RESUMEN
With optimized technique, the water-soluble contrast challenge is effective at triaging patients for operative vs non-operative management of suspected small bowel obstruction. Standardized study structure and interpretation guidelines aid in clinical efficacy and ease of use. Many tips and tricks exist regarding technique and interpretation, and their understanding may assist the interpreting radiologist. In the future, a CT-based water-soluble contrast challenge, utilizing oral contrast given as part of the initial CT examination, might allow for a more streamlined algorithm and provide more rapid results.
Asunto(s)
Medios de Contraste/administración & dosificación , Obstrucción Intestinal/diagnóstico por imagen , Intestino Delgado/diagnóstico por imagen , Administración Oral , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Colon/diagnóstico por imagen , Tratamiento Conservador , Diatrizoato de Meglumina/administración & dosificación , Tránsito Gastrointestinal , Humanos , Obstrucción Intestinal/etiología , Obstrucción Intestinal/terapia , Intubación Gastrointestinal/métodos , Yohexol/administración & dosificación , Persona de Mediana Edad , Radiografía Abdominal/métodos , Resultado del Tratamiento , Triaje/métodosRESUMEN
BACKGROUND: We had previously reported that the administration of Gastrografin through a nasogastric tube (NGT-G) followed by long tube (LT) strategy could be a novel standard treatment for adhesive small bowel obstruction (ASBO); however, the long-term outcomes after initial improvement remain unknown. This study aimed to analyze the long-term outcomes of first-line NGT-G. METHODS: Enrolled patients with ASBO were randomly assigned to receive LT or NGT-G between July 2016 and November 2018. Thereafter, the cumulative surgery rate, cumulative recurrence rate, and overall survival (OS) rate were analyzed. In addition, subset analysis was conducted to determine the cumulative recurrence rate according to colonic contrast with Gastrografin at 24 h. RESULTS: A total of 223 patients (LT group, n = 111; NGT-G group, n = 112) were analyzed over a median follow-up duration of 550 days. The cumulative 1-year surgery rates, cumulative 1-year recurrence rates, and 1-year OS rates in the LT and NGT-G groups were 18.8% and 18.1%, 30.0% and 31.7%, and 99.1% and 96.6%, respectively; no significant differences were observed between both groups. In the NGT-G group, a negative colonic contrast at 24 h demonstrated a higher tendency for future recurrence compared with a positive colonic contrast at 24 h (1-year recurrence rate: negative contrast, 46.9% vs positive contrast, 27.6%). CONCLUSIONS: Gastrografin through a nasogastric tube followed by LT can be a promising treatment strategy for ASBO, with long-term efficacies equivalent to initial LT placement.
Asunto(s)
Diatrizoato de Meglumina , Obstrucción Intestinal , Intubación Gastrointestinal , Medios de Contraste/administración & dosificación , Diatrizoato de Meglumina/administración & dosificación , Humanos , Obstrucción Intestinal/etiología , Obstrucción Intestinal/terapia , Intestino Delgado , Adherencias Tisulares/complicaciones , Resultado del TratamientoRESUMEN
BACKGROUND: Gastrografin challenge is increasingly used as a diagnostic tool to predict patients who may benefit from nonoperative management in adhesive small bowel obstruction. This study explores the optimal timing of Gastrografin in the management of adhesive small bowel obstruction by comparing early versus late Gastrografin challenge. METHODS: A retrospective chart review from January 2016 to January 2018 identified patients with adhesive small bowel obstruction who underwent Gastrografin challenge. A receiver operating characteristic curve, to predict a duration of stay less than 5 days, calculated a 12-hour limit which separated early and late groups. Nonoperative and operative patients were compared separately. Our primary outcome was duration of stay. Secondary outcomes included operative requirement, time to the operating room, complication rate, and 1-year mortality. In a separate analysis, multivariable logistic regression identified independent risk factors for 1-year mortality. RESULTS: One hundred thirty-four patients were identified (58 early, 76 late). In nonoperative patients, the early group had a shorter duration of stay (3.2 days vs 5.4 days), fewer complications, and a lower complication and 1-year mortality rate (P < .05). In operative patients, the early group had a shorter preoperative duration of stay (1.8 days vs 3.9 days) (P < .05). On multivariable regression, congestive heart failure, any postoperative complication, and operative requirement were the best predictors of 1-year mortality (R2 = 0.321; P < .05). CONCLUSION: Gastrografin administration within 12 hours of adhesive small bowel obstruction diagnosis had favorable outcomes in terms of duration of stay, complications, and mortality in nonoperative patients. Moreover, in operative patients, preoperative duration of stay was shortened. Our findings suggest protocolizing early Gastrografin challenge may be an important principle in adhesive small bowel obstruction management.
