Adhesive Small Bowel Obstruction

Introduction

Welcome to the APSA Quality and Safety Committee Adhesive Small Bowel Obstruction toolkit. This toolkit is intended to help anyone who is interested in quality improvement (QI) projects related to management of adhesive small bowel obstruction.

Available toolkit projects are listed below. Many of the approaches described are evidence based - some are not. These approaches have not been approved by APSA.

Water Soluble Contrast Challenge

Various institutions have implemented protocols for the management of adhesive small bowel obstructions. Several examples are shared below.

Cincinnati Children’s Hospital

Developed a standardized, collaborative protocol between the surgery and radiology services for the management of patients with adhesive small bowel obstruction (ABSO) .

Protocol

Resources

  • In addition to the protocol, other key steps that helped were:
    • The creation an Epic order set CCHMC Epic Order Set
    • The education of surgical faculty, fellows, and residents. The education of radiology attending and fellows, radiology technicians. The involvement of a clinical pharmacist in a consulting role was also beneficial.

Stakeholders

Surgery, radiology, pharmacy

Challenges and solutions

Spread knowledge about the use of gastrografin in ASBO, gain acceptance from radiologists, establish reasonable and safe work flow for administration of gastrografin, patients not primarily on surgical service (i.e. intensive care unit patients) can provide communication challenges.

Submitted by: Beth Rymeski

Additional Implementers: Irene Isabel (Iris) Lim-Beutel

Children’s Hospital of Wisconsin

mplemented a protocol using water soluble contrast for the management of patients with ABSO which was developed collaboratively between pediatric surgery and radiology [1].

Protocol

Resources

  • In addition to the protocol, other key steps that helped were:
    • The creation an Epic order set CHW Epic Order Set
    • The education of surgical faculty, fellows, and residents, as well as radiologists and radiology technicians

Stakeholders

Surgery, radiology, pharmacy

Challenges and solutions

  • Gaining understanding/acceptance from radiologists – having a radiologist partner who was invested in the project and who could serve as a liaison was key.
  • Limited data on use in children.
  • Limited data on which contrast agent is best and how much volume is appropriate for various size children.
  • Confusion when other pediatric services tried to use the protocol on patients for whom it was not indicated. Making it an order for use only by the surgical team helped.

Submitted by: Kyle Van Arendonk

Additional implementers: Kevin Boyd (pediatric radiologist)

Nemours-AI duPont Hospital for Children

Uses a pathway for the use of watern soluble contrast for adhesive small bowel obstruction is also utilized. This protocol has no age limit and has been utilized in neonates.

Protocol

Resources

Stakeholders

Surgery and radiology (including radiologist and fluoroscopy technician)

Challenges and solutions

Some resistance due to concern about high osmolarity of contrast and whether this would result in fluid shifts or respiratory compromise if aspirated, especially in neonates. We have no age limit for the protocol and we have not observed any adverse events related to contrast administration, even in neonates.

Links to published data: refer to the recent research section.

IRB approval: exempt as a QI project.

Submitted by: Loren Berman

Additional implementers: Radiologists: Sharon Gould, Lauren Averill; Fluoroscopy technician: Theresa Moore

Recent Research

For recent research pertaining to the management of patients with adhesive small bowel obstruction, please refer to the references below [1][2][3].

References

  1. Linden AF, Raiji MT, Kohler JE, et al. Evaluation of a water-soluble contrast protocol for nonoperative management of pediatric adhesive small bowel obstruction. J Pediatr Surg. 2019;54(1):184-188.  [PMID:30414689]
  2. Lee CY, Hung MH, Lin LH, et al. Evaluation of a water-soluble contrast agent for the conservative management of adhesive small bowel obstruction in pediatric patients. J Pediatr Surg. 2015;50(4):581-5.  [PMID:25840067]
  3. Zielinski MD, Haddad NN, Cullinane DC, et al. Multi-institutional, prospective, observational study comparing the Gastrografin challenge versus standard treatment in adhesive small bowel obstruction. J Trauma Acute Care Surg. 2017;83(1):47-54.  [PMID:28422909]