Rectal washout

The purpose of this guideline is to provide guidance on procedure for rectal washout at Great Ormond Street Hospital (GOSH).

Various methods can be used to empty or clean the bowel. In the majority of cases it is preferable to use laxatives (Rationale 1).

It is important to consider the underlying problem, as laxatives would be contra-indicated in some cases and rectal washouts contra-indicated in others (Rationale 2).

Rectal washouts may be requested to:

• deflate the bowel in Hirschsprung's disease (Molenaar & Meijers 1998)
• prepare the bowel for surgery or investigation
• treat constipation
• control faecal incontinence (Bohr 2009)

Consideration must be given to the psychological affects of rectal procedures in children (Rationale 3). It is unusual to be asked to perform a rectal washout on a child older than a toddler. Other methods of emptying the bowel would be preferable such as high rectal enemas or colonic irrigation.

Preparation for rectal washout on an infant

  • Explain the procedure to the parent/carer(s) (Rationale 4).

  • Prepare the environment where the washout will be carried out (Rationale 5).

  • Gather equipment together (Rationale 6):

    • disposable gloves and apron (Rationale 7)

    • incontinence sheets

    • warm saline

    • rectal tube (10fr or 12fr)

    • 20ml catheter syringe (Rationale 8)

    • disposable bowls

    • lubricating jelly

Procedure 

  • Undress the infant feet to waist and lay down on incontinence sheets. Lying prone with feet held up is preferred (Rationale 9).

  • Wash hands.
  • Pour warm saline into the bowl, draw up 20mls into the syringe and attach the rectal tube.

  • Prime the tube with saline (Rationale 10).

  • Put on apron and disposable gloves. Lubricate the end of the tube.

  • Locate the anus and gently insert the tube about 1-2 inches (Rationale 11).

  • Slowly inject the saline into the rectum. Once it has entered gently draw back on the syringe. If any pressure is felt stop drawing back. If no saline can be drawn back, disconnect the syringe from the tube and gently move the tube back and forth to stimulate evacuation by gravity (Rationale 12).

  • Evacuated stool and saline should be collected in a disposable bowl (Rationale 13).

  • No more than 20mls of saline should be instilled at one time. Medical staff should decide the amounts of saline to be used in pre-term babies (Rationale 14).

  • Repeat the above steps until the abdomen is deflated or the saline is running clean (Rationale 15).

  • Medical staff may have prescribed how much saline to be used in total. If not, the warmth of the child should be considered (Rationale 16)

  • When the washout is completed gently remove the tube, clean the infant and dress.

  • Dispose of equipment, wash hands and document washout and result in the infant's notes.

Rationale

Rationale 1: Laxatives can be a simpler and more effective means of cleaning the bowel, as well as being less embarrassing and uncomfortable for the child.
Rationale 2: If the child has a mechanical obstruction of the bowel, stimulating peristalsis with laxatives can cause increased discomfort and possibly perforation. Children with inflammatory bowel disease have friable bowels and insertion of a rectal catheter or enema nozzle could cause perforation. 
Rationale 3: These procedures can be seen as intrusive and in some cases a form of assault (Royal College of Nursing, 2003a; Royal College of Nursing, 2003b). 
Rationale 4: This can be a distressing procedure for families of new babies. Explanation throughout the procedure can lessen their distress.
Rationale 5: The room needs to be warm as the infant will be partially clothed.
Rationale 6: To ensure the procedure is uninterrupted.
Rationale 7: To adhere to standard precautions.
Rationale 8: Catheter syringe is needed if a rectal tube is used.
Rationale 9: The infant can potentially assume any position, lying prone with the feet up allows good visibility of the anus, legs cannot kick out and the parents are closer to provide comfort to the infant.
Rationale 10: The tube needs to be primed, as air will be introduced into the rectum. This will cause extra distension of the rectum.
Rationale 11: one to two inches is enough to begin with; the rectum can be emptied and the tube can then be advanced more easily if necessary.
Rationale 12: Drawing back on the syringe allows the procedure to be performed more quickly, and will cause no problems as long as there is no pressure felt.
Rationale 13: It is necessary to check the amount of saline being introduced into the bowel is being returned. This is to avoid over-distending the bowel.
Rationale 14: Overfilling the rectum/sigmoid colon could cause distension and possible perforation.
Rationale 15: This will depend upon why the washout has been prescribed. If the washout is bowel prep for surgery the saline should run clean. If the infant has Hirschsprung's disease or is constipated the washout can stop when the abdomen is deflated.
Rationale 16: Attempts should be made to keep the infant warm at all times. If the infant cannot be kept warm the washout should be stopped and if required repeated later.

References

Reference 1:
Bohr C (2009) Using rectal irrigation for faecal incontinence in childrenNursing Times 105 (7): 42, 44. [Accessed on 25/02/2015]

Reference 2:
Molenaar JC, Meijers C (1998) Hirschsprung's disease in paediatric surgery (Chap. 23) Atwell JD In: Paediatric Surgery. London, Edward Arnold Publishers. 

Reference 3:
Royal College of Nursing (2003a) Digital rectal examination and the manual removal of faeces: the role of the nurse 3rd edition. [Accessed on 25/02/2015]

Reference 4:
Royal College of Nursing (2003b) Digital rectal examination: Guidance for nurses working with children and young people. [Accessed on 25/02/2015] 

Document control information

Lead Author(s)

Helen Johnson, Clinical Nurse Specialist: Stoma Care, Surgery

Document owner(s)

Helen Johnson, Clinical Nurse Specialist: Stoma Care, Surgery

Reviewing and Versioning

First introduced: 
17 May 2005
Date approved: 
24 February 2015
Review schedule: 
Three years
Next review: 
24 February 2018
Document version: 
2.0
Previous version: 
1.0