Introduction:
Whole bowel irrigation is a medical process that removes unwanted or toxic substances from the gastrointestinal tract and cleanses the entire colon. It involves the administration of large volumes of solution either orally or via a nasogastric tube to clean the gastrointestinal tract. Whole bowel irrigation can be safely used in pediatric patients also. They are also safe for use in pregnancy.
What Are the Indications for Whole Bowel Irrigation?
This procedure is usually performed to prepare the patients before surgery or for patients with drug or substance overdose.
The procedure is performed under the following conditions:
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Prior to intestinal surgery, colonoscopy, or a barium enema to clean the bowel.
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Ingestion or overdose of some life-threatening sustained-release or enteric-coated medications.
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Ingestion or overdose of some life-threatening medications not absorbed by activated charcoal.
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Ingestion of illicit drugs.
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Ingestion of whole skin patches.
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Whole bowel irrigation may lessen the need for more invasive procedures such as hemodialysis in sustained-release lithium or potassium chloride overdose.
What Are the Contraindications for Whole Bowel Irrigation?
Whole bowel irrigation is not done in the following conditions:
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Uncooperative patient.
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Patient with uncontrolled vomiting.
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In whom a nose tube cannot be placed.
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Patients with decreased consciousness.
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Patient with compromised airway.
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With intestinal obstruction.
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With unstable vital signs.
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A patient who is ventilated or intubated.
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A person with a risk of seizure.
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Abnormalities in the upper gastrointestinal tract.
What Solutions Are Used in Whole Bowel Irrigation?
Initially, a solution of sodium chloride, potassium chloride, and sodium bicarbonate was used, but this solution was absorbed by the body, sometimes leading to complications. Later, a specialized irrigation fluid was developed, consisting mainly of an iso-osmolar solution of macrogol. With the macrogol solution, there is negligible absorption into the body.
How Do These Solutions Work?
Current methods of gastrointestinal decontamination (emesis, gastric lavage, and activated charcoal administration) focus primarily on decontaminating the stomach. But the toxins are mostly absorbed in the small intestine. Sustained-release medications liberate drugs when they pass through the intestine and are absorbed into the gastrointestinal tract.
Infusion of polyethylene glycol electrolyte solution decreases the contact time with the gastrointestinal mucosa. This reduces the absorption of the drug or toxin throughout the gastrointestinal tract, and also the solution is specifically designed to prevent electrolyte and fluid shifts.
What Are the Preparatory Steps to Be Done Before the Procedure?
All necessary equipment should be placed at the bedside and assembled before beginning the procedure.
The equipment used for whole bowel irrigation includes:
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10 % Lidocaine solution.
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2 % Lidocaine jelly for lubrication.
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Nasogastric tube of appropriate size.
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Polyethylene glycol electrolyte solution.
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Reservoir bag to hold the irrigation solution.
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Intravenous pole to hang the bag.
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Bedside commode.
Explain the procedure, its risks, benefits, and alternatives to the patient. Informed consent should be obtained for toxin ingestion in suicidal cases. Inspect the nasal passages and oropharynx to rule out any anatomic abnormalities or obstructions that would obstruct the passage of a nasogastric tube.
How Is a Nasogastric Tube Inserted?
Place the patient in the upright or semi-upright position. The patient’s vitals are monitored throughout the procedure. First, 1 mL of 10 % Lidocaine solution is sprayed into each nostril. Then the nasogastric tube is lubricated with Lidocaine jelly—this reduces patient pain and discomfort during the insertion of the nasogastric tube.
A nasogastric tube is inserted from the nose to the stomach. Flexion of the neck may facilitate passage of the tube into the esophagus and avoid endotracheal insertion. The conscious and cooperative patient may be asked to swallow water through a straw or swallow saliva to facilitate the passage of the tube. Stridor, cough, or cyanosis may indicate endotracheal passage and should result in the removal of the tube. If resistance is felt during the insertion of the nasogastric tube, do not insert it forcefully.
Try the following steps, which can help in nasogastric tube insertion:
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Warm water helps soften the tip of the nasogastric tube and thereby makes insertion easier.
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Tie a knot at the tip of the nasogastric tube, which creates a curve and makes insertion easier.
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Curve the tip of the nasogastric tube and place it in a cup of ice for some minutes and insert the stiffener tube.
A plain abdominal film should be taken to confirm the placement of the nasogastric tube before the irrigation solution is administered.
What Happens During the Procedure?
The patient should be comfortably seated on the bedside commode. When administered to adults to prepare for surgery, colonoscopy, or any other procedure, the solution is given orally unless oral administration is contraindicated. The patient is given Metoclopramide intravenously to minimize vomiting.
A large volume of the nonabsorbable solution called Polyethylene glycol-electrolyte is usually given. Orally, the solution is taken at a rate of 240 mL every ten to 20 minutes. Nasogastrically, the solution is given at a rate of 500 mL per hour in children of nine months to six years, 1000 mL per hour in children six to 12 years, and 1500 to 2000 mL per hour in adults. The procedure may take up to six hours until the fecal discharge is clear.
If vomiting occurs during the procedure, the rate of administration is slowed. The procedure is stopped if the patient has abdominal distension or loss of abdominal sounds. Once the procedure is completed, the tube is removed, and the patient is kept under observation and monitoring.
What Are the Complications of Whole Bowel Irrigation?
Whole bowel irrigation is a risky procedure.
The complications include:
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Nausea, vomiting, and severe diarrhea.
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Pulmonary aspiration of the solution.
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Abdominal bloating.
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Injury to the digestive tract or organs.
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Anal irritation.
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Allergic reactions.
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Swelling of lips.
Conclusion:
Whole bowel irrigation is a technique to decontaminate the gut after acute toxic ingestion. Unfortunately, full bowel irrigation is a poorly tolerated procedure. It causes discomfort and can lead to complications in some cases. So, doctors should always analyze the patients thoroughly, get a proper history, and check if the patient would tolerate the procedure before performing this procedure.
