Guidelines for the Use of Gastrografin in Small Bowel Obstruction (SBO) for Diagnosis/Treatment

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Small bowel obstruction (SBO) is a common indication for admission to the hospital from the emergency department (ED), and most patients have a CT scan performed in the ED for diagnosis. The Acute Care Surgery team is then consulted for evaluation to determine need for admission and optimal treatment (medical with nasogastric decompression and IV hydration vs. surgical exploration).

The diagnostic and therapeutic role of hyperosmolar water-soluble contrast agents in small bowel obstruction has been investigated in many studies. A recent systematic review and meta-analysis confirmed that the administration of water-soluble contrast agent with serial radiographs is accurate in predicting the need for surgery, and also reduced the need for surgery and reduced hospital length of stay and time to SBO resolution ¹

We have established the following protocol to standardize the use of this diagnostic/therapeutic test:

Inclusion Criteria:

• Patients with partial SBO (not complete SBO) confirmed on CT scan imaging
• No evidence of perforation and no signs of sepsis, strangulation or peritonitis
• No evidence of infectious abdominal process, cancer, incarcerated hernia
• No pregnancy, history of pelvic radiation, abdominal surgery within 6 week.

Protocol for Administration:

• All SBO patients will have nasogastric tube placement and decompression for 12 hours
• Patients without aspiration risk factors (paraesophageal hernia, hiatal hernia, COPD, home oxygen) will undergo the Gastrografin Challenge test:
• Gastrografin (100 ml, diluted 50 ml water) will be administered via the nasogastric tube
• The nasogastric tube will be clamped for 1 hour after gastrografin administration
• If patient develops nausea or increasing abdominal pain, NGT will be placed to suction

Protocol for “Gastrografin Challenge” Radiologic Examinations:·

• Plain abdominal radiograph will be obtained 8 hours after Gastrografin administration.
• If enteral contrast is visualized in the colon at 8 hours, no additional radiographs will be obtained and conservative management of SBO will be continued
• If enteral contrast is not visualized in the colon at 8 hours, additional plain abdominal radiograph will be obtained at 24 hours after Gastrografin administration.
• If enteral contrast is not visualized in the colon at 24 hours, surgical intervention for SBO will be strongly considered by hospital day 5

In the absence of clinical signs of deterioration, recent practice guidelines recommend limiting non-operative therapy to periods between 3-5 days. ^{2 3} One study found an increased incidence of death and prolonged LOS if surgery is delayed for > 4 days. ⁴ Some studies document an increased rate of small bowel resection with longer non-operative management. ⁵ In contrast, another study reported that the average time to SBO resolution is 6.9 days, but can take up to 12 days. If a 5-day-cutoff was used as the trigger for surgery for SBO, 141 of the 220 patients who eventually had spontaneous resolution of SBO would have had unnecessary surgery. ⁶ There is significant controversy over the duration of non-operative management of SBO, but use of the Gastrografin protocol can assist in determination of which patients may not require surgery for SBO. ⁷

A failed test (no contrast in colon) should result in consideration of operation based on clinical judgement.