Implementation of a Contrast Challenge Algorithm for Adhesive Small Bowel Obstructions in Children: A Prospective, Multi-Institutional Study.

Objective: Evaluate if hyperosmolar water-soluble contrast challenges (CC) can improve clinical outcomes and reduce hospital length-of-stay (LOS) in children with adhesive small bowel obstruction (ASBO).

Background: Despite documented efficacy of CC algorithms in adults with ASBO, ongoing variability exists in management of children.

Methods: This is a multi-institutional prospective, pre/post-algorithm implementation study of a contrast challenge algorithm in children (≤18 y) admitted with ASBO (10/2021-09/2023). Primary analysis compared patients managed in the pre-implementation phase to those in the post-implementation phase. Secondary analysis compared all patients undergoing CC to those who did not. Primary outcome was LOS. Secondary outcomes included proportion of patients receiving CC, CC-associated complications, and proportion of patients undergoing surgery. Sensitivity, specificity, negative (NPV) and positive (PPV) predictive values of CC were calculated.

Results: 264 patients were treated for ASBO (pre-implementation phase: n=77, adoption phase: n=80, post-implementation phase: n=107). CC use increased from 53% to 86% (pre-to-post-implementation; P<0.001). The proportion of patients undergoing surgery (35.1 vs 37.4%, P=0.747) and LOS remained similar (5.1 vs 5.6 d, P=0.802). Across all three phases, 189 patients received a CC with zero contrast-related complications. Compared to patients who did not receive CC (n=75), those receiving CC had a similar proportion undergoing surgery (42.7 vs. 33%, P=0.154) with similar LOS (5.0 vs 6.3 d, P=0.137) but significantly lower rates of readmission (2.6 vs 10.7%, P<0.001). Diagnostic performance of the CC included a sensitivity 100%, specificity 81%, NPV 100%, PPV 91%.

Conclusion: Contrast challenges in children are safe with excellent diagnostic performance to guide clinical decision-making.