What is the role of Gastrograffin (diatrizoate meglumine) in patients undergoing bowel resection and loop ileostomy?

Role of Gastrograffin in Bowel Resection and Loop Ileostomy

Gastrograffin (diatrizoate meglumine) has limited therapeutic value in routine management of patients with loop ileostomy after bowel resection and should be used selectively rather than routinely.

Diagnostic Applications

Gastrograffin is primarily indicated for radiographic examination of segments of the gastrointestinal tract, including the esophagus, stomach, proximal small intestine, and colon 1. In patients with loop ileostomy after bowel resection, Gastrograffin can be used for:

• Anastomotic integrity assessment: To evaluate the integrity of distal anastomosis prior to ileostomy reversal, though evidence suggests limited value in routine use
• Contrast enhancement: As an adjunct for contrast enhancement in computed tomography of the abdomen when unenhanced imaging may not provide sufficient definition 1

Therapeutic Applications

While Gastrograffin has been studied for therapeutic purposes, its routine use in patients with loop ileostomy after bowel resection has limited evidence:

• Small bowel obstruction: May have therapeutic effect in adhesive small bowel obstruction by:

  • Reducing hospital stay (2.69 ± 1.02 days vs 4.67 ± 1.18 days) 2
  • Potentially decreasing need for surgical management, though not statistically significant (14.5% reduction, p=0.07) 2
  • Accelerating resolution of obstruction (mean time to first stool: 6.2 hours vs 23.3 hours in controls) 3

• Loop ileostomy management: Limited evidence for routine use in patients with loop ileostomy

Evidence Against Routine Use

A review of 81 patients who underwent low anterior resection with loop ileostomy for rectal cancer found that:

• Gastrograffin enema was performed in 69 patients (85.2%)
• Only 4 patients (5.8%) had a positive radiological leak without clinical suspicion
• 2 of these patients subsequently had ileostomy closed despite positive results
• The other 2 had repeat Gastrograffin enema showing no leak 4

The study concluded that routine Gastrograffin enema in the absence of clinical suspicion of anastomotic failure appears to be of little value 4.

Specific Considerations in Loop Ileostomy Patients

High Output Management

Patients with loop ileostomy often experience high output, which can lead to:

• Dehydration
• Electrolyte imbalances
• Malnutrition

For these patients, management should focus on:

1. Fluid and electrolyte balance:

   • Oral rehydration solutions containing sodium and glucose 5
   • Restriction of hypotonic/hypertonic fluids to <1000 mL daily 5
   • Remaining fluid requirements met by oral intake of isotonic glucose-saline solution 5

2. Pharmacological management:

   • Anti-diarrheal medications:
     • Loperamide (first choice, not addictive or sedative) 5
     • Codeine phosphate or opium (second line) 5
   • Octreotide for refractory high output:
     • May reduce ileostomy output 5
     • Requires careful monitoring for fluid retention 5
     • Initial dose typically 50 mcg twice daily subcutaneously 6

3. Nutritional support:

   • Early oral nutrition after surgery when possible 5
   • Adaptation of oral intake according to individual tolerance 5
   • Nutritional assessment before and after major surgery 5

When to Consider Gastrograffin

Gastrograffin may be considered in specific scenarios:

1. Clinical suspicion of anastomotic leak before ileostomy reversal
2. Adhesive small bowel obstruction (not closed loop obstruction) 7
3. Diagnostic uncertainty requiring enhanced contrast imaging

Pitfalls and Caveats

1. Avoid in closed loop obstruction: Gastrograffin should not be used in suspected closed loop obstruction as these patients can rapidly develop bowel ischemia requiring immediate surgery 7

2. Limited value in routine screening: Evidence suggests limited value in routine screening for anastomotic leaks in asymptomatic patients 4

3. Monitoring requirements: When using Gastrograffin, monitor for:

   • Passage of contrast to colon (indicates resolution of obstruction)
   • Signs of anastomotic leak
   • Potential adverse effects

4. Selective use: Reserve for cases where clinical suspicion warrants further investigation rather than routine use

In conclusion, while Gastrograffin has established diagnostic applications in gastrointestinal imaging, its routine use in patients with loop ileostomy after bowel resection has limited therapeutic value. A selective approach based on clinical suspicion and specific indications is recommended.