Rectal washouts in children with Hirschsprung’s disease

Advice for parents and carers on performing rectal washouts at home

What is Hirschsprung’s disease?

Hirschsprung’s disease is a disorder in which the nerve cells (called ‘ganglion cells’) are absent from part of the bowel. This prevents the bowel from being able to move stool (poo) along the bowel normally and so the child experiences constipation or an obstruction in the bowel. We have an information leaflet that provides detailed information for parents and carers about Hirschsprung’s disease in children; please ask a member of our staff if your child is being tested for, or has been diagnosed with, Hirschsprung’s disease and you have not been provided with this leaflet.

What is a rectal washout?

The medical term for a rectal washout is ‘trans-anal irrigation’. Rectal washouts are a way of emptying stool from the bowel via the anus. A tube (called a rectal catheter) is lubricated then gently passed into your child’s bottom. Warm (body temperature) salty water is then instilled down the tubing, through the catheter and into your child. This warm salty water helps to make the stool more liquid. As soon as the salty water has been given, the tubing is lowered and the poo containing water is drained back out. This process is repeated, often many times, until the colour of the fluid that is leaving your child’s bottom via the catheter is a very pale (barley) colour.

Why does my child require rectal washouts?

Due to the absence of ganglion cells within the bowel, children with Hirschsprung’s disease are unable to fully clear their bowel of stool and flatus (gas) themselves. Rectal washouts therefore decompress the bowel, that is, clear the bowel of stool and gas.

How often will my child require a rectal washout?

Children who have Hirschsprung’s disease and are waiting for surgery to remove the affected part of the bowel will need a washout at least daily and, in most cases, twice per day.

After corrective surgery, most children do not need regular washouts but some will continue to need washouts for a period of a few weeks, whilst swelling after surgery settles. Some children will need intermittent washouts for short periods during times of concurrent illness when they have become constipated.

Who will teach me to undertake a rectal washout?

The nurses on our children’s ward will teach you how to perform the rectal washouts.

Who will need to be taught?

Two people are needed to undertake a bowel washout, although very occasionally, when a parent has become very experienced and the child is willing to lie very still, one parent can complete the washout by him/herself.

Before you go home we will ensure that at least two people have been trained to perform the rectal washouts; this is usually the child’s parents or carers. However, we advise that another person (family member or good friend) is also made aware of how to undertake the rectal washouts so that, if a parent/carer becomes unwell or for some other reason is not available, the washout can still go ahead without causing problems for the child.

Is there an alternative to undertaking rectal washouts at home?

In children receiving home rectal washouts due to underlying Hirschsprung’s disease, the alternative is for your child to have a stoma formed. Forming a stoma is an operation in which a section of the bowel is brought out onto the surface of the skin so that stool is then passed into a bag. The stoma would be closed at a later date, after surgery to remove the affected section of bowel has been completed.

What are the benefits of rectal washouts?

• Effective rectal washouts ensure that the child’s stool is regularly cleared and so keeps the child healthy.
• Rectal washouts clear any trapped wind, which can otherwise be very uncomfortable.
• Rectal washouts avoid the need for a stoma in the majority of cases.
• In most cases, where rectal washouts can be given at home, the child spends less time in hospital overall.

What are the risks/ complications of rectal washouts?

As with all procedures there are risks, but these are rare. They include:

• Bleeding – Occasionally a small amount of blood may be seen on the rectal catheter or in the fluid containing stool. It is important to ensure that adequate amounts of lubricating jelly are used when the rectal catheter is inserted, to prevent trauma to the bowel from insertion of the tube.
• Failure to adequately clear the bowel of faeces (‘inadequate decompression’) – It is important that the washout is given until the fluid running out is light barley coloured as this is the best indicator that the bowel has been adequately cleared of faeces. You will also notice that the abdomen feels soft after a washout that has adequately decompressed the bowel.

How will we get supplies of the items we need to perform the rectal washouts?

When you leave hospital you will be supplied with seven to 14 days of all items of equipment that you need.

How you receive ongoing supplies of equipment will depend on where you live, but you will be informed of this before you leave hospital. For most children, equipment is available through a combination of prescriptions via your child’s general practitioner (GP), a home delivery company and your child’s community nursing team.

The nurse specialist team will, with your permission, arrange a referral for your child to be seen by a children’s community nurse, but it is essential that you have registered your child with a GP. The nurse referral and GP registration must be completed before you leave hospital to ensure that you continue to receive the equipment that you need without interruption.

