Bowel irrigation ( rectal washout ) for under one year old infants and children - Guideline for the management of

Publication: 23/02/2012  --
Last review: 26/09/2018  
Next review: 26/09/2021  
Clinical Guideline
CURRENT 
ID: 2858 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the management of bowel irrigation (rectal washout) for under one year old infants and children

Aim

To rationalise and streamline the procedure of bowel washouts in infants and children who have Hirschsprung’s disease, meconium ileus, a cloaca or have a distal stoma requiring irrigation.

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Objectives

  • To provide details of the procedures and equipment used.
  • To identify potential problems
  • To provide the evidence collated
  • To provide an abdominal assessment tool for guidance
  • To prevent potentially hazardous bowel infections

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Background

Bowel irrigation is a means of emptying and cleaning the large intestine using a catheter and sodium chloride 0.9%.

Currently there is no available national consensus regarding the procedure of rectal Washout (RWO) or Distal Loop Washout (DLWO) at less than one year of age. A literature search highlights the variability of how much sodium chloride 0.9% is used either per instillation or per procedure; which type of tube should be inserted or how far to advance the rectal tube.

However, the scanty literature found, lends itself to some of the current practice at the Leeds Teaching Hospitals NHS Trust for procedures such as:

  • a time intensive procedure as in Hirschsprung’s disease
  • a less time consuming intervention for meconium ileus
  • a brief sterile distal loop washout as for a baby who has cloaca
  • or a non sterile brief DLWO/RWO once per month- or as instructed by surgeons.

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Assessment of the infant

Initial assessment of the sick infant who has or potentially has Hirschsprung’s Disease shows an indication of the urgency for a rectal washout to be undertaken.

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Types of bowel irrigation

1 Hirschsprung’s Disease (HD)

The infant with this condition is unable to pass stool or wind effectively, due to the absence of ganglion cells within the intestinal mucosa which initiates peristalsis. Therefore, rectal washouts for suspected or confirmed Hirschsprung’s Disease are the most essential part of the whole safe management of these patients in prevention of Hirschsprung’s Enterocolitis (HE). This involves RWO starting at 2 - 3 times daily after surgeons review, reducing to once daily prior to discharge, and using approximate volumes of 100mL/ kg of sodium chloride 0.9% for irrigation.

2 Meconium Ileus (MI)

This condition presents itself in the neonatal period causing intestinal obstruction due to thick, sticky Meconium within the intestines usually found as an indicator of Cystic Fibrosis. Acetylcysteine solution used as a rectal washout assists in breaking down the Meconium so it may be passed more easily. Please see: http://www.leedsformulary.nhs.uk/chaptersSubDetails.asp?FormularySectionID=24&SubSectionRef=24.16&SubSectionID=A100&drugmatch=3576#3576
Using smaller volumes of sodium chloride 0.9%, 50mL/kg, leave the Acetylcysteine in situ for 10 minutes and then irrigate the bowel again with sodium chloride 0.9% until clear.

3 Post stoma surgery distal loop washout (DLWO)

Where an ano-rectal malformation is diagnosed and a colostomy is subsequently formed, it is essential to ensure the large intestinal segment from the mucus fistula to the anus is clean. 20mL/kg of sodium chloride 0.9% is used in 10 - 20ml increments into the mucus fistula and allowed to drain out again until the solution is clear. This is done monthly or less frequently depending on the surgeons advice.

4 Cloaca

A colostomy may need to be formed as a neonate for imperforate anus but there may be connecting fistulae from the colon to the vagina or bladder. The DLWO would need to be undertaken under aseptic techniques with 20mL/Kg sodium chloride 0.9% to prevent cross contamination. The washout needs to be requested by the patient’s surgeon. Sometimes antibiotics are prescribed to prevent infection due to translocation of bacteria that can occur during the washout.

