Whole-Bowel Irrigation Periprocedural Care: Equipment, Patient Preparation

Sections

Whole-Bowel Irrigation

Periprocedural Care

Equipment

The materials required for whole-bowel irrigation (WBI) include the following:

10% lidocaine solution (see the first image below)
2% lidocaine jelly or KY jelly for lubrication (see the second image below)
Nasogastric (NG) tube of appropriate size (see the third image below)
Reservoir bag to hold irrigation polyethylene glycol electrolyte solution (PEG-ES; see the fourth image below)
PEG-ES (eg, GoLYTELY; see the fifth image below)
Intravenous (IV) pole on which to hang the bag of irrigation solution
Bedside commode (see the sixth image below)

10% lidocaine solution

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2% Xylocaine jelly or KY jelly for lubrication

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Nasogastric tube.

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Nasogastric feeding bag (reservoir bag for the irrigation solution).

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Polyethylene glycol electrolyte solution.

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Bedside commode.

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Anesthesia

Two studies, one involving 60 patients^[29]and the other 206 patients,^[30]demonstrated that the use of both lidocaine spray and lubricating jelly for the insertion of NG tubes was superior to the use of lubricating jelly alone. First, 1 mL of 10% lidocaine solution was sprayed into each nostril, in conjunction with 2 mL of 10% lidocaine solution sprayed into the back of the oropharynx. An NG tube was then lubricated with either lidocaine jelly or KY jelly.

These two simple steps significantly reduced patient pain, discomfort, and related adverse events (cough, epistaxis, chest pain, vomiting, shortness of breath, dizziness, and epigastric pain).^[30]Moreover, the application of lidocaine spray before NG tube insertion increased both physicians' and nurses’ satisfaction during the procedures.^{[29, 30]}

Positioning

A plain abdominal film should be obtained to confirm NG tube placement before the irrigation solution is administered. The patient should be comfortably seated on the bedside commode.

