EP's sometimes have difficulty deciding when to administer whole bowel irrigation and how to implement it. With what common toxins/overdoses would you recommend whole bowel irrigation? How should it be performed?

by
Oliver Hung, M.D.
Attending Physician
Department of Emergency Medicine
Morristown Memorial Hospital
Morristown, NJ

Gastrointestinal decontamination is considered an essential part of treatment of the poisoned patient in the emergency department. The goal is to remove the toxin from the gastrointestinal tract before it can be absorbed systemically. Whole bowel irrigation (WBI) is a relatively new form of gastrointestinal decontamination in which an isotonic and iso-osmolar fluid (polyethylene glycol and electrolytes lavage solution [GolytelyÒ, ColyteÒ]) is administered by a gastric tube into the stomach to quickly flush the ingested toxin through gastrointestinal tract and out the rectum. Administration of large volumes of WBI solution for GI decontamination has been demonstrated to be safe in both adult and pediatric patients. In one case report, a 33 month old with an iron overdose safely received 44.3 liters of WBI solution over a 72 hour period.1

WBI is best suited for decontaminating toxins that are slowly absorbed by the GI tract and that are inadequately adsorbed by activated charcoal. These include: sustained release tablets (e.g. cardizem CDÒ), enteric-coated drugs (e.g. theodur), metals (e.g. lead, lithium, iron), and drug packets (e.g. cocaine "body packer"). Contraindications for WBI include: bowel perforation/obstruction, ileus, acute gastrointestinal hemorrhage, intractable vomiting, and unprotected compromised airway, and hemodynamic instability.

The recommended dose for WBI is 2 liters/hr until rectal effluent is clear (4-6 hrs) for adults and 0.5 liter/hr until rectal effluent is clear (4-6hrs) for infants and children. The major complication from WBI is vomiting and appears related to the rate of administration. Administration of an anti-emetic such as metoclopramide or a serotonin antagonist (e.g. ondansetron) may be required to limit vomiting.

References:

1. Kaczorowski JM, Wax PM. Five days of whole-bowel irrigation in a case of pediatric iron ingestion. Ann Emerg Med 1996;27:258-263.

2. American Academy of Clinical Toxicologists and European Association of
Poisons Centres and Clinical Toxicologists. Position statement: whole bowel
irrigation. J Clin Toxicol 1997;35:753-762.

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