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Hirschsprung’s Disease

Equipment

Warm sodium chloride 0.9% (100mL/kg)
Lubricating gel - alcohol free
Bowl
Measuring jug
Large bore, soft catheter (from at least size 12)
50mL bladder syringe
Apron
Gloves
Large towel/disposable pad
Changing mat
Baby wipes
Disposable bag

Procedure

Note: Bowel washouts and flatus tubes are prescribed care and should be carried as requested by the surgeon. Details of the washout need to be documented afterwards. Escalate to surgeon if the washout is not effective or does not decompress the abdomen. Washouts should be done at roughly the same time each day.

  1. Prepare equipment and ensure a warm environment.
  2. Wash hands and apply apron and gloves.
  3. Place on a changing mat in a comfortable position.
  4. Wrap a towel around the upper half of the body and expose the buttocks.
  5. Observe their behaviour, perfusion and feel the abdomen before and after the procedure. Consider use off soother/pacifier, if parents agree.
  6. Remove plunger from the syringe, connect empty syringe to the catheter.
  7. Lay onto the left side or supine to aid the flow into the large intestine. Apply lubricating gel to the tip and length of the catheter (approx 10cm), and the anus. (An empty catheter inserted at the beginning releases flatus before the start of the washout). Run 10mL sodium chloride 0.9% through the catheter and kink the tubing.
  8. Gently insert the catheter into the rectum and unkink the tubing allowing the sodium chloride 0.9% to run in whilst advancing the tubing until resistance is felt. Allow the sodium chloride 0.9% to drain out into syringe.
  9. Holding the catheter in position with one hand, fill the syringe barrel to 20mL and allow the fluid to run in, by gravity. Abdominal massage at this point is helpful to move the stool, if tolerated. Lower the syringe and allow the fluid to flow out again holding the syringe in a way that you can measure the output, pour into the large collecting bowl.
  10. The procedure should be repeated until the sodium chloride 0.9% in the jug has been used or the fluid draining out is clear.
  11. Gently and slowly withdraw the catheter in 2cm increments from the anus whilst massaging the abdomen. Only remove the catheter if the tube becomes blocked with thick stool if really necessary, gently re-insert. Do not keep taking the tube out. Observe the colour, consistency and smell of the effluent.
  12. Wash and dry the buttocks, apply barrier cream.
  13. Measure the fluid in the bowl, approximately 50mL may be short due to spillages or fluid escaping around the catheter during the washout.
  14. The aim is to irrigate the large bowel with 100mL/kg and gain 100mL/kg with stool by the end of the procedure.
  15. Dispose of the soiled fluid. Wash thoroughly and dry the equipment.
  16. Change the consumables weekly.
  17. Assess the abdomen after the washout to ascertain effectiveness of washout.

Signs of Infection- Hirschsprung’s Enterocolitis

  • Offensive smell from stools.
  • Unusual colour of stools.
  • Looser consistency, explosive stools.
  • Blood, mucus in the stools.
  • Lethargy, poor feeding, vomiting, pallor.
  • Temperature of unknown origin.

Post procedure

If the final result of the washout for HD is not entirely clear, it may be necessary to repeat the procedure later in the day. However, take notice of the abdomen and further soiled nappies later, it may not be necessary to repeat the procedure.

If there was a good result from the washout (HD) but later the baby appears to be uncomfortable and has a full abdomen, the rectal tube can be passed into the rectum, without sodium chloride 0.9%; the relief from expelling flatus may be all that is required.

Problem solving for rectal washout in HD

Most of the problems with the process of the washout involve the stools that are too thick and block the tube or prevent the tube from passing into the rectum.

  • Hold the syringe barrel high and rapidly squeeze and release the catheter tubing.
  • Place plunger in top of syringe and press very gently until the sodium chloride 0.9% starts to flow then remove the plunger.
  • Gently move tube around to re-position tip of tube.
  • As a last resort, remove the tube, rinse through the catheter and re-insert.
  • Occasional specks of blood are seen in the tubing, due to irritation of the tube with the intestinal tract.
  • Fresh bleeding down the catheter - stop the rectal washout and inform the babies Surgeon. May be requested to retry after a couple of hours.
  • As weeks go by there may be some difficulty passing the tube initially, this can be eased by introducing the catheter and advancing the tube whilst the sodium chloride 0.9% is flowing in.