Asunto(s)
Medios de Contraste/administración & dosificación , Diatrizoato de Meglumina/administración & dosificación , Obstrucción Intestinal/diagnóstico por imagen , Obstrucción Intestinal/cirugía , Intestino Delgado , Anciano , Anciano de 80 o más Años , Esquema de Medicación , Femenino , Humanos , Obstrucción Intestinal/etiología , Tiempo de Internación , Masculino , Persona de Mediana Edad , Selección de Paciente , Valor Predictivo de las Pruebas , Curva ROC , Estudios Retrospectivos , Adherencias Tisulares , Tomografía Computarizada por Rayos XAsunto(s)
Medios de Contraste/administración & dosificación , Obstrucción Intestinal/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Abdomen/diagnóstico por imagen , Administración Oral , Diatrizoato de Meglumina/administración & dosificación , Servicio de Urgencia en Hospital/organización & administración , Humanos , Intestino Delgado/diagnóstico por imagen , Pelvis/diagnóstico por imagen , Factores de Tiempo , Flujo de TrabajoRESUMEN
BACKGROUND: Gastrointestinal decompression is generally applied to a non-strangulated acute small bowel obstruction (NSASBO). Although long tube (LT) placement and administration of Gastrografin through a nasogastric tube (NGT-G) have shown advantages over NGT alone in previous studies, no studies appear to have compared LT and NGT-G. METHODS: In this multicenter, randomized controlled trial, patients with NSASBO were randomly assigned to receive LT or NGT-G between July 2016 and November 2018 at 11 Japanese institutions. The primary endpoint was non-inferiority of NGT-G compared to LT for non-surgery rate, and the lower limit of the 95% confidence interval for the non-surgery rate (-15%) was set as the lower margin for inferiority of NGT-G compared to LT. RESULTS: In total, 223 patients (LT group, n = 111; NGT-G group, n = 112) were analyzed in the present trial. The non-surgery rate was 87.4% in the LT group and 91.1% in the NGT-G group, with a 3.7% difference between NGT-G and LT (95.3%CI - 5.55 to 12.91; non-inferiority P = 0.00002923). On the other hand, the non-surgery rate with pure NGT-G alone (76.8%) that represents non-cross-over NGT-G without subsequent LT was significantly lower than that with LT (P = 0.039). Median procedure time was significantly shorter with NGT-G (1 min) than with LT (25 min; P < 0.001), whereas no significant differences in mortality or hospital stay were noted between groups. CONCLUSION: NGT-G is an effective alternative to LT as a first-line treatment for NSASBO. A sequential strategy comprising NGT-G followed by LT might offer a new standard for NSASBO. CLINICAL TRIALS REGISTRATION: This trial was registered with the University Hospital Medical Information Network Clinical Trials Registry (umin.ac.jp/ctr Identifier: UMIN000022669) prior to the start of this trial.
