Bowel Washout

Indications

• Babies and children to relieve low intestinal obstruction (e.g. suspected Hirschsprung Disease (HD), meconium plug disease, meconium ileus or intestinal dysmotility).

• Temporary management in proven cases of HD until definitive surgery is performed

• Enterocolitis

• Preoperative preparation for stoma procedures

• Management of constipation

The rationale of bowel washouts is to clean the bowel of stool to prevent “stasis” (failure of stool to empty from the bowel). The rectal washout is done by doing multiple small rectal irrigations. The patient’s rectum and left bowel should be irrigated with warm normal saline solution 10-20 mL flush at a time. If the flush is returned during the irrigation process, then this volume can be repeated. In older children, the incremental irrigations may be 30-50 mLs based on age.

Irrigations of 10-20 mL can continue for an unlimited volume of saline as long as no more than 20 mL/kg of fluid is retained within the child’s bowel for each completed washout procedure as per the example.

Example

Definitions of terms

Meconium plug: Thickened and immobile meconium causes a transient form of distal obstruction
Meconium ileus: Obstruction caused by thick, tenacious meconium which is unable to be propelled through the small intestine. Usually the bowel is not damaged and remains in continuity. It may be associated with volvulus, intestinal atresia or perforation.
Hirschsprung Disease: Always affects the rectum and usually a variable length of distal large bowel. Characterised by the lack of normal development of the nerve supply to the bowel wall (ganglion cells). This prevents effective peristalsis and results in functional obstruction.
Hirschsprung-Associated Enterocolitis (HAEC): Condition of bowel inflammation characterised clinically by fever, abdominal distension, diarrhoea and sepsis.

Assessment of the infant before a washout

Prior to bowel washouts it is essential to assess the infant’s condition and feeding pattern to determine the effectiveness of the previous washout. These findings should be documented in the clinical notes. Any marked changes in condition should be reported to the surgical team.

• Is the abdomen distended, tense or soft?

• Is the baby feeding well?

• Is the baby vomiting? If so, milky or green bile?

• Is the baby stooling between washouts?

• Are the stools normal? Watery? Foul smelling? Bloody?

• Is the baby alert, sleepy or lethargic?

Alert the clinical team if any of the following are present:

• Abdominal distension or tenderness

• Bile vomiting

• Lethargy, poor colour

• Blood in stools

Supplies required

• Nelaton catheter
  *8-10FG for children under 3kg
  *12-14FG for children under one year of age
  *16-20FG for children over one year of age
  (*This is based on child size, this may vary by age, anus size and integrity of the rectum. The larger the lumen the better to allow passing of thick stool through the catheter)

• Hegar dilators
  12 for children over 3kg
  13 for children 4-8 months
  14 for children 8-12 months

• 60 mL catheter tip syringe

• Lubricant (water soluble), such as Surgi-lube or KY jelly (nothing petroleum based)

• Warm saline solution – 10-20 mL/kg to start (this volume can be repeated multiple times until clear as long as no more than 10 mL/kg is left unreturned at any one stage)

• 2 non-sterile containers such as vomit containers

• Incontinence pads or towels to lay under the child

• Consider second staff member or parent to assist

Procedure

To begin:

1. Place bottle of saline into a container of warm – hot water (do not use boiling water)

2. Warm the saline until it is lukewarm

3. Position infants on their back, wrap their upper body to keep them warm. For the older child have them lie on their left side with knees bent towards their chest.

4. Assess the baby as above

5. Pour the saline solution into a container

6. Using a 60 mL catheter tip syringe, draw up 20 mL of the solution attach to catheter and prime with saline

7. Gently insert the appropriate size lubricated Hegar dilator into the rectum for 10 seconds

8. Gently insert the appropriate size lubricated catheter into the rectum and left bowel, approximately 15 centimeters (cm), pushing small amounts of saline to help pass **This distance should be modified for the age and size of the child (a premature newborn for example, might only need 5-10cm)**

9. Allow any stool or gas to run out into the second container

10. Gently advance the catheter further while flushing saline to allow any other “pockets” of stool/gas to empty.
    - If there is resistance to advancing the catheter then stop
    - Sometimes the catheter can be advanced further when instilling the saline

11. Place the catheter tip syringe into the end of the catheter and slowly push in 20 ml of the solution into the rectum. Hold the catheter in place at the level of the anus so it does not fall out.

12. Disconnect the syringe from the end of the catheter; allow the solution to drip into your discard container.
    - Gently slide the catheter in and out slowly allowing pockets of stool/gas to empty
    - The abdomen can also be gently massaged to aid the emptying

13. Repeat this process until the fluid draining from the catheter is clear. With each irrigation, advance the catheter a few centimetres further as able
    - Do not force or advance the catheter further than the coloured hub of the catheter.
    - If gently pushed, the catheter should follow the curve of the bowel.

14. Document result on fluid balance or washout chart and in clinical notes
    - Volume, colour, consistency and type of substance (stool/meconium/saline)

Note:

It is important to allow the discarded solution to drain from the catheter into the vomit container between the 20 mL solution irrigations.

• For example, if you are giving 100 mL of normal saline, you should drain the same amount of solution into the basin in addition to any stool.

If the amount of return is not equal to, or more than the volume of the fluid used for the irrigation, reinsert the catheter and gently draw back on the syringe. The catheter may be held in place high in the bowel for a few minutes to help expel any gas that is not relieved with the irrigations.

Problem solving

Most of the problems involve stools that are too thick and block the tube or prevent the tube from passing into the rectum.

• If the tube becomes blocked - remove it and flush the catheter with the solution until the catheter is cleared and then recommence procedure

• Difficulty advancing the tube - could also be causing by tube kinking within the bowel, remove tube and re-insert

• Specks of blood in the tubing – may be occasionally seen due to the irritation of the intestine by the tube, ok to continue gently

• If there is fresh bleeding down the catheter – stop the washout and alert the surgical team

• Solution doesn’t drain out fully – check the tube is not blocked, reposition the baby, observe nappies as the baby may pass it later