Introduction

Rectal washouts are performed to decompress the lower intestine and deflate the abdomen by removing gas and stool using small amounts of Sodium Chloride 0.9% (normal saline).

They are:

• Performed in babies and children to relieve low bowel obstruction, e.g. suspected Hirschsprung disease (HD), meconium plug disease, meconium ileus or intestinal dysmotility.
  
• Used as a mode of temporary management in proven cases of Hirschsprung disease until definitive surgery is performed.
  
• Used in the management of patients admitted with Hirschsprung Associated Enterocolitis (HAEC).
  
• Used preoperatively in patients undergoing closure of stoma procedures.
  
• May be used in the management of constipation in children.
  

Aim

This guideline is to assist clinicians performing rectal washouts for patients of all ages at the RCH.

Definition of terms

• Hirschsprung disease:  Affects the rectum and usually a variable length of the distal bowel. It is characterised by a lack of normal development of the nerve supply to the bowel wall (ganglion cells). This prevents effective peristalsis and results in a functional bowel obstruction.
  
• Meconium Plug:  Inspissated (thickened) and immobile meconium causes a transient form of distal colonic or rectal obstruction.
  
• Meconium Ileus: This form of obstruction is caused by thick, tenacious meconium which is unable to be propelled through the distal small bowel. Usually the bowel remains in continuity. It may also be associated with volvulus, intestinal atresia or perforation.
  
• Nelaton catheter: smooth rounded catheter for short term temporary drainage, or “in/out”
  
• Peristeen®: Peristeen ®is a bowel washout system that may be used to manage faecal incontinence and chronic constipation for children over 3 years of age.

Assessment

See nursing assessment guideline. 

Physical

Assess and record any signs of bowel obstruction in the EMR flowsheets. These include:

• Vomiting
  • Frequency
  • Colour (containing bile, blood)
  • Amount
• Increasing Nasogastric aspirate
  • Colour
  • Amount
    Note: Green vomitus/nasogastric aspirate indicates the presence of bile, making bowel obstruction more likely. If present, notify surgical team immediately.
• Abdominal distension
  • Describe e.g. tight, shiny, soft, firm, visible bowel loops, visible veins
  • Describe degree of distension of the abdomen prior to performing rectal washout
• Bowel action
  • Time of each bowel action
  • Note - frequency, amount, consistency, colour, +/- blood
  •  Odour – malodorous stools are more common in HAEC
  Note: Routine measurement of abdominal girth is not used as an accurate method of determining abdominal distension

Investigations that may be required prior to a washout:

• Abdominal x-ray
• Lower gastrointestinal contrast study
• Upper gastrointestinal contrast study
• Rectal biopsy

Medical orders

Medical orders by the treating surgeons/senior medical staff must be active in the EMR. 

Washouts need to be ordered on the MAR and should include:

• Frequency
• Size of catheter (in French)
• Amount (mL) of 0.9% Sodium Chloride solution to be instilled (Maximum 20mL/kg per procedure)
  

Note: Use only Sodium Chloride 0.9% solution 

Procedure

Perform the rectal washout as prescribed. The frequency of washouts is determined according to the effectiveness of decompression of the bowel and treatment protocols should be individualised based on the underlying condition. Notify the surgical team if the washout fails to achieve abdominal decompression.

Equipment

• Nelaton catheter with a round tip end and side holes
• Water based lubricant
• 60mL catheter tip syringe
• 0.9% Sodium chloride . This can be the 500mL bottles or 30mL sachets, depending on volume required.
• Blueys/incontinence sheets
• Gloves 
  

Nelaton catheters sizing

Confirm orders with treating surgeon/doctor if they vary from the below guide. Nelaton catheters can be found in the store room of most wards and in the operating theatre. 

Considerations prior to the washout

• Ensure procedural consent obtained by treating surgical team before commencement
• Performing the washout in a treatment room, away from the child's bedside
• A referral to Child Life Therapy for support
• The use of sedation.
• Non-pharmacological pain management strategies, such as sucrose and/or distraction for older children
• See the Acute pain management and/or Procedure Management guideline
• A second staff member or parent to assist
• Ensure the 0.9% Sodium Chloride is warmed prior to use (Do Not use the microwave). Children may cool quite rapidly if the solution is cold.
• Ensure that the child remains warm throughout the procedure. Consider using a blanket or towel to cover their top half.