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Meconium Ileus

Follow the procedure for rectal washout as for Hirschsprung's Disease except use 50mL/kg in total of warmed sodium chloride 0.9%, in 20mL increments. Instill Acetylcysteine solution, leave for 10-15 minutes, and allow draining out via rectal tube.

Please see monograph for dosage and administration of Acetylcysteine: http://www.leedsformulary.nhs.uk/chaptersSubDetails.asp?FormularySectionID=24&SubSectionRef=24.16&SubSectionID=A100&drugmatch=3576#3576

Equipment;

Acetylcysteine- Required dose
Warm sodium chloride 0.9% (50mL/kg)
Lubricating gel - alcohol free
Bowl
Measuring jug
Large bore, soft catheter - at least size 10Fg
50mL bladder syringe
Apron
Gloves
Large towel/disposable pad
Changing mat
Baby wipes
Disposable bag

Procedure

  1. Prepare equipment and ensure a warm environment.
  2. Wash hands and apply apron and gloves.
  3. Place on a changing mat in a comfortable position.
  4. Wrap a towel around the upper half of the body and expose the buttocks.
  5. Observe behaviour and perfusion, and feel the abdomen before and after procedure.
  6. Remove plunger from the syringe, connect empty syringe to the catheter.
  7. Lay onto left side or supine to aid the flow into the large intestine. Apply lubricating gel to the tip and length of the catheter (approx 10cm), and the anus. An empty catheter inserted at the beginning releases flatus before the start of the washout. Run 10mL sodium chloride 0.9% through the catheter and kink the tubing.
  8. Gently insert the catheter into the rectum and unkink the tubing allowing the sodium chloride 0.9% to run in whilst advancing the tubing until resistance is felt. Allow the sodium chloride 0.9% to drain out into a bowl. Instil Acetylcysteine as per pharmacy guidance.
  9. Allow the Acetylcysteine to remain in situ for 10 - 15 mins if possible. Drain out the fluid before continuing the procedure.
  10. Holding the catheter in position with one hand, fill the syringe barrel to 20mL and allow the fluid to run in. Lower the syringe and allow the fluid to flow out again holding the syringe in a way that you can measure the output, pour into the large collecting bowl.
  11. The procedure should be repeated until the sodium chloride 0.9% in the jug has been used or the fluid draining out is clear.
  12. Gently and slowly withdraw the catheter in 2cm increments from the anus whilst massaging the abdomen.
  13. Observe the colour, consistency and smell of the effluent.
  14. Wash and dry the buttocks, apply barrier cream.
  15. Measure the fluid in the bowl to ensure most of the fluid has been excreted.
  16. The aim is to irrigate the large bowel with 50mL/kg and gain 50mL/kg with stool by the end of the procedure.
  17. Dispose of the soiled fluid. Wash and dry the equipment thoroughly.
  18. Change the consumables weekly.

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Distal Loop Washout (DLWO)

Equipment

Warm sodium chloride 0.9% (100mL bag)
Pair of scissors
Lubricating gel - alcohol free
Bowl
Measuring jug
Size 6 and 8 ng tubes or size 10 rectal tubes
20mL bladder syringe
Apron
Gloves
Large towel/disposable pad
Changing mat
Baby wipes
Disposable bag

Procedure

NB: Liaise with the Consultant Paediatric Surgeon prior to the procedure regarding potential problems.

i.e: some infants may have a fistula between the bowel and genitourinary tract and therefore may develop a urinary tract infection.