Asunto(s)
Diatrizoato de Meglumina/administración & dosificación , Obstrucción Intestinal/terapia , Intestino Delgado/diagnóstico por imagen , Intubación Gastrointestinal/métodos , Anciano , Anciano de 80 o más Años , Medios de Contraste/administración & dosificación , Femenino , Humanos , Obstrucción Intestinal/diagnóstico por imagen , Intestino Delgado/patología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Radiografía/métodosRESUMEN
BACKGROUND: Water-soluble contrast agent (WSCA) administration is commonly used to evaluate adhesive small bowel obstruction (SBO) either via a challenge or follow-through study. This analysis aimed to determine optimal timing to first abdominal radiograph after WSCA administration. MATERIALS AND METHODS: A post hoc review of the Eastern Association for the Surgery of Trauma SBO database was used to compare data from two institutions using different methodologies, either the small bowel follow through method or the challenge method, from March 2015-January 2018. The primary outcome was timing of contrast into the colon. Outcomes were also analyzed. A multivariate regression analysis controlled for age, sex, body mass index, previous SBO admissions, and abdominal surgeries. RESULTS: A total of 236 patients met inclusion and exclusion criteria (A, 119; B, 117). There were minor demographic differences between cohorts and no significant differences between institutions regarding the confirmed presence of WSCA in the colon, rates of operative intervention, length of operation, hospital length of stay, or 30-d readmission rates.Institution A, where the challenge method was practiced, had 95 (80%) patients with contrast to colon overall; four of 95 (4%) patients had confirmed contrast to colon at or before 7 h, and 89 of 95 (94%) patients had confirmed contrast to colon between 7.1 and 10 h. Institution B, where the small bowel follow through method was practiced, had 94 (80%) patients with contrast to colon overall; 73 of 94 (78%) patients had confirmed contrast to colon at or before 7 h, and 15 of 94 (16%) patients had confirmed contrast to colon between 7.1 and 10 h. CONCLUSIONS: Either method is effective for evaluation of SBO. Adding a radiograph at 4 h is feasible, could promote earlier disposition, be conducted as part of an emergency department protocol, and possibly allow for the selection of patients who are candidates for outpatient treatment.
Asunto(s)
Medios de Contraste/administración & dosificación , Obstrucción Intestinal/diagnóstico , Intestino Delgado/diagnóstico por imagen , Cuidados Preoperatorios/métodos , Adherencias Tisulares/diagnóstico , Anciano , Anciano de 80 o más Años , Toma de Decisiones Clínicas , Diatrizoato de Meglumina/administración & dosificación , Estudios de Factibilidad , Femenino , Humanos , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Intestino Delgado/cirugía , Tiempo de Internación , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Selección de Paciente , Radiografía/métodos , Factores de Tiempo , Adherencias Tisulares/complicaciones , Adherencias Tisulares/cirugíaRESUMEN
OBJECTIVES: Pharyngocutaneous fistulae are dreaded complications following total laryngectomy. This paper presents our experience using 3-5 ml gastrografin to detect pharyngeal leaks following total laryngectomy, and compares post-operative videofluoroscopy with clinical follow-up findings in the detection of pharyngocutaneous fistulae. METHODS: A retrospective case-control study was conducted of total laryngectomy patients. The control group (n = 85) was assessed clinically for development of pharyngocutaneous fistulae, while the study group (n = 52) underwent small-volume (3-5 ml) post-operative gastrografin videofluoroscopy. RESULTS: In the control group, 24 of 85 patients (28 per cent) developed pharyngocutaneous fistulae, with 6 requiring surgical correction. In the study group, 24 of 52 patients (46 per cent) had videofluoroscopy-detected pharyngeal leaks; 4 patients (8 per cent) developed pharyngocutaneous fistulae, but all cases resolved following non-surgical management. Patients who underwent videofluoroscopy had a significantly lower risk of developing pharyngocutaneous fistulae; sensitivity and specificity in the detection of pharyngocutaneous fistulae were 58 per cent and 100 per cent respectively. CONCLUSION: Small-volume gastrografin videofluoroscopy reliably identified small pharyngeal leaks. Routine use in total laryngectomy combined with withholding feeds in cases of early leaks may prevent the development of pharyngocutaneous fistulae.
