Therapeutic Value of Gastrografin in Adhesive Small Bowel Obstruction After Unsuccessful Conservative Treatment: A Prospective Randomized Trial

Hok-Kwok Choi, FRCS (Edin); Kin-Wah Chu, FRCS (Edin), FACS; Wai-Lun Law, FRCS (Edin), FACS

Disclosures

Annals of Surgery. 2002;236(1) 

In This Article

Abstract and Introduction

Objective: To assess the therapeutic value of Gastrografin in the management of adhesive small bowel obstruction after unsuccessful conservative treatment.
Summary Background Data: Gastrografin is a hyperosmolar water-soluble contrast medium. Besides its predictive value for the need for surgery, there is probably a therapeutic role of this contrast medium in adhesive small bowel obstruction.
Methods: Patients with clinical evidence of adhesive small bowel obstruction were given trial conservative treatment unless there was suspicion of strangulation. Those who responded in the initial 48 hours had conservative treatment continued. Patients showing no clinical and radiologic improvement in the initial 48 hours were randomized to undergo either Gastrografin meal and follow-through study or surgery. Contrast that appeared in the large bowel within 24 hours was regarded as a partial obstruction, and conservative treatment was continued. Patients in whom contrast failed to reach the large bowel within 24 hours were considered to have complete obstruction, and laparotomy was performed. For patients who had conservative treatment for more than 48 hours with or without Gastrografin, surgery was performed when there was no continuing improvement.
Results: One hundred twenty-four patients with a total of 139 episodes of adhesive obstruction were included. Three patients underwent surgery soon after admission for suspected bowel strangulation. Strangulating obstruction was confirmed in two patients. One hundred one obstructive episodes showed improvement in the initial 48 hours and conservative treatment was continued. Only one patient required surgical treatment subsequently after conservative treatment for 6 days. Thirty-five patients showed no improvement within 48 hours. Nineteen patients were randomized to undergo Gastrografin meal and follow-through study and 16 patients to surgery. Gastrografin study revealed partial obstruction in 14 patients. Obstruction resolved subsequently in all of them after a mean of 41 hours. The other five patients underwent laparotomy because the contrast study showed complete obstruction. The use of Gastrografin significantly reduced the need for surgery by 74%. There was no complication that could be attributed to the use of Gastrografin. No strangulation of bowel occurred in either group.
Conclusions: The use of Gastrografin in adhesive small bowel obstruction is safe and reduces the need for surgery when conservative treatment fails.

Adhesive small bowel obstruction remains a leading cause of hospital admission. The natural course of this clinical problem is still unclear. Patients with this condition are often difficult to assess and require careful evaluation and management. Immediate surgery is recommended when strangulation is suspected or in complete bowel obstruction.[1] A trial of conservative treatment is acceptable if the obstruction is incomplete.[2,3] However, the optimal duration of this trial of conservative treatment has not been well defined.

The role of water-soluble contrast medium in adhesive small bowel obstruction has been evaluated recently. Studies have documented a diagnostic value of this contrast medium in assessing the need for surgical treatment.[4,5,6,7] A possible therapeutic effect of this agent has also been suggested, but the efficacy is still controversial.[8,9,10,11] Gastrografin (Schering AG, Berlin, Germany) is the water-soluble contrast medium that has been most commonly studied. This prospective randomized study aimed to examine objectively the therapeutic role of Gastrografin in adhesive small bowel obstruction for patients who failed to respond to conservative treatment.

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