Whole bowel irrigation
Encyclopedia
Whole bowel irrigation is a medical process involving the rapid administration of large volumes of an osmotically
balanced polyethylene glycol
solution (GoLYTELY, CoLyte), either orally or via a nasogastric tube, to flush out the entire gastrointestinal tract
.
or colonoscopy
. Initially a solution of sodium chloride
, potassium chloride
, and sodium bicarbonate
was used but this electrolyte
solution was shown to be absorbed by the body, sometimes leading to complications. To solve this problem a specialized irrigation fluid was developed consisting mainly of an iso-osmolar solution of polyethylene glycol
. With the polyethylene glycol solution there is negligible fluid or electrolyte absorption and several studies have shown the overall safety of the procedure. Whole bowel irrigation was also suggested as a possible treatment for toxic ingestions. WBI has the effect of mechanically flushing the ingested poison
out of the gastrointestinal tract before it can be absorbed into the body. A study provided evidence that whole bowel irrigation is an effective and safe gastrointestinal decontamination procedure for acute poisoning.
. The solution is administered at a rate of 500 mL/h in children 9 months to 6 years, 1000 mL/h in children 6 to 12 years, and 1500 to 2000 mL/h in adolescents and adults. The patient is usually seated on a toilet and the procedure continues until the rectal effluent is clear. The entire procedure usually takes 4 to 6 hours. Often patients vomit (especially if ipecac
was given prior to the procedure or following ingestion of a drug that produces vomiting such as aspirin
or theophylline
), indicating that the rate of infusion may need to be slowed or an antiemetic
such as metoclopramide
given.
to cleanse the bowel. Whole bowel irrigation is not used routinely in poisoning situations. It is usually reserved for patients who have ingested toxic doses of medications not absorbed by activated charcoal (such as iron
and lithium
), potentially toxic ingestions of sustained-release or enteric-coated drugs, or in the situation of packaged drug ingestion (body packing/stuffing
).
in the presence of ileus
, significant gastrointestinal hemorrhage, hemodynamic instability, uncontrollable intractable vomiting, bowel obstruction, bowel perforation, and in patients with a decreased level of consciousness with a compromised unprotected airway.
, vomiting
, abdominal cramps, and bloating
. Patients with altered mental status or a compromised and unprotected airway are at risk for pulmonary aspiration
.
Osmoregulation
Osmoregulation is the active regulation of the osmotic pressure of an organism's fluids to maintain the homeostasis of the organism's water content; that is it keeps the organism's fluids from becoming too diluted or too concentrated. Osmotic pressure is a measure of the tendency of water to move...
balanced polyethylene glycol
Polyethylene glycol
Polyethylene glycol is a polyether compound with many applications from industrial manufacturing to medicine. It has also been known as polyethylene oxide or polyoxyethylene , depending on its molecular weight, and under the tradename Carbowax.-Available forms:PEG, PEO, or POE refers to an...
solution (GoLYTELY, CoLyte), either orally or via a nasogastric tube, to flush out the entire gastrointestinal tract
Gastrointestinal tract
The human gastrointestinal tract refers to the stomach and intestine, and sometimes to all the structures from the mouth to the anus. ....
.
History
Whole bowel irrigation was originally developed to cleanse the large bowel before surgerySurgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
or colonoscopy
Colonoscopy
Colonoscopy is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It may provide a visual diagnosis and grants the opportunity for biopsy or removal of suspected...
. Initially a solution of sodium chloride
Sodium chloride
Sodium chloride, also known as salt, common salt, table salt or halite, is an inorganic compound with the formula NaCl. Sodium chloride is the salt most responsible for the salinity of the ocean and of the extracellular fluid of many multicellular organisms...
, potassium chloride
Potassium chloride
The chemical compound potassium chloride is a metal halide salt composed of potassium and chlorine. In its pure state, it is odorless and has a white or colorless vitreous crystal appearance, with a crystal structure that cleaves easily in three directions. Potassium chloride crystals are...
, and sodium bicarbonate
Sodium bicarbonate
Sodium bicarbonate or sodium hydrogen carbonate is the chemical compound with the formula Na HCO3. Sodium bicarbonate is a white solid that is crystalline but often appears as a fine powder. It has a slightly salty, alkaline taste resembling that of washing soda . The natural mineral form is...
was used but this electrolyte
Electrolyte
In chemistry, an electrolyte is any substance containing free ions that make the substance electrically conductive. The most typical electrolyte is an ionic solution, but molten electrolytes and solid electrolytes are also possible....
solution was shown to be absorbed by the body, sometimes leading to complications. To solve this problem a specialized irrigation fluid was developed consisting mainly of an iso-osmolar solution of polyethylene glycol
Polyethylene glycol
Polyethylene glycol is a polyether compound with many applications from industrial manufacturing to medicine. It has also been known as polyethylene oxide or polyoxyethylene , depending on its molecular weight, and under the tradename Carbowax.-Available forms:PEG, PEO, or POE refers to an...
