within 1 year and the outcome of conception were ascertained from multiple sources.

RESULTS

Of 666 women, 204 (30.6%) had at least one pregnancy, and 136 (20.4%) had live births. The rates of live births were 20.4% (54 of 260) after HSG with WSCM, 19.4% (53 of 273) after HSG with OSCM, and 21.8% (29 of 133) after HSG with both WSCM and OSCM. Differences in reproductive outcome among contrast material groups were not statistically significant ((chi2)8 = 6.08, P = .64). Whatever the cause of infertility, the use of different contrast materials led to no significant differences in the rates of live births.

CONCLUSION

There is no evidence to suggest that the choice of contrast material affects the rate of term pregnancy.

Meconium ileus: a ten-year review of thirty-six patients

Of 36 neonates with meconium ileus secondary to cystic fibrosis treated over a 10-year period, twenty-one (58%) had simple uncomplicated disease while fifteen (42%) had complications which included perforation (5), volvulus (6) and atresia (5). Gastrografin enema was employed in 20 infants with relief of obstruction in 8 (40%). Operative procedures consisted of resection and primary anastomosis in seventeen patients, stomas were fashioned in six, three had an enterotomy with irrigation only and two had Bishop-Koop enterostomy. Post-operative complications developed in 5 (18%) of these 28 patients. The overall survival rate was 97%. The one death occurred in an infant with short bowel syndrome, patent ductus arteriosus, hydrocephalus and pulmonary damage. There were eight additional patients who had meconium obstruction in the absence of cystic fibrosis.

[Gastrografin for mechanical partial, small bowel obstruction due to adhesions]

The therapeutic effect of gastrografin is occasionally mentioned in the literature. However, this effect has not been objectively evaluated. We studied prospectively the effect of Gastrografin in cases of adhesive, simple, partial, small bowel obstruction (SBO) compared to conventional management. During 3 years, a total of 137 episodes of simple, partial SBO in 127 patients (10 recurrent episodes) were treated. The episodes were randomized into a control group (80 episodes), treated conventionally, and a trial group (77 episodes), which received in addition 100 ml of Gastrografin administered through the nasogastric tube. The two groups were well-matched with regard to age, gender, weight, medical and surgical background and duration of complaints before admission. Time to first stool and resolution of obstruction, complications, need for surgery, and hospital stay were noted. Mean time to first stool was significantly shorter in the trial group: 6.2 +/- 3.9 hours vs 23.5 +/- 12.7 (p < .0001). Mean hospital stay for unoperated patients was also shorter in the trial group: 2.7 +/- 2 days vs 5.5 +/- 2 days, (p < .0001). In addition, significantly fewer episodes in the trial group required operation, 10.4 vs 26.7% (p < 0.013). 1 patient in each group dies following operation. There were no Gastrografin-related complications and it was effective and safe for adhesive, partial, simple SBO. It significantly speeds resolution of obstruction, reduces the need for operation, and shortens convalescence.

[Study on intravascular pressure change during sclerotherapy for cavernous hemangiomas (CHs)]

To investigate the regulation and significance of the intravascular pressure change of cavernous hemangiomas during the treatment of sclerotherapy, we did observations in 29 cases with slowing down the efferent blood flow of the CHs in their treatment. It was found that the baseline intravascular pressure of CHs is 5-15 mmHg, the lowest being at the neck. The efferent rate of CHs is higher than the afferent rate. The higher the efferent rate, the more times of injection and more amount of thrombotic agent were needed. At the beginning of the thrombosis, the CHs pressure rose gradually to a flat curve, which suggested that the efferent veins were being thrombosed one by one. Then the CHs pressure curve became a blunt peak, which suggested that all the efferent veins were thrombosed and it was time to inject the sclerosing agent. Finally the CHs pressure curve became a sharp peak, suggesting that the whole CHs was thrombosed and sclerosed. Follow-up from 6 months to 3 years revealed that CHs disappeared in 26 of 29 cases, recurred in 3 cases. No severe complications were found. The authors concluded that the treatment can improve the curative effect and decrease complications.

Is it necrotizing enterocolitis, microcolon of prematurity, or delayed meconium plug? A dilemma in the tiny premature infant

Failure of a small premature newborn to adequately evacuate meconium for days or weeks has been attributed to "probable necrotizing enterocolitis (NEC)" or "microcolon of prematurity." The authors present an unusual type of "meconium plug syndrome" with the same clinical picture, seen in tiny premature babies (500 to 1,500 g), which required a contrast enema or Gastrografin upper gastrointestinal (UGI) series to evacuate the plugs. The obstruction resolved. Twenty babies (480 to 1,500 g) presented with the same clinical picture without any x-ray suggestion of NEC; contrast enemas were performed because of the suspicion of meconium plug syndrome. All 20 had extensive meconium plugs that were evacuated by the enema or by a Gastrografin UGI series. Most of them improved after the plugs were passed. These infants differ from typical full-term babies with meconium plug syndrome in a number of ways: (1) many of the mothers were on magnesium sulfate (MgSO4) or had eclampsia; (2) the plugs were diagnosed late rather than shortly after birth; and (3) the plugs were significant, extending to the right colon. The authors believe that when a tiny premature baby has findings consistent with meconium plug syndrome, the baby should be transported to radiology, for a Gastrografin enema, despite the difficulties involved. Delay postpones the start of feedings, and increases the number of radiographic studies.