Technique

Goldfarb DS, Ghannoum M. Principles and techniques applied to enhance elimination. Nelson LS, Howland MA, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS, eds. Goldfrank's Toxicologic Emergencies. 11th ed. New York: McGraw-Hill; 2019. 91-100.
Position paper: whole bowel irrigation. J Toxicol Clin Toxicol. 2004. 42 (6):843-54. [QxMD MEDLINE Link]. [Full Text].
Bretaudeau Deguigne M, Hamel JF, Boels D, Harry P. Lithium poisoning: the value of early digestive tract decontamination. Clin Toxicol (Phila). 2013 May. 51 (4):243-8. [QxMD MEDLINE Link].
Gunja N. Decontamination and enhanced elimination in sustained-release potassium chloride poisoning. Emerg Med Australas. 2011 Dec. 23 (6):769-72. [QxMD MEDLINE Link].
Lo JC, Ubaldo C, Cantrell FL. A retrospective review of whole bowel irrigation in pediatric patients. Clin Toxicol (Phila). 2012 Jun. 50 (5):414-7. [QxMD MEDLINE Link].
Roberts DM, Buckley NA. Pharmacokinetic considerations in clinical toxicology: clinical applications. Clin Pharmacokinet. 2007. 46 (11):897-939. [QxMD MEDLINE Link].
Nordt SP, Won KJ, Tomaszweski C, Clark RF. Polyethylene glycol electrolyte lavage solution increases tablet dissolution of acetaminophen in an in vitro model mimicking acute poisoning. Am J Emerg Med. 2020 Feb. 38 (2):325-328. [QxMD MEDLINE Link].
Thanacoody R, Caravati EM, Troutman B, Höjer J, Benson B, Hoppu K, et al. Position paper update: whole bowel irrigation for gastrointestinal decontamination of overdose patients. Clin Toxicol (Phila). 2015 Jan. 53 (1):5-12. [QxMD MEDLINE Link].
Deguigne M, Legeay M, Scholastique AS, Chauveau P, Descatha A. Whole-bowel irrigation in cases of poisoning: A retrospective multicentre study of feasibility, tolerability, and effectiveness. Aust Crit Care. 2022 Apr 27. [QxMD MEDLINE Link].
Höjer J, Forsberg S. Successful whole bowel irrigation in self-poisoning with potassium capsules. Clin Toxicol (Phila). 2008 Dec. 46 (10):1102-3. [QxMD MEDLINE Link].
Verschueren MV, Jansman FGA, Touw DJ, Kramers C. [Treating poisoning; how do you choose the best type of gastrointestinal decontamination?]. Ned Tijdschr Geneeskd. 2018. 162:D1574. [QxMD MEDLINE Link].
Graudins A, Lee HM, Druda D. Calcium channel antagonist and beta-blocker overdose: antidotes and adjunct therapies. Br J Clin Pharmacol. 2016 Mar. 81 (3):453-61. [QxMD MEDLINE Link]. [Full Text].
Schwarz KA, Alsop JA. Pediatric ingestion of seven lead bullets successfully treated with outpatient whole bowel irrigation. Clin Toxicol (Phila). 2008 Nov. 46 (9):919. [QxMD MEDLINE Link].
Faust AC, Terpolilli R, Hughes DW. Management of an oral ingestion of transdermal fentanyl patches: a case report and literature review. Case Rep Med. 2011. 2011:495938. [QxMD MEDLINE Link].
Horowitz R, Mazor SS, Aks SE, Leikin JB. Accidental clonidine patch ingestion in a child. Am J Ther. 2005 May-Jun. 12 (3):272-4. [QxMD MEDLINE Link].
Mrvos R, Feuchter AC, Katz KD, Duback-Morris LF, Brooks DE, Krenzelok EP. Whole fentanyl patch ingestion: a multi-center case series. J Emerg Med. 2012 May. 42 (5):549-52. [QxMD MEDLINE Link].
Jackson J, Randell KA, Knapp JF. Two Year Old With Water Bead Ingestion. Pediatr Emerg Care. 2015 Aug. 31 (8):605-7. [QxMD MEDLINE Link].
Bryant SM, Naples J. Morbidity associated with whole bowel irrigation. Pediatr Emerg Care. 2007 Nov. 23 (11):846. [QxMD MEDLINE Link].
Cumpston KL, Aks SE, Sigg T, Pallasch E. Whole bowel irrigation and the hemodynamically unstable calcium channel blocker overdose: primum non nocere. J Emerg Med. 2010 Feb. 38 (2):171-4. [QxMD MEDLINE Link].
Hendrickson RG, Horowitz BZ, Norton RL, Notenboom H. "Parachuting" meth: a novel delivery method for methamphetamine and delayed-onset toxicity from "body stuffing". Clin Toxicol (Phila). 2006. 44 (4):379-82. [QxMD MEDLINE Link].
Atta-Politou J, Macheras PE, Koupparis MA. The effect of polyethylene glycol on the charcoal adsorption of chlorpromazine studied by ion selective electrode potentiometry. J Toxicol Clin Toxicol. 1996. 34 (3):307-16. [QxMD MEDLINE Link].
Atta-Politou J, Kolioliou M, Havariotou M, Koutselinis A, Koupparis MA. An in vitro evaluation of fluoxetine adsorption by activated charcoal and desorption upon addition of polyethylene glycol-electrolyte lavage solution. J Toxicol Clin Toxicol. 1998. 36 (1-2):117-24. [QxMD MEDLINE Link].
Hoffman RS, Chiang WK, Howland MA, Weisman RS, Goldfrank LR. Theophylline desorption from activated charcoal caused by whole bowel irrigation solution. J Toxicol Clin Toxicol. 1991. 29 (2):191-201. [QxMD MEDLINE Link].
Makosiej FJ, Hoffman RS, Howland MA, Goldfrank LR. An in vitro evaluation of cocaine hydrochloride adsorption by activated charcoal and desorption upon addition of polyethylene glycol electrolyte lavage solution. J Toxicol Clin Toxicol. 1993. 31 (3):381-95. [QxMD MEDLINE Link].
Lapatto-Reiniluoto O, Kivistö KT, Neuvonen PJ. Activated charcoal alone and followed by whole-bowel irrigation in preventing the absorption of sustained-release drugs. Clin Pharmacol Ther. 2001 Sep. 70 (3):255-60. [QxMD MEDLINE Link].
Arimori K, Furukawa E, Nakano M. Adsorption of imipramine onto activated charcoal and a cation exchange resin in macrogol-electrolyte solution. Chem Pharm Bull. 1992. 40 (11):3105-3107. [Full Text].
Arimori K, Deshimaru M, Furukawa E, Nakano M. Adsorption of mexiletine onto activated charcoal in macrogol-electrolyte solution. Chem Pharm Bull (Tokyo). 1993 Apr. 41 (4):766-8. [QxMD MEDLINE Link]. [Full Text].
Kumar VV, Isbister GK, Duffull SB. The effect of decontamination procedures on the pharmacodynamics of venlafaxine in overdose. Br J Clin Pharmacol. 2011 Jul. 72 (1):125-32. [QxMD MEDLINE Link].
Pongprasobchai S, Jiranantakan T, Nimmannit A, Nopmaneejumruslers C. Comparison of the efficacy between lidocaine spray plus lidocaine jelly lubrication and lidocaine jelly lubrication alone prior to nasogastric intubation: a prospective double-blind randomized controlled study. J Med Assoc Thai. 2007 Nov. 90 Suppl 2:41-7. [QxMD MEDLINE Link].
Chan CP, Lau FL. Should lidocaine spray be used to ease nasogastric tube insertion? A double-blind, randomised controlled trial. Hong Kong Med J. 2010 Aug. 16 (4):282-6. [QxMD MEDLINE Link].
Greene S, Harris C, Singer J. Gastrointestinal decontamination of the poisoned patient. Pediatr Emerg Care. 2008 Mar. 24 (3):176-86; quiz 187-9. [QxMD MEDLINE Link].
Scharman EJ, Lembersky R, Krenzelok EP. Efficiency of whole bowel irrigation with and without metoclopramide pretreatment. Am J Emerg Med. 1994 May. 12 (3):302-5. [QxMD MEDLINE Link].
Adamcewicz M, Bearelly D, Porat G, Friedenberg FK. Mechanism of action and toxicities of purgatives used for colonoscopy preparation. Expert Opin Drug Metab Toxicol. 2011 Jan. 7 (1):89-101. [QxMD MEDLINE Link].
Givens ML, Gabrysch J. Cardiotoxicity associated with accidental bupropion ingestion in a child. Pediatr Emerg Care. 2007 Apr. 23 (4):234-7. [QxMD MEDLINE Link].
Narsinghani U, Chadha M, Farrar HC, Anand KS. Life-threatening respiratory failure following accidental infusion of polyethylene glycol electrolyte solution into the lung. J Toxicol Clin Toxicol. 2001. 39 (1):105-7. [QxMD MEDLINE Link].
Sari Gökay S, Çelik T, Yusuf Sari M, Ekinci F, Dinçer Yildizdaş R, Levent Yilmaz H. Urticaria as a Rare Side Effect of Polyethylene Glycol-3350 in a Child: Case Report. Acta Clin Croat. 2018 Mar. 57 (1):187-189. [QxMD MEDLINE Link]. [Full Text].
Assal C, Watson PY. Angioedema as a hypersensitivity reaction to polyethylene glycol oral electrolyte solution. Gastrointest Endosc. 2006 Aug. 64 (2):294-5. [QxMD MEDLINE Link].
Savitz JA, Durning SJ. A rare case of anaphylaxis to bowel prep: a case report and review of the literature. Mil Med. 2011 Aug. 176 (8):944-5. [QxMD MEDLINE Link].
de Graaf P, Slagt C, de Graaf JL, Loffeld RJ. Fatal aspiration of polyethylene glycol solution. Neth J Med. 2006 Jun. 64 (6):196-8. [QxMD MEDLINE Link]. [Full Text].
Hodgman M, Holland MG, Englich U, Wojcik SM, Grant WD, Leitner E. The Influence of Polyethylene Glycol Solution on the Dissolution Rate of Sustained Release Morphine. J Med Toxicol. 2016 Dec. 12 (4):391-395. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Polyethylene glycol electrolyte solution.
Nasogastric feeding bag (reservoir bag for the irrigation solution).
Nasogastric tube.
Bedside commode.
10% lidocaine solution
2% Xylocaine jelly or KY jelly for lubrication