A chart is available at the end of this leaflet, which we will complete so that you know exactly from where your child’s supply of equipment has been arranged.

What support will we get whilst at home and whom should I call with any queries?

What is the procedure when undertaking a rectal washout?

The environment:

It is important to have an appropriate area in which to perform the rectal washout. This should be an area where you have good light and sufficient space, is warm for your child and has a comfortable surface that is of appropriate height to both protect your back and to allow the washout fluid to run below the height at which your child is lying.

Preparation of the sodium chloride (salty water)

It is important to warm the salty water to body temperature before starting the washout. This will ensure the washout is as comfortable as possible for your child (using cool water can result in cramping sensations during the washout), and the warm water will help to break down the stool into a liquid consistency more effectively. Sodium chloride can be warmed in a sink or bowel filled with hot water.

Preparation of your equipment

• Put on your disposable gloves and apron
• Connect the catheter tipped syringe to the rectal catheter
• Apply lubricating jelly to the rectal catheter
• Arrange the remainder of the equipment so that it is within your reach

Positioning and preparation of your child

In babies, rectal washouts are performed with the baby lying on his/her back. An old towel is useful to cover your child’s upper body to help keep him/her warm.

In older children, rectal washouts should be performed with the child positioned on his/her left side.

Young babies often fall asleep during rectal washouts, but older babies and children may benefit from having a toy or activity to distract them during washouts.

Your preparation for undertaking the washout

Decide who will be person A and who will be person B during the rectal washout. Person A will insert the rectal catheter, whilst person B administers the washout and collects the stool.

In mothers who have recently given birth, we advise that the mother takes on the role of person A, as she can insert the catheter and then position herself sitting next to the child in a more comfortable position.

Undertaking the washout

• Person ‘A’ gently pushes the rectal catheter into the child’s bottom. The exact length of tubing to be inserted will depend on your child’s age and size, but (1) it is essential that all of the eyelet holes enter the child’s bottom to ensure that the salty water is administered into your child’s bowel; (2) if an insufficient length of tubing is inserted, the salty water will be observed leaking out of your child’s bottom immediately, and still clear in colour.
• Once the rectal catheter is in place, Person ‘B’ should lower the extension tubing to below the height of the child to evacuate any trapped wind or stool that is immediately ready to be cleared. Person ‘B’ then needs to raise the syringe above the height of the child and pour some of the sodium chloride (‘salty water’) into the syringe. The sodium chloride should run down the tubing via gravity. The exact volume of fluid to be administered per washout (and as a portion of the total) will be advised by the nurses and will depend on your child’s age and size. As a guide, newborn babies usually have 20ml of fluid given per portion. Babies aged over three months may have 30 to 40ml and older children will usually have at least 50ml of fluid per portion.

The volume of sodium chloride advised for my child at the time of discharge from hospital

is__________ ml per aliquot (portion of the total volume)

The total volume per washout advised for my child is_________________

• Once the advised volume of fluid has run down the extension set and into your child’s bottom, person ‘B’ needs to immediately lower the syringe down below the height of the child and ensure that the receptacle is available in which to allow the stool containing fluid to run and be collected.
• Instilling further aliquots (portions) of fluid is then repeated until the output is light yellow (barley) coloured.
• Whilst person ‘B’ is instilling and draining the salty water, it is useful for person ‘A’ to gently massage the child’s abdomen. Not only is this comfortable for the child but it can also help to break down the stool and so speed up the overall time of the washout.
• Once the output is running ‘clear’ (that is, pale yellow in colour), person ‘B’ needs to slowly remove the rectal catheter, whilst ensuring that the syringe is being maintained at a position lower than the height of the child. This will ensure that as much of the salty water is drained as possible.
• All equipment used is disposable so should be placed into an appropriate rubbish bag at the end of the procedure.
• The 0.9% sodium chloride can be kept, re-sealed and used for 24 hours but after 24 hours any remaining fluid must be discarded into a sink and a new bottle opened.
• It is important for your child to be washed/ bathed at the end of the procedure and for you to ensure that you wash your hands carefully.
• It is useful to make a note of the total volume of sodium chloride used as children tend to have a pattern with regards to how much fluid they need, and your care team is likely to ask you about this during review consultations.

Useful contact details

For further information/queries please contact:

Your nurse specialist (Mon to Fri 0800 to 1800) 01223 586973

Your children’s community nursing team

____________________________________

The ward you were on

___________________________________________________

Your child’s home delivery company

________________________________________