Adhesive Small Bowel Obstruction Water-Soluble Contrast Guideline

1. SBO diagnosis and initial management
    1. A diagnosis of SBO should be made clinically and/or radiographically using cross-sectional imaging.
      1. Any suspicion of non-adhesive etiologies should be appropriately investigated.
    2. Clinical stability must initially be ensured and appropriately reassessed.
      1. Signs of clinical instability due to suspected bowel ischemia or perforation may warrant urgent surgical exploration, based on the surgeon’s judgment.
    3. IV access and relevant bloodwork should be obtained. Fluid resuscitation should be initiated, correcting for any electrolyte abnormalities or acute kidney injury.
    4. The patient should be made NPO and a nasogastric (NG) tube should be inserted. Gastric decompression with low-intermittent or continuous suction should be started.
    5. Computed tomography (CT) with IV contrast (if no contraindications) may be performed to aid in diagnosis. Findings concerning for ischemia, such as free fluid, heterogeneous bowel wall enhancement, or closed loop configuration, may warrant urgent surgical exploration, based on the surgeon’s judgment.
2. Initiating the water-soluble radiographic contrast (WSC) pathway
    1. A nasogastric tube should be inserted, and placement should be confirmed with an X-ray. Reposition NG tube and repeat X-ray as necessary to confirm appropriate NG placement.
    2. Once the NG tube placement is confirmed, it should be put to low-intermittent or continuous suction for at least 2 hours prior to administering WSC.
    3. The head of the bed should be elevated to >30o at all times.
    4. After 2 hours of NG tube decompression, 90mL of undiluted Gastrografin or similar WSC should be administered through the NG tube.
      1. Note: Some centers may consider using other WSC agents depending on local policies and procedures. Substitute as necessary
      2. Document the time of WSC administration.
    5. The NG tube should be clamped or placed to gravity for 1 hour to allow antegrade contrast passage.
      1. If at any point the patient feels nauseous, vomits, has worsening abdominal pain or distension, the NG tube should be placed back to suction. Continuation of non-operative management is at the discretion of the surgeon
3. Using the WSC pathway
    1. Obtain early (suggested at 4 hours) abdominal radiographs (upright + supine) after WSC administration.
      1. Note: Some centers may perform a low dose, non-contrast computed tomogram instead of X-rays for this step depending on individual center policy and procedures.
      2. If the contrast is in the cecum or any part of the colon, the patient has passed the protocol and the SBO will likely fully resolve non-operatively.
        1. Remove NG tube.
        2. Start sips of clear fluids and monitor serially.
        3. If patient tolerates clear fluid diet and is otherwise stable, he/she can be discharged home at surgeon’s discretion.
      3. If the contrast on the early radiograph is not in the cecum but still seen in small bowel, keep NG tube in and on suction.
      4. If no contrast is seen in the small intestine or colon on the early radiograph (ie. no contrast present or contrast present only in bladder), then contrast should be re-administered as above and the pathway restarted as the contrast may not have been administered properly.
    2. Repeat abdominal radiographs (upright + supine) 24 hours after WSC administration.
      1. If the contrast is in the cecum or any part of the colon, the patient has passed the protocol and the SBO will likely fully resolve non-operatively.
        1. Remove NG tube.
        2. Start sips of clear fluids and monitor serially.
        3. If patient tolerates clear fluid diet and is otherwise stable, he/she can be discharged home at surgeon’s discretion.
      2. If the contrast on the delayed radiograph is not in the cecum but still seen in small bowel, the patient has failed the protocol.
        1. The obstruction is unlikely to resolve non-operatively. Surgical intervention should be considered.