Step by step guide

• Perform hand hygiene
• Prepare your equipment prior to starting the washout
• Warm 0.9% Sodium Chloride sachets (in a jug of warm tap water)
• Position the neonate or child on his/her back with legs in the frog position 
• You may position an older child on their left side 
• Perform hand hygiene and don gloves
• Select appropriately sized catheter for use
• Lubricate tip of catheter and gently insert into the rectum 
• Initially place an empty catheter into the rectum to dispel any gas
• Remove catheter and then prime with warmed 0.9% Sodium Chloride
• Leave syringe attached to ensure no air enters the catheter
• Lubricate tip of catheter again and gently insert into the rectum
• Length to be determined by the table above
• Instil 0.9% Sodium Chloride solution in 10 - 30 mL aliquots (by pushing in with syringe plunger) over 1-2 minutes (there should be no resistance when injecting the normal saline)
• Remove syringe and let fluid run into nappy/kidney dish/emesis bag.
• Continue to repeat until the prescribed amount of 0.9% Sodium Chloride solution has been used
• Remove catheter from the rectum and leave the patient clean and dry
• Remove gloves and perform hand hygiene
• Clean area, dispose of waste and perform hand hygiene
• Note and record results of rectal washout accurately on the MAR and the fluid balance section of the EMR flowsheets
• Do not use excessive force if resistance is felt. Contact medical staff if unsure
• Do not pull back on syringe to aspirate. Allow the 0.9% Sodium Chloride to run out naturally. Sometimes manipulating the catheter in and out a few centimetres gently and massaging the abdomen may encourage fluid returns to be expelled.
• Do not exceed maximum of 20mL/kg
• If there is 0.9% Sodium Chloride retention or return volume cannot be determined, contact surgeon  
• Monitor for Signs of Hirschsprung's Associated Enterocolitis (HAEC) including: 
  • Offensive smelling stools
  • Unusual colour of stools
  • Looser consistency, explosive stools
  • Blood in stool

Documentation

Link to nursing documentation guideline

Note any reduction in abdominal distension and/or abdominal decompression in the progress notes

 Document the washout result including,

• Signing the MAR
• Updating the fluid balance chart via Flowsheets
• Colour, consistency and type of substance expelled; e.g. stool/meconium/instilled fluid

Complications

1. Reabsorption of 0.9% Sodium Chloride, especially if most of the solution is not expelled. 

In the case of retention of instilled solution: 

• contact the surgical/neonatal team 
• record volume of fluid retained 

2. Bowel perforation

3. Nausea and vomiting

4. Abdominal discomfort

Peristeen

• Peristeen®- The system consists of a bag for water, a control unit for regulation of air and water, a pump for activating the balloon and pumping the water, and a pre-coated rectal catheter with a balloon.
  • Peristeen® may only be used after thorough medical assessment to evaluate precautions and exclude any contraindications. The stomal therapist/continence nurse teaches the parents/carer or child how to use the system.
  • The Peristeen ® system is available on the continence scheme and needs to be ordered for each individual child as requested.  The control unit allows the younger children to participate in their own care and the older children to carry out their washout independently.
    
  • The amount of water used and the frequency of washout are worked out by the stomal therapist/continence nurse according to each child’s needs. The washout is usually performed with the child sitting on the toilet. The washouts may reach stool as far up as the splenic flexure, enabling a more complete emptying.

Special Considerations

• Increased volumes of washout are occasionally required for children that are unable to be adequately decompressed. Members of the treating surgical team (registrar, fellow, consultant and/or the Clinical Nurse Consultant) may use their clinical discretion to increase the washout volume used and the size of the catheters.
• The Colorectal and Pelvic Reconstruction Service Clinical Nurse Consultants will assist in educating families in how to perform rectal washouts if they are required at home. 

Links

• RCH Sucrose nursing clinical guideline
• RCH Neonatal pain clinical guideline
• RCH Comfort kids
• RCH Procedural pain nursing clinical guideline
• RCH Nursing assessment clinical guideline
• RCH Nursing documentation clinical guideline
• CPRS Booklet- Bowel Washout (Rectal)(1).pdf (rch.org.au)
  

Evidence table

The evidence table can be viewed here.

Please remember to read the disclaimer.

The revision of this nursing guideline was coordinated by Jessica Taranto, and Suzie Jackson-Fleurus, CNC, Colorectal & Pelvic Reconstruction Service (CPRS), and approved by the Nursing Clinical Effectiveness Committee. Updated February 2023.