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Author

Rittirak Othong, MD, FACMT, FTCEP Medical Toxicologist, Residency Program Director, Deputy Director, Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Thailand

Rittirak Othong, MD, FACMT, FTCEP is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, Asia Pacific Association of Medical Toxicology

Disclosure: Nothing to disclose.

Coauthor(s)

Stella C Wong, DO Assistant Professor, Department of Emergency Medicine, Emory University School of Medicine

Stella C Wong, DO is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, American College of Osteopathic Emergency Physicians, American Osteopathic Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sophia Sheikh, MD, FACEP Clinical Assistant Professor, Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville; Assistant Medical Director, Florida/USVI Poison Information Center, UF Health Jacksonville

Sophia Sheikh, MD, FACEP is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pain Medicine, American Association of Poison Control Centers, American College of Emergency Physicians, American College of Medical Toxicology, American Pain Society, International Association for the Study of Pain, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Ann-Jeannette Geib, MD Assistant Professor of Emergency Medicine, Director, Medical Toxicology Program, Rutgers Robert Wood Johnson Medical School

Ann-Jeannette Geib, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FFST(Ed), FIMSA, MAMS, MASCRS Dean (Academic) and Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FFST(Ed), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Fellow of the Faculty of Surgical Trainers (RCSEd), Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center

Andrew K Chang, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American Academy of Pain Medicine, American College of Emergency Physicians, American Geriatrics Society, American Pain Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

Whole-Bowel Irrigation Periprocedural Care

Equipment

Patient Preparation

Anesthesia

Positioning

References

Tables

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