. With the polyethylene glycol solution there is negligible fluid or electrolyte absorption and several studies have shown the overall safety of the procedure. Whole bowel irrigation was also suggested as a possible treatment for toxic ingestions. WBI has the effect of mechanically flushing the ingested poison
Poison
In the context of biology, poisons are substances that can cause disturbances to organisms, usually by chemical reaction or other activity on the molecular scale, when a sufficient quantity is absorbed by an organism....
out of the gastrointestinal tract before it can be absorbed into the body. A study provided evidence that whole bowel irrigation is an effective and safe gastrointestinal decontamination procedure for acute poisoning.
Technique
Whole bowel irrigation is undertaken either by having the patient drink the solution or a nasogastric tube is inserted and the solution is delivered down the tube into the stomachStomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
. The solution is administered at a rate of 500 mL/h in children 9 months to 6 years, 1000 mL/h in children 6 to 12 years, and 1500 to 2000 mL/h in adolescents and adults. The patient is usually seated on a toilet and the procedure continues until the rectal effluent is clear. The entire procedure usually takes 4 to 6 hours. Often patients vomit (especially if ipecac
Syrup of ipecac
Syrup of ipecac , commonly referred to as ipecac, is derived from the dried rhizome and roots of the ipecacuanha plant, and is a well known emetic .-Preparation:...
was given prior to the procedure or following ingestion of a drug that produces vomiting such as aspirin
Aspirin
Aspirin , also known as acetylsalicylic acid , is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication. It was discovered by Arthur Eichengrun, a chemist with the German company Bayer...
or theophylline
Theophylline
Theophylline, also known as dimethylxanthine, is a methylxanthine drug used in therapy for respiratory diseases such as COPD and asthma under a variety of brand names. Because of its numerous side-effects, the drug is now rarely administered for clinical use. As a member of the xanthine family, it...
), indicating that the rate of infusion may need to be slowed or an antiemetic
Antiemetic
An antiemetic is a drug that is effective against vomiting and nausea. Antiemetics are typically used to treat motion sickness and the side effects of opioid analgesics, general anaesthetics, and chemotherapy directed against cancer....
such as metoclopramide
Metoclopramide
Metoclopramide is an antiemetic and gastroprokinetic agent. It is commonly used to treat nausea and vomiting, to facilitate gastric emptying in people with gastroparesis, and as a treatment for the gastric stasis often associated with migraine headaches.-Medical uses:Metoclopramide is commonly...
given.
Indications
Whole bowel irrigation is indicated prior to surgery, colonoscopy, or a barium enemaBarium enema
A lower gastrointestinal series, also called a barium enema, is a medical procedure used to examine and diagnose problems with the human colon . X-ray pictures are taken while barium sulfate fills the colon via the rectum.-Procedure:...
to cleanse the bowel. Whole bowel irrigation is not used routinely in poisoning situations. It is usually reserved for patients who have ingested toxic doses of medications not absorbed by activated charcoal (such as iron
Iron
Iron is a chemical element with the symbol Fe and atomic number 26. It is a metal in the first transition series. It is the most common element forming the planet Earth as a whole, forming much of Earth's outer and inner core. It is the fourth most common element in the Earth's crust...
and lithium
Lithium
Lithium is a soft, silver-white metal that belongs to the alkali metal group of chemical elements. It is represented by the symbol Li, and it has the atomic number 3. Under standard conditions it is the lightest metal and the least dense solid element. Like all alkali metals, lithium is highly...
), potentially toxic ingestions of sustained-release or enteric-coated drugs, or in the situation of packaged drug ingestion (body packing/stuffing
Mule (smuggling)
A mule or courier is someone who smuggles something with him or her across a national border, including bringing in to and out of an international plane, especially a small amount, transported for a smuggling organization. The organizers employ mules to reduce the risk of getting caught...
).
Contraindications
Major gastrointestinal dysfunction precludes the use of whole bowel irrigation. WBI is specifically contraindicatedContraindication
In medicine, a contraindication is a condition or factor that serves as a reason to withhold a certain medical treatment.Some contraindications are absolute, meaning that there are no reasonable circumstances for undertaking a course of action...
in the presence of ileus
Ileus
Ileus is a disruption of the normal propulsive ability of the gastrointestinal tract.Ileus is commonly defined simply as bowel obstruction. However, authoritative sources define it as decreased motor activity of the GI tract due to non-mechanical causes...
, significant gastrointestinal hemorrhage, hemodynamic instability, uncontrollable intractable vomiting, bowel obstruction, bowel perforation, and in patients with a decreased level of consciousness with a compromised unprotected airway.
Complications
Minor complications include nauseaNausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...
, vomiting
Vomiting
Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...
, abdominal cramps, and bloating
Bloating
Bloating is any abnormal general swelling, or increase in diameter of the abdominal area. As a symptom, the patient feels a full and tight abdomen, which may cause abdominal pain sometimes accompanied by increased borborygmus or more seriously the total lack of borborygmus.-Symptoms:The most common...
. Patients with altered mental status or a compromised and unprotected airway are at risk for pulmonary aspiration
Pulmonary aspiration
Pulmonary aspiration is the entry of material from the oropharynx or gastrointestinal tract into the larynx and lower respiratory tract...
.