Oral water soluble contrast for the management of adhesive small bowel obstruction

Abbas S, Bissett IP, Parry BR

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Summary

This review addresses two questions. First, "Does the oral administration of water soluble contrast media followed by serial abdominal radiographs during the following 24 hours predict the need for early operation or resolution?"

Second, "Does the administration of water soluble contrast media in patients with adhesive small bowel obstruction facilitate the resolution of symptoms and shorten hospital stay?"
Six studies that addressed the first question were included. The pooled results indicated that oral gastrografin is a very accurate predictor of non operative resolution of adhesive small bowel obstruction with a sensitivity of 0.97, specificity of 0.96 and area under the ROC curve of 0.98.
Five studies addressed the second question were included, although Gastrografin does not reduce the need for surgery it does reduce hospital stay in those patients who do not require surgery.

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2010 Issue 1, Copyright © 2010 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This record should be cited as: Abbas S, Bissett IP, Parry BR. Oral water soluble contrast for the management of adhesive small bowel obstruction. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004651. DOI: 10.1002/14651858.CD004651.pub3.

This version first published online: January 24. 2005
Last assessed as up-to-date: March 06. 2007

Abstract

Background

Adhesions are the leading cause of small bowel obstruction. Gastrografin transit time may allow for the selection of appropriate patients for non-operative management. Some studies have shown when the contrast does not reach the colon after a designated time it indicates complete intestinal obstruction that is unlikely to resolve with conservative treatment. When the contrast does reach the large bowel, it indicates partial obstruction and patients are likely to respond to conservative treatment. Other studies have suggested that the administration of water-soluble contrast is therapeutic in resolving the obstruction.

Objectives

To determine the reliability of water-soluble contrast media and serial abdominal radiographs in predicting the success of conservative treatment in patients admitted with adhesive small bowel obstruction.
Furthermore, to determine the efficacy and safety of water-soluble contrast media in reducing the need for surgical intervention and reducing hospital stay in adhesive small bowel obstruction.

Search strategy

The search was conducted using MESH terms: ''Intestinal obstruction'', ''water-soluble contrast'', "Adhesions" and "Gastrografin". The later combined with the Cochrane Collaboration highly sensitive search strategy for identifying randomised controlled trials and controlled clinical trials.

Selection criteria

1. Prospective studies were included to evaluate the diagnostic potential of water-soluble contrast in adhesive small bowel obstruction.
2. Randomised clinical trials were selected to evaluate the therapeutic role.

Data collection and analysis

1. Studies that addressed the diagnostic role of water-soluble contrast were critically appraised and data presented as sensitivities, specificities and positive and negative likelihood ratios. Results were pooled and summary ROC curve was constructed.
2. A meta-analysis of the data from therapeutic studies was performed using the Mantel -Henszel test using both the fixed effect and random effect models.

Main results

The appearance of water-soluble contrast in the colon on an abdominal X ray within 24 hours of its administration predicts resolution of an adhesive small bowel obstruction with a pooled sensitivity of 0.97, specificity of 0.96. The area under the curve of the summary ROC curve is 0.98. Six randomised studies dealing with the therapeutic role of gastrografin were included in the review, water-soluble contrast did not reduce the need for surgical intervention (OR 0.81, p = 0.3). Meta-analysis of four of the included studies showed that water-soluble contrast did reduce hospital stay compared with placebo (WMD= - 1.83) P<0.001.

Authors' conclusions

Published literature strongly supports the use of water-soluble contrast as a predictive test for non-operative resolution of adhesive small bowel obstruction. Although Gastrografin does not cause resolution of small bowel obstruction there is strong evidence that it reduces hospital stay in those not requiring surgery.

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