Asunto(s)
Fístula Cutánea/diagnóstico por imagen , Diatrizoato de Meglumina/administración & dosificación , Fluoroscopía/métodos , Laringectomía/efectos adversos , Enfermedades Faríngeas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Fístula Cutánea/prevención & control , Fístula Cutánea/terapia , Femenino , Fluoroscopía/tendencias , Humanos , Masculino , Tamizaje Masivo/instrumentación , Persona de Mediana Edad , Faringe/diagnóstico por imagen , Faringe/patología , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
OBJECTIVE: To assess the frequency and indications for use of oral water-soluble contrast challenge as a diagnostic test for small bowel obstruction in four regions of the USA. MATERIALS AND METHODS: We distributed a 9-question web-based survey to the abdominal section heads of academic radiology departments throughout the USA (N = 97). The questions pertained to use of water-soluble contrast for management of small bowel obstruction. Descriptive statistics and Fisher's exact tests were used for data analysis. RESULTS: The overall response rate was 46%. Eighty percent of the responding hospitals had more than 500 beds in operation. Water-soluble contrast challenge was considered standard of care for management of non-operative small bowel obstruction in 60% of the responding radiology departments. The majority of the responding departments (41%) performed 2-8 contrast challenge studies per month on average. The most frequent indication for the study was distinguishing partial vs complete bowel obstruction. Eighty percent of the responding radiologists believed that the contrast challenge is useful for management of small bowel obstruction. Overall, there was no statistically significant difference in frequency and indication for use of water-soluble contrast challenge based on geographic location. CONCLUSION: The water-soluble contrast challenge was considered standard of care for non-operative management of small bowel obstruction in majority of the academic radiology departments represented in this survey. Surgeons were referring clinicians in every case. The most common clinical indication for the study was distinguishing partial versus complete small bowel obstruction.
Asunto(s)
Medios de Contraste/administración & dosificación , Obstrucción Intestinal/diagnóstico por imagen , Obstrucción Intestinal/terapia , Intestino Delgado , Pautas de la Práctica en Medicina/estadística & datos numéricos , Administración Oral , Diatrizoato de Meglumina/administración & dosificación , Humanos , Encuestas y Cuestionarios , Estados UnidosRESUMEN
Differentiation between SBO that will resolve with supportive measures and those requiring surgery remains challenging. WSC administration may be diagnostic and therapeutic. The purpose of this study was to evaluate use of a SBO protocol using WSC challenge. A protocol was implemented at five tertiary care centers. Demographics, prior surgical history, time to operation, complications, and LOS were analyzed. 283 patients were admitted with SBO; 13% underwent immediate laparotomy; these patients had a median LOS of 7.5 days. The remaining 245 were candidates for WSC challenge. Of those, 80% received contrast. 139 (71%) had contrast passage to the colon. LOS in these patients was 4 days. Sixty-five patients (29%) failed contrast passage within 24â¯h and underwent surgery. LOS was 9 days. 8% of patients in whom contrast passage was observed at 24â¯h nevertheless subsequently underwent surgery. 4% of patients who failed WSC challenge did not proceed to surgery. Our multicenter trial revealed that implementation of a WSC protocol may facilitate early recognition of partial from complete obstruction.
Asunto(s)
Medios de Contraste/administración & dosificación , Diatrizoato de Meglumina/administración & dosificación , Obstrucción Intestinal/diagnóstico por imagen , Obstrucción Intestinal/cirugía , Intestino Delgado , Tomografía Computarizada por Rayos X , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
The aim of this study was to describe the specific gross and radiographic anatomy of the digestive tract of inland bearded dragons (Pogona vitticeps). Eleven bearded dragon cadavers of both sexes (6 females, 5 males) were dissected to examine, measure, and document the specific gross anatomy of the alimentary canal. Measurements collected from the cadavers included snout-vent length, total length of the alimentary canal, and the lengths of the individual sections of the gastrointestinal tract, including the esophagus, stomach, small intestine, ampulla coli, isthmus coli, rectum, and the distance from the coprodeum to the vent opening. Twenty-two healthy adult bearded dragons (13 females, 9 males) maintained under standardized husbandry conditions underwent a physical examination, blood collection, and whole-body dorsoventral and lateral survey radiographs; these animals were used to provide the radiographic images of the complete digestive tract. For the subsequent contrast passage studies, two different contrast media, barium sulfate (BaSO4, Barilux suspension) and an iodinated ionic radiocontrast agent (Sodium meglumine amidotrizoate [SMAT], Gastrografin), were used. Water-diluted Barilux suspension (dose 9 ml/kg) was administered orally to 5 bearded dragons, while Gastrografin (dose 5ml/kg) was administered orally to 21 bearded dragons. Four animals were used for both contrast media studies, but received a break of four weeks in between. Dorsoventral and laterolateral radiographs were collected at 0 (baseline), 15, 30, and 45 minutes and 1, 2, 3, 4, 5, 6, 8, 10, 12, 24, 30, and 36 hours after each contrast medium was administered. Both contrast media were found to illustrate the alimentary tracts in the adult bearded dragons. Transit time was substantially faster with SMAT, and SMAT illustrated the entire gastrointestinal tract within 36 hours; BaSO4 did not fully illustrate the gastrointestinal tract in 36 hours. These results might serve as a guideline for the interpretation of subsequent contrast studies in this lizard species.
