What is the purpose and procedure of the Gastrograffin (diatrizoate) challenge in assessing bowel obstruction or perforation?

From the Guidelines

The Gastrograffin challenge is a valuable diagnostic tool for assessing bowel obstruction, involving the administration of 100 mL of diatrizoate meglumine and diatrizoate sodium diluted in 50 mL of water, with follow-up radiographs at 8 and 24 hours to differentiate partial or low-grade SBO from complete or high-grade SBO. This procedure is based on the most recent evidence from the Journal of the American College of Radiology, which highlights the use of a water-soluble contrast challenge to predict the success of conservative measures in suspected small-bowel obstruction 1. The primary purpose of the Gastrograffin challenge is to determine if a mechanical obstruction exists and to potentially facilitate resolution of partial obstructions.

Key Aspects of the Procedure

• The challenge involves oral or enteric tube administration of the contrast agent
• Follow-up radiographs are performed at 8 hours and 24 hours after ingestion
• The procedure helps differentiate partial or low-grade SBO from complete or high-grade SBO, depending on whether the oral contrast reaches the colon by 24 hours
• Patients in which contrast reaches the colon by 24 hours rarely require surgery, as indicated by studies 1

Clinical Implications

• The Gastrograffin challenge has diagnostic value in determining the need for surgery
• It also has therapeutic potential in resolving partial small bowel obstructions without surgical intervention
• However, its use in the immediate postoperative period was not shown to predict the need for re-exploration, and early reports of possible therapeutic benefits in patients with postoperative SBO remain controversial and uncertain 1
• The procedure should be used with caution, taking into account the patient's hydration status and potential contraindications such as complete obstruction, suspected perforation, or hemodynamic instability.

From the FDA Drug Label

INDICATIONS AND USAGE Diatrizoate meglumine and diatrizoate sodium solution is indicated for radiographic examination of segments of the gastrointestinal tract (esophagus, stomach, proximal small intestine, and colon). The preparation is particularly indicated when a more viscous agent such as barium sulfate, which is not water-soluble, is not feasible or is potentially dangerous Diatrizoate meglumine and diatrizoate sodium solution may also be used as an adjunct to contrast enhancement in computed tomography of the torso (body imaging);

The Gastrograffin challenge uses diatrizoate to assess bowel obstruction or perforation by providing radiographic contrast to visualize the gastrointestinal tract.

• The purpose is to evaluate the presence of bowel obstruction or perforation when other agents like barium sulfate are not suitable.
• The procedure involves oral administration of diatrizoate for radiographic evaluation of the esophagus, stomach, and proximal small intestine 2. The diatrizoate meglumine and diatrizoate sodium exert a mild laxative effect and are sparingly absorbed from the intact gastrointestinal tract, allowing for gastrointestinal opacification and delineation after oral administration 2.

From the Research

Purpose of the Gastrograffin Challenge

• The Gastrograffin challenge is used to assess bowel obstruction or perforation, specifically in cases of small bowel obstruction (SBO) 3, 4, 5.
• The challenge involves the administration of a water-soluble contrast agent, such as Gastrograffin, followed by serial abdominal radiographs to evaluate the passage of contrast through the bowel 4.

Procedure of the Gastrograffin Challenge

• The procedure typically involves the injection of 100 ml of Gastrograffin in adults, or 20-50 ml in children, via a nasogastric tube 4.
• Supine plain abdominal radiographs are taken at 30 minutes and 4 hours after administration to assess the passage of contrast through the bowel 4.
• If contrast passes to the colon, a non-operative course is typically followed, while a clear cut-off in contrast level in the small bowel or failure to pass into the large bowel by 4 hours may indicate the need for surgery 4.

Indications and Contraindications

• The Gastrograffin challenge is indicated for patients with symptoms and signs suggestive of acute small bowel obstruction, but is contraindicated in patients with signs of strangulation or closed loop obstruction 5, 6.
• Patients with a history of abdominal or pelvic malignancy can undergo the Gastrograffin challenge, but may have a higher risk of complications and mortality 7.

Outcomes and Efficacy

• The Gastrograffin challenge has been shown to be safe and effective in predicting the need for operative management in patients with SBO, with comparable long-term recurrence rates to traditional management 6.
• The challenge can also help to reduce the need for operative exploration and improve patient outcomes, including quality of life, in patients with a history of abdominal or pelvic malignancy 7.