APSA - A contrast challenge is safe in children with adhesive small bowel obstruction- a multi-institutional review - Nathan Rubalcava

Adhesive small bowel obstructions are a well-known cause of morbidity in children following abdominal surgery

Traditional treatment for adhesive small bowel obstruction has been gastric decompression, bowel rest, fluid resuscitation, and electrolyte replacement

Over the last two decades, the use of water-soluble contrast agents in the management of small bowel obstructions has become well established in the adult literature, given their ability to predict the success of non-operative management

A contrast challenge is performed when a patient presents with a small bowel obstruction that qualifies for non-operative management; after gastric decompression, the patient is given contrast and an abdominal X-ray is obtained 8 to 10 hours later

Contrast in the colon is considered having passed the contrast challenge, and after clinical improvement with tolerance of a regular diet, the patient is discharged

For those who still don't have contrast in their colon after a repeat abdominal X-ray at 24 hours, they're considered to have failed their contrast challenge and will be taken to surgery for exploration

Limited data exists with regards to safety and use of a contrast challenge in the pediatric population, yet multiple pediatric institutions have adopted contrast challenge algorithms

The study performed a retrospective review of all children undergoing a contrast challenge across 5 children's hospitals over a period of 8 years

By group consensus, a complication rate less than 5% would be considered safe to use a contrast challenge for clinical practice

Major complications were defined as aspiration, pneumonia, anaphylaxis, cardiovascular complications, and renal failure; minor complications included urticaria, dyspnea, and worsening abdominal pain

Overall, 82 children underwent a contrast challenge; 57 initially passed their challenge, of which 53 had clinical improvement and were successfully discharged

There were no major or minor complications in the study, with a 0% complication rate and a confidence interval of 0 to 3.6%, significantly below the pre-set acceptable complication rate of 5%

There were 25 who failed and were taken to surgery; the 4 that failed to completely resolve were also taken to surgery

There were no mortalities in either group

The group that failed their contrast challenge had a significantly longer hospital stay by 5 days

There was a significant age difference between the two groups, with those passing the challenge being a median of 7 years older

A total of 6 patients were readmitted within 30 days for a recurrent small bowel obstruction

The cohort included patients affected with neurologic and pulmonary comorbidities which were present in over 30% of patients

The contrast challenge has a sensitivity of 100%, specificity of 86%, negative and positive predictive values of 100% and 93% respectively for predicting successful non-operative management

The contrast agents used were institution-specific, all had relatively similar osmodality, with dilute gastrographin being the most commonly utilized agent

This review of 82 patients is the largest to date in children demonstrating that a contrast challenge is safe, effective, and highly predictive

Every institution had a similar protocol that had been mirrored to Doctor Grace Mack from University of Chicago's study from 2018

The Midwest Pediatric Surgery Consortium is conducting a prospective study looking at contrast challenges in pediatric adhesive small bowel obstruction

More pediatric surgeons are adopting contrast challenges after seeing that it was safe with zero complications and effective in predicting which child will be successfully managed non-operatively

This contrast challenge will positively impact the management of every single child that undergoes abdominal surgery because for the rest of their life, they're at risk of adhesive small bowel obstruction