In reply:

Abstract

The issue of gastrointestinal decontamination has generated intense discussion and disagreement for many years. If one peruses the information available regarding the 3 most common procedures: activated charcoal, gastric emptying, and whole bowel irrigation, the most striking observation is the similarity of evidence available for each procedure. Each procedure has supporting data from “volunteer human trials” that support their efficacy. (Volunteer trials enroll healthy volunteers, do not use a toxic dose of the test substance, and avoid clinically important variables that might muddy the data.) These trials indicate that all 3 procedures can reduce the blood concentration of some poisons. In addition to volunteer trials, each technique has some enticing small studies or trials (usually with serious limitations) that also support a belief in their efficacy. Finally, all 3 have still other studies that question their effectiveness in clinical practice. Particularly in the case of whole bowel irrigation, there are solid data that question the efficacy, effectiveness, and overall value of the procedure.Activated charcoal has the most evidence available and is used by emergency physicians commonly. It also has meaningful published safety data supporting its use. In contrast, there are several troubling aspects regarding the data available for whole bowel irrigation. First, whole bowel irrigation has by far the least data available; therefore, the uncertainty about the meaning of the data is large. Second, data regarding safety are sparse. Even if whole bowel irrigation is effective, we do not know if its net impact is beneficial in practice. Finally, the data available are the most divided and conflicting among the 3 procedures. In addition to the publication by Ly et al,1.Ly B.T. Schneir A.B. Clark R.F. Effect of whole bowel irrigation on the pharmacokinetics of an acetaminophen formulation and progression of radiopaque markers through the gastrointestinal tract.Ann Emerg Med. 2004; 43: 189-195Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar other studies indicate that whole bowel irrigation may be ineffective and have little or marginal clinical value.2.Lapatto-Reiniluoto O. Kivisto K.T. Neuvonen P.J. Activated charcoal alone and followed by whole-bowel irrigation in preventing the absorption of sustained-release drugs.Clin Pharmacol Ther. 2001; 70: 255-260Crossref PubMed Scopus (20) Google Scholar, 3.Mayer A.L. Sitar D.S. Tenenbein M. Multiple-dose charcoal and whole-bowel irrigation do not increase clearance of absorbed salicylate.Arch Intern Med. 1992; 152: 393-396Crossref PubMed Scopus (40) Google Scholar, 4.Scharman E.J. Lembersky R. Krenzelok E.P. Efficiency of whole bowel irrigation with and without metoclopramide pretreatment.Am J Emerg Med. 1994; 12: 302-305Abstract Full Text PDF PubMed Scopus (15) Google ScholarUntil more data are available, it is not unreasonable to exercise our clinical skills and use whole bowel irrigation in carefully selected cases. Until clinically meaningful data are produced, the debate about whether whole bowel irrigation is effective or not will remain an argument of the proverbial glass “half-empty” or “half-full.” We should not forget that syrup of ipecac was embraced in the same manner for 3 decades, but is now discouraged, except for selected applications. The issue of gastrointestinal decontamination has generated intense discussion and disagreement for many years. If one peruses the information available regarding the 3 most common procedures: activated charcoal, gastric emptying, and whole bowel irrigation, the most striking observation is the similarity of evidence available for each procedure. Each procedure has supporting data from “volunteer human trials” that support their efficacy. (Volunteer trials enroll healthy volunteers, do not use a toxic dose of the test substance, and avoid clinically important variables that might muddy the data.) These trials indicate that all 3 procedures can reduce the blood concentration of some poisons. In addition to volunteer trials, each technique has some enticing small studies or trials (usually with serious limitations) that also support a belief in their efficacy. Finally, all 3 have still other studies that question their effectiveness in clinical practice. Particularly in the case of whole bowel irrigation, there are solid data that question the efficacy, effectiveness, and overall value of the procedure. Activated charcoal has the most evidence available and is used by emergency physicians commonly. It also has meaningful published safety data supporting its use. In contrast, there are several troubling aspects regarding the data available for whole bowel irrigation. First, whole bowel irrigation has by far the least data available; therefore, the uncertainty about the meaning of the data is large. Second, data regarding safety are sparse. Even if whole bowel irrigation is effective, we do not know if its net impact is beneficial in practice. Finally, the data available are the most divided and conflicting among the 3 procedures. In addition to the publication by Ly et al,1.Ly B.T. Schneir A.B. Clark R.F. Effect of whole bowel irrigation on the pharmacokinetics of an acetaminophen formulation and progression of radiopaque markers through the gastrointestinal tract.Ann Emerg Med. 2004; 43: 189-195Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar other studies indicate that whole bowel irrigation may be ineffective and have little or marginal clinical value.2.Lapatto-Reiniluoto O. Kivisto K.T. Neuvonen P.J. Activated charcoal alone and followed by whole-bowel irrigation in preventing the absorption of sustained-release drugs.Clin Pharmacol Ther. 2001; 70: 255-260Crossref PubMed Scopus (20) Google Scholar, 3.Mayer A.L. Sitar D.S. Tenenbein M. Multiple-dose charcoal and whole-bowel irrigation do not increase clearance of absorbed salicylate.Arch Intern Med. 1992; 152: 393-396Crossref PubMed Scopus (40) Google Scholar, 4.Scharman E.J. Lembersky R. Krenzelok E.P. Efficiency of whole bowel irrigation with and without metoclopramide pretreatment.Am J Emerg Med. 1994; 12: 302-305Abstract Full Text PDF PubMed Scopus (15) Google Scholar Until more data are available, it is not unreasonable to exercise our clinical skills and use whole bowel irrigation in carefully selected cases. Until clinically meaningful data are produced, the debate about whether whole bowel irrigation is effective or not will remain an argument of the proverbial glass “half-empty” or “half-full.” We should not forget that syrup of ipecac was embraced in the same manner for 3 decades, but is now discouraged, except for selected applications. In reply:Annals of Emergency MedicineVol. 44Issue 6PreviewDr. Tenenbein raises a valid issue about the interpretation provided in the capsule summary. The more a summary is condensed (and details omitted), the more interpretation exists. We have cautioned readers about this in the initial editorial introducing this new feature1; we think they understand this limitation well and prefer the brevity to increasingly lengthy explanations. Anyone genuinely interested in the topic of a capsule summary is strongly advised to actually read the article before they come to a conclusion. Full-Text PDF