Therapeutic effect of oral Gastrografin in adhesive, partial small-bowel obstruction: a prospective randomized trial

BACKGROUND

Previous published clinical observations claim that Gastrografin, a hyperosmolar gastrointestinal water-soluble contrast agent, speeds the resolution of postoperative ileus, barium impaction ileus, adhesive small-bowel obstruction, and intestinal obstruction caused by parasites and bezoars. However, no objective data exist that support the therapeutic effects of Gastrografin in these situations.

METHODS

A total of 107 episodes of adhesive, partial small-bowel obstruction in 99 patients were randomized into a control group (48 episodes), who were treated with conventional methods, and a trial group (59 episodes), who were treated with 100 ml of Gastrografin administered through the nasogastric tube. The following variables were examined: time to resolution of partial small-bowel obstruction, the need for operation, complications, and hospital stay.

RESULTS

Mean timing of the first stool was 23.3 hours in the control group and 6.2 hours in the patients receiving Gastrografin (p < 0.00001). Ten obstructive episodes (21%) in the control group required operative treatment compared with six (10%) in the trial group (p = 0.12). Mean hospital stay for the patients who responded to conservative treatment was 4.4 days and 2.2 days in the control and trial groups, respectively (p < 0.00001). One patient in each group died after operation. No Gastrografin-related complications were observed.

CONCLUSIONS

Orally administered Gastrografin is safe and has a therapeutic role in adhesive, partial small-bowel obstruction. It significantly prompts the resolution of the obstructive episodes and shortens hospital stay. However, further studies are necessary to confirm the significance of our observation that it may reduce the need for operation.

Meconium ileus-like condition in Chinese neonates

Between January 1985 and May 1990, 16 neonates were treated for meconium ileus (MI) at this hospital. All babies were born to Chinese couples. Seven of them were premature, but none of them weighed less than 1,000 g. Eight patients underwent operations either because of mistaken diagnosis, as ileal atresia or long-segment Hirschsprung's disease, or because of complicated MI, including two meconium peritonitis and one associated with ileal atresia. Gastrograffin enema was successful in management of eight uncomplicated MI. The albumin content in the meconium of the last nine cases, including four complicated cases, ranged from 9.2 to 93.3 mg/g dry meconium. Usually, albumin is not present in normal meconium. All cases received sweat test, which were negative. Three patients died in the follow-up period. Sepsis of unknown origin, multiple congenital anomalies, and severe metabolic problems were the causes of death. The other 13 patients are doing well. They have exhibited no pulmonary or digestive problems during their follow-up period, which ranged from 11 months to 5 years. They are healthy and receive regular diets. Growth and development are appropriate for their age groups.

CT monitoring of therapy for meconium ileus

Meconium ileus equivalent is a common complication of cystic fibrosis in the postneonatal period. Because of the added risks of surgery in these patients, conservative management is preferred. We describe here a method of monitoring the conservative treatment of this condition using CT and suggest that its application will reduce the need for potentially dangerous surgical intervention.

[Treatment of sudden deafness: our experience]

The sudden deafness is a common pathology with unilateral affectation and unknown etiology. Nowadays, the treatment is not completely clarified. We compare a urografin-CO2 treatment with CO2 as a single therapy.

Intussusception: hydrostatic pressure equivalents for barium and meglumine sodium diatrizoate

The pressures generated by a barium suspension and various solutions of meglumine sodium diatrizoate in water were measured with a manometer. A pressure of 120 mm Hg was produced by a 3.5-foot (105-cm) column of 60% wt/vol barium and a 5-foot (150-cm) column of either a 1:3 or 1:4 solution of meglumine sodium diatrizoate and water. This is the pressure used to reduce an intussusception with air.

[Intraarterial chemotherapy of experimentally metastasized liver carcinoma with anticancer emulsion containing surface-active agent]

The w/o Emulsion (w/o) of 0.3% adriamycin (ADR) in the mixture of a water-soluble contrast medium, 60% urografin, and an oily contrast medium, lipiodol, at the ratio of 1 : 4 was combined with 0.5% lecithin. This combination could stabilize the micelles and make the emulsion desirably slow releasing form. ADR emulsion was injected into the hepatic artery of rabbit with metastatic liver carcinoma 7 days after intraportal transplantation of VX2 tumor. The examination at day 5 revealed good accumulation and retention of ADR in tumor. This emulsion was histologically confirmed to be effective in suppressing the growth of metastatic lesion, and it was considered that this ADR emulsion would have a great possibility for clinical application in the treatment of hepatic metastasis of gastrointestinal carcinomas.

Use of the appendix stump in the treatment of meconium ileus

Three neonates with meconium ileus who failed to respond to non-operative measures were successfully treated by appendicectomy and irrigation with Gastrografin into the small bowel via the appendix stump. The meconium was emptied out and the stump ligated. This method avoids enterotomy, enterostomies or resection of bowel. The post-operative course is simplified and hospital stay decreased. Removal of the appendix precludes future disease of this organ which may be problematic in patients with cystic fibrosis.