  1. Prepare equipment and ensure a warm environment.
  2. Wash hands and apply apron and gloves.
  3. Place on a changing mat, in a comfortable position.
  4. Wrap a towel around the upper half of the body and expose the mucous fistula.
  5. Observe and feel the abdomen before and after procedure.
  6. Remove the plunger from the syringe; connect the empty syringe to ng tube.
  7. Run 10mL of warmed sodium chloride 0.9% through the syringe barrel and tube, kink the tubing to prevent the flow.
  8. Lubricate the tip of the tube with lubricating gel.
  9. Gently insert the catheter into the mucous fistula allowing sodium chloride 0.9% to run in whilst advancing the tubing until resistance is felt. Allow the sodium chloride 0.9% to drain out into a bowl.
  10. Holding the catheter in position with one hand, fill the syringe barrel to 10- 20mL and allow the fluid to run in. Lower the syringe and allow the fluid to flow out again holding the syringe in a way that you can measure the output, pour into the large collecting bowl. There may be a delay in drainage. If so, remove the tube and run through with 5mL of sodium chloride 0.9% to clear the tube. The mucous within the fistula is often thick and blocks the small tube.
  11. Insert the tube again and allow the sodium chloride 0.9% to drain out of the fistula.
  12. Turn baby from side to side a couple of times to allow mucous to be dislodged and mixed with sodium chloride 0.9%.
  13. Observe the colour, consistency and smell of the effluent.
  14. Wash and dry the area, advise the family that there might be some natural drainage later.
  15. Measure the drainage in comparison to what was started with, if possible.
  16. Dispose of the soiled fluid.
  17. Discard all consumables. Repeat the process monthly or as directed by the Consultant Paediatric Surgeon.

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Cloaca

Equipment
Warm sodium chloride 0.9% (100mL bag) or 20mL/kg
Pair of scissors
Lubricating gel - alcohol free
Bowl
Measuring jug
Size 6 and 8 Ng tubes- sterile
Size 10 rectal tube-sterile
20mL bladder syringe-sterile
Apron
Large towel/disposable pad
Changing mat
Baby wipes
Disposable bag
Sterile dressing pack and sterile gloves (powder free)

NB: Liaise with the Consultant Paediatric Surgeon prior to the procedure regarding potential problems.

I.E: some infants may have a fistula between the bowel and genitourinary tract and therefore may develop a urinary tract infection. There is also a risk of bacterial translocation through the gut wall, which may in turn lead to a bacteraemia. Prophylactic antibiotics may be indicated.

Procedure:

  1. Prepare equipment and ensure a warm environment.
  2. Wash hands and apply apron and gloves.
  3. Place on a changing mat in a comfortable position.
  4. Wrap a towel around the upper half of the baby and expose the mucous fistula.
  5. Observe and feel the abdomen before and after procedure.
  6. Remove the plunger from the syringe; connect the empty syringe to ng tube.
  7. Run 10mL of warmed sodium chloride 0.9% through the syringe barrel and ng tube, kink the tubing to prevent the flow.
  8. Lubricate the tip of the tube with aquagel.
  9. Gently insert the catheter into the mucous fistula tubing allowing sodium chloride 0.9% to run in whilst advancing the tubing until resistance is felt.
  10. Holding the catheter in position with one hand, fill the syringe barrel to 20mL and allow the fluid to run in. Lower the syringe and allow the fluid to flow out again holding the syringe in a way that you can measure the output, pour into the large collecting bowl. There may be a delay in drainage, if so, remove the tube and run through with 5mL of sodium chloride 0.9% to clear the tube. The mucous within the fistula is often thick and blocks the small tube.
  11. Insert the tube again and allow the sodium chloride 0.9% to drain out of the fistula.
  12. Turn from side to side a couple of times to allow mucous to be dislodged and mixed with sodium chloride 0.9%.
  13. Observe the colour, consistency and smell of the effluent.
  14. Wash and dry the area, advise the family that there might be some natural drainage later.
  15. Measure the drainage in comparison to what was started with.
  16. Dispose of the soiled fluid. Discard all consumables. Repeat the process monthly or as directed by the Consultant Paediatric Surgeon.
  17. Advise parent of potential pyrexia post procedure and what action to take. Ensure contact telephone numbers of professional advice is available.

An additional person is required to assist, this enables the procedure to be as clean as possible.

It is essential to document the following information for the parent/carers and nurses prior to discharge into primary care with all competencies completed and signed by an expert in undertaking all the documented procedures in this guideline.