Asunto(s)
Tracto Gastrointestinal/anatomía & histología , Tránsito Gastrointestinal/fisiología , Lagartos/anatomía & histología , Animales , Australia , Sulfato de Bario/administración & dosificación , Medios de Contraste/administración & dosificación , Diatrizoato de Meglumina/administración & dosificación , Femenino , Tracto Gastrointestinal/diagnóstico por imagen , Alemania , Guías como Asunto , MasculinoRESUMEN
The use of Gastrografin may have a therapeutic effect on resolving adhesive small bowel obstruction. Adhesive Small Bowel obstruction (ASBO) accounts for the majority of patients with small bowel obstruction. Most patients are managed conservatively; frequent admissions create a considerable burden. We sought to examine the adherence to the Bologna guidelines for the management of ASBO in a high volume tertiary center and whether or not Gastrografin had a therapeutic effect. A comparison was made between an initial retrospective audit looking at ASBO and a prospective re-audit after applying standards derived from the Bologna guidelines. During re-audit it was found that more patients underwent conservative management and fewer patients had surgery as first line management. In the re-audit, those who had to undergo surgery within/after a period of 72h of conservative management were also fewer. Whether they were managed surgically primarily or after a period of conservative management, the average length of stay was also shorter. In comparison to the preliminary audit, there appeared to be no change in the way that medical history and physical examination was documented during the re-audit. However, there was a marked difference in the use of appropriate blood tests and CT scans. Changes were made successfully following the initial audit results and have been implemented, thus closing the audit loop. This study shows that the use of Gastrografin has decreased the need for surgical intervention in a group of patients with small bowel obstruction.
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Diatrizoato de Meglumina/administración & dosificación , Diatrizoato de Meglumina/uso terapéutico , Obstrucción Intestinal/tratamiento farmacológico , Adherencias Tisulares/tratamiento farmacológico , Diatrizoato de Meglumina/farmacología , Humanos , Obstrucción Intestinal/complicaciones , Obstrucción Intestinal/diagnóstico por imagen , Estudios Prospectivos , Estándares de Referencia , Estudios Retrospectivos , Adherencias Tisulares/complicaciones , Adherencias Tisulares/diagnóstico por imagenAsunto(s)
Estreñimiento , Fibrosis Quística , Diatrizoato de Meglumina , Insuficiencia Pancreática Exocrina , Hipertiroidismo , Trasplante de Pulmón/efectos adversos , Complicaciones Posoperatorias , Adulto , Estreñimiento/tratamiento farmacológico , Estreñimiento/etiología , Estreñimiento/fisiopatología , Medios de Contraste/administración & dosificación , Medios de Contraste/efectos adversos , Fibrosis Quística/fisiopatología , Fibrosis Quística/cirugía , Diatrizoato de Meglumina/administración & dosificación , Diatrizoato de Meglumina/efectos adversos , Duración de la Terapia , Insuficiencia Pancreática Exocrina/etiología , Insuficiencia Pancreática Exocrina/fisiopatología , Insuficiencia Pancreática Exocrina/terapia , Femenino , Motilidad Gastrointestinal/efectos de los fármacos , Humanos , Hipertiroidismo/inducido químicamente , Hipertiroidismo/diagnóstico , Obstrucción Intestinal/diagnóstico , Obstrucción Intestinal/etiología , Obstrucción Intestinal/prevención & control , Trasplante de Pulmón/métodos , Masculino , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/terapia , Cintigrafía/métodos , Pruebas de Función de la Tiroides/métodos , Privación de TratamientoRESUMEN
INTRODUCTION: There is no consensus as to the most optimal bowel preparation regime for Computed Tomographic Colonography (CTC). Concerns regarding laxative bowel preparation (LBP) include tolerability, adverse effects and complexity of regimen. Two hospitals in Auckland changed CTC bowel preparation from standard LBP to Gastrografin (GG) in 2015. The aim of this study is to retrospectively assess objective and subjective quality measures of these different bowel preparations. METHODS: Two study groups were selected retrospectively from patients who underwent CTC at two hospitals in September-October 2013 (LBP) and September- October 2015 (GG). Each study group comprised 60 patients (30 consecutive patients from each hospital). Patients were randomized and anonymized to reduce bias in analysis. Study patients were assessed independently by three experienced Radiologists using a simple grading system derived from the literature. RESULTS: There was significantly less faecal residue (P = 0.006) and better faecal tagging (P = 0.001) in the right colon in the GG group. There was significantly higher fluid residue in the GG group than the LBP group (P = 0.0001), particularly in the right colon, with better fluid tagging in the GG group(P ≤ 0.0001). Higher Hounsfield Units of residual fluid were observed in the GG group (P ≤ 0.0001). There was no statistically significant difference in the subjective quality scores (P = 0.219), between the two preparations. CONCLUSIONS: This study has demonstrated better faecal cleansing and faecal tagging in the GG group. Higher fluid residue in the GG group was offset by better fluid tagging.