Hypaque and steroids in the treatment of sudden sensorineural hearing loss

While the origins of sudden sensorineural hearing loss remain unproven and treatment empirical, the most appropriate therapy remains a matter of controversy. In this paper we have analysed the current forms of treatment, i.e. diatrizoate meglumine, steroids and a vasodilator. The results suggest that although several related factors were shown to indicate a good prognosis regardless of the therapy, none of the currently available regimens produces consistently better results than the spontaneous recovery rate of 65% reported by Mattox & Simmons.

Meconium ileus: a fifteen-year experience with forty-two neonates

From 1969 to 1984, 42 neonates were managed for meconium ileus caused by cystic fibrosis. Simple, uncomplicated meconium ileus occurred in 24 infants (57%) and complicated meconium ileus occurred in 18 (43%). Meglumine diatrizoate (Gastrografin) enema completely relieved the obstruction in 13 patients with simple meconium ileus (54%) and caused colonic and rectal perforations in three (13%). Six operative procedures were used in 29 patients: double enterostomy (seven), resection with primary anastomosis (seven), Bishop-Koop enterostomy (seven), intraluminal lavage (four), colostomy (three), and Mikulicz enterostomy (one). Postoperative complications included malabsorptive diarrhea (nine), pneumonia (three), intestinal obstruction (two), total parenteral nutrition-catheter sepsis (two), and anastomotic leak (one). Infants managed nonoperatively by Gastrografin enema had a significantly shorter hospitalization (average, 15 days) than those undergoing operation for simple meconium ileus (54 days) and complicated meconium ileus (111 days). Postoperative survival rate was 100% with a late survival rate of 86%.

Gastrografin in acute meconium ileus equivalent

Twenty-five (37%) patients with cystic fibrosis attending our clinic have experienced acute meconium ileus equivalent. In one year 37 of 40 episodes were treated with single dose oral Gastrografin with an 81% success rate, 75% being treated as outpatients. Patients found this treatment preferable to other recommended treatment.

Diagnosis and hydrostatic reduction of an intussusception under ultrasound guidance

A case of ileo-colic intussusception with successful hydrostatic reduction under ultrasound guidance is reported. This has not been described previously in the literature.

[Clinical study on the use of urografin in the treatment of sudden deafness. Necessary preliminary study, results and review]

We treated 33 patients with a sudden hearing loss with Natrium - Meglumine-diatrizoat (Urografin) when all other standard therapy had failed. Detailed investigations were carried out, and thorough measures were taken against anaphylactic reactions before and during the intravenous administration of Urografin. In 10 cases (30%) an improvement of hearing of at least 20 dB was observed with restitution of almost normal hearing in some cases. The treatment was most successful in those cases where an excessive hearing loss (more than 40 dB) occurred for the first time. Since the drug is only intended for diagnostic use, further use as a therapeutic agent will require legal endorsement.

Method for ejecting cestodes: duodenal tube injection of gastrografin

Most of the conventional anthelmintics for cestodiasis are known to destroy the worm body. The risk of cysticercosis and recurrence of cestodiasis will be avoided only if tapeworms are ejected with intact bodies and scoleces . Two cases with Diphyllobothrium latum and two with Taenia saginata were treated by administration of 200-300 ml of Gastrografin through a duodenal tube. The worm bodies were confirmed by fluoroscopy, and the expelled worms were alive and had intact scoleces . No adverse effects were noted in the patients during or after the treatment.

Gastrografin treatment of intestinal obstruction due to Ascaris lumbricoides

Gastrografin was used to relieve subacute intestinal obstruction due to Ascaris lumbricoides in children. This hyperosmolar and wetting agent proved to be highly efficient to achieve this goal. Statistical evaluation of the hospital stay and first bowel action showed a significant difference between the treated "gastrografin group' and the untreated by gastrografin "control group,' in favor of the "gastrografin group.' Our data strongly suggest the use of Gastrografin in subacute intestinal obstruction due to Ascaris lumbricoides. This treatment should be instituted provided the patient has been adequately hydrated prior to administration.

Pediatric urography: comparison of metrizamide and methylglucamine diatrizoate

A non-ionic contrast medium (metrizamide) was compared to an ionic agent (methylglucamine diatrizoate) for pediatric urography. Fifty children were divided into two age groups: under 5, and 5 to 10. In younger children, metrizamide gave more excellent images (19% vs. 0%) and fewer inadequate images (0% vs. 18%) than methylglucamine diatrizoate (p = 0.06). In older children, metrizamide likewise gave more excellent images (44% vs. 14%) and fewer inadequate images (0% vs. 7%). The same pattern was seen when the two groups were combined (excellent, 28% vs. 8%; inadequate, 0% vs. 12%) (p = 0.05). Differences with respect to changes in hematocrit, serum osmolality, serum sodium, and SGOT were statistically significant, but not adverse reactions. In terms of both efficacy and safety, the authors conclude that metrizamide is preferred for pediatric urography.