Whole bowel irrigation

Whole bowel irrigation (WBI) is a medical process involving the rapid administration of large volumes of an osmotically balanced macrogol solution (GoLYTELY, CoLyte), either orally or via a nasogastric tube, to flush out the entire gastrointestinal tract.

History

Whole bowel irrigation was originally developed to cleanse the large bowel before surgery or colonoscopy.^[1] 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 macrogol.^[2] With the macrogol 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.^[2] 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 in 1987 provided evidence that whole bowel irrigation is an effective and safe gastrointestinal decontamination procedure for acute poisoning.^[3] Its common administration for toxic ingestions has been largely replaced with that of activated charcoal.

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 stomach. 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.^[4] 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.^[5] 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.

Indications

Whole bowel irrigation is sometimes used prior to colonoscopy, bowel surgery, other abdominal/pelvic surgery, or a barium enema examination, to cleanse the intestines, enhancing visibility of the intestines' inner surfaces, preventing complications from occurring as a result of spillage of bowel contents into the abdominal cavity, and potentially providing other benefits depending on the type of procedure being performed.

Whole bowel irrigation is also used in certain 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).^[4]

Contraindications

Major gastrointestinal dysfunction precludes the use of whole bowel irrigation. WBI is specifically contraindicated 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.^[4]

Complications

Minor complications include nausea, vomiting, abdominal cramps, and bloating.^[6] Patients with altered mental status or a compromised and unprotected airway are at risk for pulmonary aspiration.^[4]

Alternatives

Several other laxatives are available for cleansing of the bowels prior to colonoscopy, surgery, or other procedures. Studies have shown some of these to be comparable to macrogol solutions in terms of effectiveness and better tolerated by patients due to the lower volume of laxative which must be ingested. Enemas are another option.

Alternatives to WBI in cases of poisoning may include gastric lavage, activated charcoal, syrup of ipecac, mechanically-induced vomiting, administration of alternate laxatives, antidotes and/or symptomatic treatment for systemic poisoning, and watchful waiting. However, every poisoning situation is unique and appropriate treatment options are evaluated on a case-by-case basis.

See also

• Poison
• Colonoscopy

References

1. Hewitt J, Reeve J, Rigby J, Cox A (1973). "Whole-gut irrigation in preparation for large-bowel surgery". Lancet. 2 (7825): 337–40. doi:10.1016/S0140-6736(73)93189-9. PMID 4124525.
2. Davis G, Santa Ana C, Morawski S, Fordtran J (1980). "Development of a lavage solution associated with minimal water and electrolyte absorption or secretion". Gastroenterology. 78 (5 Pt 1): 991–5. PMID 7380204.
3. Tenenbein M, Cohen S, Sitar D (1987). "Whole bowel irrigation as a decontamination procedure after acute drug overdose". Arch Intern Med. 147 (5): 905–7. doi:10.1001/archinte.147.5.905. PMID 3579442.
4. "Position paper: whole bowel irrigation". J Toxicol Clin Toxicol. 42 (6): 843–54. 2004. doi:10.1081/CLT-200035932. PMID 15533024.
5. Tenenbein M (1988). "Whole bowel irrigation as a gastrointestinal decontamination procedure after acute poisoning". Med Toxicol Adverse Drug Exp. 3 (2): 77–84. doi:10.1007/bf03259934. PMID 3287090.
6. Ernstoff J, Howard D, Marshall J, Jumshyd A, McCullough A (1983). "A randomized blinded clinical trial of a rapid colonic lavage solution (Golytely) compared with standard preparation for colonoscopy and barium enema". Gastroenterology. 84 (6): 1512–16. PMID 6341159.