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Sulfato de Bario/administración & dosificación , Catárticos/administración & dosificación , Colonografía Tomográfica Computarizada , Medios de Contraste/administración & dosificación , Diatrizoato de Meglumina/administración & dosificación , Laxativos/administración & dosificación , Adulto , Anciano , Anciano de 80 o más Años , Heces , Femenino , Humanos , Masculino , Persona de Mediana Edad , Nueva Zelanda , Estudios RetrospectivosRESUMEN
PURPOSE: To investigate the novel zein-based non-adhesive precipitating liquid embolic HEIE1_2017. MATERIALS AND METHODS: Zein-based liquid embolics are an own class of embolization material. In this study, HEIE1_2017, a novel zein-based liquid embolic, was investigated. Visibility was assessed in vitro in CT and MRI phantoms, embolization characteristics were assessed in vivo in the kidneys of 12 pigs. Components of HEIE1_2017 were zein as occlusion material, ethanol as solvent, and iodized oil as radiopaque material. HEIE1_2017 was used in pure (HEI-PURE) and manually modified (HEI-MOD) form and compared with 6% ethylene vinyl alcohol copolymer (EVOH). Different radiological methods (CT, MRI, DSA, cone-beam CT, and micro-CT) and histopathologic analyses were applied to compare visibility and vascular occlusion patterns. RESULTS: In CT phantoms, all embolics were definitely visible as hyperdense materials. In MRI phantoms, signal-to-noise ratio was highest for HEI-PURE, followed by HEI-MOD and EVOH. In all kidneys, embolization procedures were technically successful and without complications. In DSA, all embolics were definitely visible during and after embolization. Only EVOH caused substantial artifacts in cone-beam CT and CT. In micro-CT and histopathology, HEI-PURE showed a homogeneous occlusion from segmental arteries to glomerular capillaries. HEI-MOD demonstrated the deepest vascular penetration (up to the level of peritubular capillaries), but with an inhomogeneous distribution. For EVOH, there was inhomogeneous vascular occlusion from segmental arteries to glomerular capillaries. CONCLUSION: HEIE1_2017 is a promising novel zein-based liquid embolic. Further preclinical and clinical studies with higher case numbers and long-term follow-up are needed to further assess the value of this embolic material.