The practitioner will:

  • Record the reason why the baby is having rectal washouts
  • The size and type of catheter to be used
  • How far to insert the catheter
  • The volume of fluid
  • The type of fluid
  • The temperature of the fluid
  • Discuss the principles of effective hand washing
  • Demonstrate effective hand washing and drying
  • Discuss the consequences of ineffective hand washing
  • Discuss the preparation of the environment before and after performing the rectal washout
  • State how often the rectal washouts need to be performed
  • Competently demonstrate the correct procedure
  • Discuss how the procedure may affect the baby
  • Discuss the potential problems which may occur
  • Discuss the strategies to overcome the problems

Provenance

Record: 2858
Objective:
  • To provide details of the procedures and equipment used.
  • To identify potential problems
  • To provide the evidence collated
  • To provide an abdominal assessment tool for guidance
  • To prevent potentially hazardous bowel infections
Clinical condition:

Hirschsprungs Disease / Meconium Ileus

Target patient group: Less than one year old
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

References

Bradnock T and Walker G (2008). The current management of Hirschsprung’s Disease in the UK: A National Summary of Practice.

Carman M (2005). Management Medical Treatment Bowel Irrigation with Sodium chloride 0.9% Solution? Colon and Rectal Surgery. Oxford

Chattopadhyay, Anindya, Prakash, Bhanu, Vepakomma, Deepti, Nagendhar, Yoga, Vijsyskumsr (2004). A prospective comparison of two regimes of bowel preparation for paediatric colorectal procedures: sodium chloride 0.9% with added potassium vs. polyethylene glycol. Paediatric Surgery International. Vol 20, No. 2, p127 - 129 (3)

Clinical Guidelines (Hospital). Neonatal Bowel Washout.http://www.rch.org.au/rchcpg/index.cfm?doc_id=9220

Gabra H, Stewart R, Nour S (2007). Mid-gut malrotation and associated Hirschsprung’s Disease: a diagnostic dilemma. Pediatric Surgery International. 23 : 703 - 705

Hosseini S, Foroutan H, Zeraation S, Sabet B (2008). Botulinium toxins, as bridge to transanal pull through in neonate with Hirschsprung’s Disease. Journal of Indian Association of Paediatric Surgeons. Vol 13, Iss 2, p69 - 71

Junj K, Masahiro N, Norihiro N, Shuichi Y, Yoshihirok, Akiko K (2003). Preoperative Colonic Decompression and Irrigation Through a Transanal Tube to Perform the One-Stage Pull-Through procedure for Hirschsprung’s Disease. Journal of the Japanese Society of Paediatric Surgeons. Vol 39, No 1, p73 - 78

Kessman J (2006). Hirschsprung’s Disease: Diagnosis and Management. American Family Physician. 74: 1319 - 1322/1327 - 1328. http://www.aafp.org/afp/AFPprimter/20061015/1319/html

Lee S, Puapong D, Dubois J (2006). Hirschsprung’s Disease. eMedicine - http://www.emedicine.com/med/TPOIC1016.HTM

Molenaar J and Meijers C (1998). Hirschsprung’s Disease in Paediatric Surgery (Chapter 23).
In: Paediatric Surgery London. Ed Arnold Publishers

Parithan P, Chiengkriwate P, Chow Chuvech V, Patrapinyoleuls, Sangkhathat S (2007). Bowel prescription for pull-through operation in Hirschsprung’s Disease. Sangkla Medical Journal. 25 (5): 401 - 406

Robb A and Lander A (2008). Hirschsprung’s Disease. Surgery (Oxford). Vol 26, Iss 7, P288 - 290

Ownership Leeds Neonatal and Paediatric services
Published August 2011
Review date September 2018
Next Review date: September 2021

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Abbreviations used:

1 RWO - Rectal washout
  HD - Hirschsprungs Disease
  HE - Hirschsprungs Enterocolitis
2 MI - Meconium Ileus
3 DLWO - Distal Loop Washout

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