Neonatal Bowel Washout (Rectal)

1. Introduction

Rectal Bowel washouts are performed to decompress the bowel and deflate the abdomen by removing gas and stool using small amounts of Normal Saline 0.9%. 
 
They are:

• Performed in babies with Hirschsprung's Disease (HD) or to relieve low intestinal obstruction due to meconium plug, meconium ileus. or intestinal dysmotility of prematurity.
• Used as a mode of temporary management in proven cases of HD till definitive surgery. (This may be for 4-12 weeks depending on each case)

2. Parameters

This Guideline is to assist clinicians performing Rectal Bowel Washouts for neonatal patients within the neonatal unit at the RCH.  It does not include older patients outside of the neonatal unit requiring bowel washouts

Procedure must be ordered by the Surgical Team following patient review. 

3. Definition of terms  

Hirschsprung's Disease:  A rare disorder of the bowel, most commonly of the large bowel (sometimes called megacolon), where there is a lack of nerves, known as ganglion cells in the bowel wall.  This prevents effective peristalsis and results in intestinal obstruction
It affects four times as many boys as girls with an increased incidence in infants with Down Syndrome 1

Meconium Plug:  This condition is the most common and mildest form of mechanical distal obstruction of the newborn.  Inspissated and immobile meconium causes a transient form of distal colonic or rectal obstruction. The aetiology of this disorder is unclear. It is most common in preterm infants.

Meconium Ileus:   The obstruction is mainly caused by thick tenacious meconium. The sticky meconium is unable to be propelled through the intestine, usually the gut is not damaged and continuity is not disrupted1.  Meconium ileus occurs in 15% of infants with Cystic Fibrosis.1  In others, the condition is associated with volvulus, atresia or perforation.1

4. Assessment

Physical

Assess and record any signs of bowel obstruction these include

• Vomiting
  • Note - frequency, colour and amount
  • Is it bile stained?

Note: Green bile staining indicates bowel obstruction, if present notify Surgical Team immediately

• Abdominal distension
  • Is abdomen tight or shiny
  • Determine and record degree of distension of the abdomen prior to performing bowel washout

• Bowel action
  • Time since last bowel action
  • Note - frequency, consistency, colour, +/- blood  

Note: Measurement of abdominal girth is no longer used as an accurate method of determining abdominal distension

Investigations

• Abdominal X ray
• Rectal biopsy
• Barium Studies

Medical orders

Medical orders for bowel washout must be written clearly on the treatment order sheet MR55B by the treating surgeons/senior medical staff.  Orders should include:

• Frequency
• Size of tube
• Length to be inserted.
• Amount (mls) Saline solution .9% to be instilled - Maximum per procedure 20mls/kg

Note: Use only saline solution 0.9% - the use of other solutions or concentrations in this patient group may be dangerous

Procedure

Perform bowel washout as prescribed.  The frequency of washouts is determined according to the effectiveness of decompression of the bowel

Notify surgeons if two successive washouts fail to achieve abdominal decompression

Documentation

Observe, and document

• Amount of decompression
  • Note reduction in abdominal distension - Is the abdomen soft, palpable?
• Washout result
  • Volume colour consistency amount and type eg. stool/meconium

Equipment                            Special consideration                         

Process                                                                                               Special Consideration

Complications

Reabsorption of saline

In premature infants, there is a risk of reabsorption of saline, especially if most of the solution is not expelled.  In the case of retention

• contact the surgical team
• consider U+Es
• record volume of saline retained

6. Links

Failure to Pass Meconium: Diagnosing Neonatal Intestinal Obstruction.
Loening-Baucke, V., Kimura, K., 1999. (Electronic version) American Family Physician, 7 http://www.aafp.org/afp/991101ap/2043.html

Bilious Vomiting in the Newborn: Rapid Diagnosis of Intestinal Obstruction. 
Kimura,K., Loening-Baucke, V., 2000. (Electronic version)  American Family Physician, 9 http://www.aafp.org/afp/20000501/2791.html

Hirschprung Disease. 
Lee, Steven.  2003  Retrieved March 30, 2004 from Emedicine: http://www.emedicine.com/med/topic1016.htm

Rectal Wash-Outs. 
Retrieved May 4, 2004-08-05 from University of Michigan section of Pediatric surgery.
pediatric.um-surgery.org/new_070198/new/Library/rectal%20washouts.htm

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