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Quimioembolización Terapéutica/métodos , Diatrizoato de Meglumina/administración & dosificación , Etanol/administración & dosificación , Riñón/diagnóstico por imagen , Propilenglicol/administración & dosificación , Zeína/administración & dosificación , Angiografía de Substracción Digital , Animales , Artefactos , Aceite Yodado , Imagen por Resonancia Magnética/métodos , Modelos Animales , Fantasmas de Imagen , Radiografía , Porcinos , Tomografía Computarizada por Rayos X , Rayos XRESUMEN
BACKGROUND: Gastrografin (GG)-based nonoperative approach is both diagnostic and therapeutic for partial small bowel obstruction (SBO). Absence of X-ray evidence of GG in the colon after 8 h is predictive of the need for operation, and a recent trial used 48 h to prompt operation. We hypothesize that a significant number of patients receiving the GG challenge require >48 h before an effect is seen. METHODS: A post hoc analysis of an Eastern Association for the Surgery of Trauma multi-institutional SBO database was performed including only those receiving GG challenge. Successful nonoperative management (NOM) was defined as passage of flatus or nasogastric tube (NGT) removal. NOM was considered a failure if operative intervention was required. Multiple logistic regression was performed to identify predictors of delayed (>48 h) GG challenge effect and expressed as odds ratios with 95% confidence intervals. RESULTS: Of 286 patients receiving GG, 208 patients (73%) were successfully managed nonoperatively. A total of 60 (29%) NOM patients had NGT decompression for >48 h (n = 54) or required >48 h to pass flatus (n = 34), with some requiring both (n = 28). Prior abdominal operations and SBO admission were protective of delayed GG effect (0.411 [0.169-1.00], P < 0.05; 0.478 [0.240-0.952], P < 0.036). CONCLUSIONS: A significant proportion of patients at 48 h (29%) "failed" the GG challenge as they had yet to pass flatus or still required NGT but were nonetheless successfully managed nonoperatively. Extending the GG challenge beyond 48 h may help avoid unnecessary operations. LEVEL OF EVIDENCE: Level II.
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Tratamiento Conservador/métodos , Medios de Contraste/administración & dosificación , Diatrizoato de Meglumina/administración & dosificación , Obstrucción Intestinal/terapia , Anciano , Anciano de 80 o más Años , Conjuntos de Datos como Asunto , Femenino , Humanos , Obstrucción Intestinal/diagnóstico por imagen , Intestino Delgado/diagnóstico por imagen , Intubación Gastrointestinal , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Multicéntricos como Asunto , Estudios Retrospectivos , Factores de Tiempo , Adherencias Tisulares/diagnóstico por imagen , Adherencias Tisulares/terapia , Resultado del TratamientoRESUMEN
BACKGROUND AND OBJECTIVES: Practice guidelines for preoperative fasting have not clearly established the fasting time needed after oral administration of water-soluble contrast media. The aim of this study was to determine the time required for the gastric emptying during the water-soluble contrast media in patients with acute abdominal pain. METHODS: This prospective longitudinal study included sixty-eight patients older than 18 years of age with acute abdominal pain, who required a water-soluble contrast media enhanced abdominal computed tomography study. Plain radiographs were obtained hourly until complete the gastric emptying. Patients with probable bowel obstruction were not included in the study. RESULTS: A total of 31 (45,6%), 54 (79,4%), and 64 (94,1%) patients achieved a complete gastric clearance of barium in 1, 2 and 3 hours, respectively. All patients achieved complete emptying of water-soluble contrast media within 6 hours. Gastric emptying time was not associated with gender (P=0,44), body mass index (P=.35), fasting time prior to water-soluble contrast media intake (P=0,12), administration of opioids in the emergency room (P=0,7), and the presence of comorbidities (P=0,36). CONCLUSION: Ninety-four percent of the patients with acute abdominal pain achieved complete gastric emptying within 3hours after the administration of water-soluble contrast media. All of them achieved complete gastric emptying within 6hours. The results suggested 6hours after oral intake of the contrast media is enough to complete transit of water-soluble contrast media through the stomach and avoid unnecessary risks.
