Whole bowel irrigation

Whole bowel irrigation involves the rapid administration of a large volume of an osmotic macrogol laxative to flush out the gastrointestinal tract, thereby preventing the absorption of ingested drugs and toxins. Whole bowel irrigation is more labour-intensive than giving activated charcoal for gastrointestinal decontamination. The median time to diarrhoea is 4 hours from the initial administration.

Consider whole bowel irrigation if a patient presents within 4 hours after ingesting a drug or toxin with a risk of significant toxicity. These include toxic doses of:

  • metals—iron, lithium
  • modified-release preparations—verapamil, diltiazem, metformin, potassium, theophylline.

Whole bowel irrigation may also be considered for ‘body packers’ and ‘body stuffers’1.

Patients must be alert, cooperative and able to protect their airway to undergo whole bowel irrigation, or be intubated and receive the whole bowel irrigation preparation via a nasogastric or orogastric tube—confirm correct placement of the nasogastric or orogastric tube beforehand. Do not initiate whole bowel irrigation in a patient at significant risk of pulmonary aspiration or with established ileus. During treatment, examine patients hourly for signs of ileus, in particular increasing abdominal distension.

Discuss the need for whole bowel irrigation and which preparation to use (see Examples of macrogol 3350 (with electrolytes) preparations used for whole bowel irrigation) with a clinical toxicologist. If whole bowel irrigation is indicated for poisoning, use:

macrogol 3350 (with electrolytes) solution 1 to 1.5 L (child: 20 to 30 mL/kg up to 1.5 L) orally or via nasogastric or orogastric tube; commence within 4 hours after the estimated time of ingestion and consume within 1 hour decontamination for poisonings macrogol

FOLLOWED BY

macrogol 3350 (with electrolytes) solution 1 L/hour (child: 20 to 30 mL/kg/hour up to 1 L/hour) orally or via nasogastric or orogastric tube, until the diarrhoea runs clear.

Reassess the patient if whole bowel irrigation is associated with vomiting, or significant returns of irrigation fluid on aspiration of the nasogastric or orogastric tube.

Table 1. Examples of macrogol 3350 (with electrolytes) preparations used for whole bowel irrigation

[NB1]

Brand (total amount of powder per sachet)

Preparation of whole bowel irrigation solution [NB2]

ColonLYTELY (68.58 g)

2 sachets in 2 L of water

Glycoprep C (70 g)

2 sachets in 2 L of water

Glycoprep (200 g)

1 sachet in 3 L of water

Movicol (13.7 g)

8 sachets in 2 L of water

Moviprep (A and B)

A plus B sachets in 2 L of water

Note:

NB1: Macrogol 3350 is also known as polyethylene glycol.

NB2: These instructions are specifically recommended for whole bowel irrigation; instructions for preparation of the solution on the product packaging may be different because these products are generally used for bowel cleansing.

1 ‘Body packer’ refers to an individual who smuggles large quantities of illicit drugs in securely sealed packages. Leakage of the packaging is usually delayed, by which time it has entered the small or large intestine; presentation to the emergency department is often long after swallowing the packages. ‘Body stuffer’ refers to an individual who hurriedly ingests illicit drugs in insecure packages to avoid arrest. This packaging has a high risk of leakage and patients are likely to present earlier.Return