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Abdomen Agudo/diagnóstico por imagen , Sulfato de Bario/farmacocinética , Medios de Contraste/farmacocinética , Ayuno , Vaciamiento Gástrico , Tomografía Computarizada por Rayos X/métodos , Abdomen Agudo/fisiopatología , Adulto , Sulfato de Bario/administración & dosificación , Diatrizoato/administración & dosificación , Diatrizoato de Meglumina/administración & dosificación , Femenino , Humanos , Estudios Longitudinales , Masculino , Guías de Práctica Clínica como Asunto , Estudios Prospectivos , Factores Sexuales , Solubilidad , Factores de TiempoAsunto(s)
Fundoplicación/efectos adversos , Obstrucción de la Salida Gástrica/etiología , Adherencias Tisulares/complicaciones , Anciano , Diatrizoato de Meglumina/administración & dosificación , Femenino , Obstrucción de la Salida Gástrica/diagnóstico por imagen , Obstrucción de la Salida Gástrica/cirugía , Humanos , Laparoscopía/métodos , Adherencias Tisulares/cirugía , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoAsunto(s)
Diatrizoato de Meglumina/administración & dosificación , Endometriosis/complicaciones , Obstrucción Intestinal , Intestino Delgado , Anciano de 80 o más Años , Tratamiento Conservador/métodos , Medios de Contraste/administración & dosificación , Endometriosis/cirugía , Femenino , Humanos , Histerectomía/métodos , Obstrucción Intestinal/diagnóstico , Obstrucción Intestinal/etiología , Obstrucción Intestinal/fisiopatología , Obstrucción Intestinal/terapia , Intestino Delgado/diagnóstico por imagen , Intestino Delgado/patología , Intubación Gastrointestinal/métodos , Multimorbilidad , Ovariectomía/métodos , Radiografía Abdominal/métodos , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
Timely recognition and treatment of small bowel obstruction is of great importance for the course of the disease. Complete obstruction of the small bowel can lead to serious complications such as bowel ischaemia and perforation. Gastrografin, which is traditionally used as an oral contrast agent in imaging diagnostics, is of prognostic and therapeutic value in patients presenting with adhesive small bowel obstruction. CT is necessary to rule out closed loop obstruction or other than adhesive causes of the bowel obstruction before using Gastrografin. Patients with closed loop obstruction can rapidly develop bowel ischaemia and immediate surgery is indicated once diagnosed. Awaiting clinical resolution of the small bowel obstruction without surgery is justified when closed loop obstruction has been ruled out, there are no signs of bowel ischaemia and an abdominal radiograph within 4-24 hours after administration of Gastrografin shows the oral contrast in the colon.
Asunto(s)
Medios de Contraste/administración & dosificación , Diatrizoato de Meglumina/administración & dosificación , Obstrucción Intestinal/tratamiento farmacológico , Intestino Delgado/diagnóstico por imagen , Colon/diagnóstico por imagen , Femenino , Humanos , Obstrucción Intestinal/diagnóstico por imagen , Obstrucción Intestinal/etiología , Intestino Delgado/irrigación sanguínea , Intestino Delgado/patología , Isquemia/diagnóstico por imagen , Isquemia/etiología , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Adherencias Tisulares/complicaciones , Adherencias Tisulares/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Management of small bowel obstruction (SBO) has become more conservative, especially in those patients with previous abdominal surgery (PAS). However, surgical dogma continues to recommend operative exploration for SBO with no PAS. With the increased use of computed tomography imaging resulting in more SBO diagnoses, it is important to reevaluate the role of mandatory operative exploration. Gastrografin (GG) administration decreases the need for operative exploration and may be an option for SBO without PAS. We hypothesized that the use of GG for SBO without PAS will be equally effective in reducing the operative exploration rate compared with that for SBO with PAS. METHODS: A post hoc analysis of prospectively collected data was conducted for patients with SBO from February 2015 through December 2016. Patients younger than 18 years, pregnant patients, and patients with evidence of hypotension, bowel strangulation, peritonitis, closed loop obstruction or pneumatosis intestinalis were excluded. The primary outcome was operative exploration rate for SBO with or without PAS. Rate adjustment was accomplished through multivariate logistic regression. RESULTS: Overall, 601 patients with SBO were included in the study, 500 with PAS and 101 patients without PAS. The two groups were similar except for age, sex, prior abdominal surgery including colon surgery, prior SBO admission, and history of cancer. Multivariate analysis showed that PAS (odds ratio [OR], 0.47; p = 0.03) and the use of GG (OR, 0.11; p < 0.01) were independent predictors of successful nonoperative management, whereas intensive care unit admission (OR, 16.0; p < 0.01) was associated with a higher likelihood of need for operation. The use of GG significantly decreased the need for operation in patients with and without PAS. CONCLUSIONS: Patients with and without PAS who received GG had lower rates of operative exploration for SBO compared with those who did not receive GG. Patients with a diagnosis of SBO without PAS should be considered for the nonoperative management approach using GG. LEVEL OF EVIDENCE: Therapeutic, level IV.