Bowel washouts using an antegrade colonic enema (ACE)

Bowel washouts are a method of dealing with constipation or with soiling, which is the leakage of faeces (poo) other than during a bowel movement. If other methods fail, doctors may recommend bowel washouts using an antegrade colonic enema (ACE). This can also be called the Malone or MACE method. This page from Great Ormond Street Hospital (GOSH) explains about bowel washouts using an ACE and what to expect when your child has treatment.There are many reasons why a child may soil including:

• congenital (present at birth) abnormalities affecting the anus and rectum
• neuropathies (nerve supply problems) as a result of spinal abnormalities like spina bifida.
• overflow incontinence which is often seen in children with severe constipation.

Other methods of treating constipation and soiling will usually be tried first, and may include bowel training, dietary changes, medications taken by mouth, medications taken rectally (enemas or suppositories) or colonic irrigation.

Before you can start doing bowel washouts, your child will need an operation under general anaesthetic to create the antegrade colonic enema (ACE) channel. This usually uses the appendix to create a channel from the skin into the large bowel at a point called the caecum. The fluid used to wash out the bowel can then be inserted easily. This fluid flushes the faeces out through the rectum in the usual way.

Some children may need to have ‘bowel preparation’ to empty their bowel of faeces before the operation – your surgeon will inform you if this is the case. Bowel preparation may involve taking a medication by mouth and washouts involving insertion of fluids into the bowel using the rectum. During this bowel emptying process, your child will not be able to eat any solid food and only drink fluids.

The surgeon will visit you to explain about the operation in more detail, discuss any worries and ask you to sign a consent form giving your permission for the operation.

At GOSH, most ACE operations are carried out using keyhole surgery (laparoscopy). Depending on the surgical method used, the surgeon may disconnect the appendix from the caecum and then reconnect it. Alternatively, they may leave the appendix in its original position and bring the end up to the wall of the tummy. In both methods, the end of the appendix is opened up to form a channel from the tummy wall to your child’s large bowel.This is called a stoma (artificial opening). If your child has already had their appendix removed or if it is not suitable, the surgeon may need to use another method to create the passage.

All surgery carries a small risk of bleeding during or after the operation. There is a small risk of infection and your child will usually be given antibiotics at the time of the operation to minimise this risk. Every anaesthetic carries a risk of complications, but this is very small. Your child’s anaesthetist is a very experienced doctor who is trained to deal with any complications. After an anaesthetic some children may feel sick and vomit. They may have a headache, sore throat or feel dizzy. These side effects are usually short-lived and not severe.

Your child will come back to the ward to recover. For the first day or two, they will have a drip giving fluids and medication until the bowel starts to recover. The drip will be removed when your child starts eating and drinking again. The surgeon will have inserted a catheter (thin, plastic tube) into the stoma to keep it open. This should stay in place for at least four to six weeks after the operation. In some cases, the catheter may need to stay in place for longer. This varies from child to child.

When your child has recovered from the operation, and eating and drinking again, the nurse will teach you how to do bowel washouts using the ACE. The first washout is usually performed on the second or third day after surgery. The washout solution varies from child to child, depending on their needs. The amount of fluid also varies and is worked out according to your child’s age and size. For the first few weeks, the make-up of the solution may need changing to get the best result.

When you are confident, you and your child will be able to return home. The stoma site needs to be treated as a wound for the first five days. Your nurse will show you how to care for it. After that, you should keep the stoma clean by washing it once a day and then patting it dry with a towel. Do not rub the stoma site as this will make it sore.

You will be asked to return to the ward four to six weeks after surgery to have the catheter tube removed. You will then be taught to insert a catheter into the ACE channel (stoma) for carrying out a washout. In between washouts, a small silicone plug will be placed into the stoma. This should stay in the stoma all the time, only being removed when a washout is needed. The stoma can shrink a little after the operation but this is prevented from being a problem by using the silicone plug.

Your nurse at GOSH will give you enough supplies to start doing bowel washouts. After this your family doctor (GP) will prescribe further supplies. Remember to order enough supplies in plenty of time. If you have any problems, please contact your specialist nurse.

It can take many weeks for a child to be free from oiling completely. It can help to keep a daily diary of progress. You will be able to keep in contact with your nurse if you have any questions or concerns. Your surgeon will also arrange a review in the outpatients department to discuss your child’s progress.

You will need:

• catheter (if it is not already in place)
• ingredients for washout solution
• measuring jug
• syringes or washout bag

1. Make up the washout solution according to your nurse’s instructions.
2. Wash your hands
3. Insert the catheter gently into the stoma. This is easier if your child is standing upright or lying down.
4. Sit your child on the toilet
5. Using the syringes or the washout bag, insert the washout fluid into the catheter at a slow and steady rate.
6. When you have inserted all the washout fluid, remove the catheter
7. Your child will need to stay on the toilet for between 30 and 45 minutes until the bowel has emptied.
8. Wash the catheter out in warm, soapy water and leave to dry.

You cannot insert the catheter into the stoma

• Reinsert the silicone ACE stopper
• Contact your nurse for advice
• On rare occasions, the stoma may need stretching and this is performed under a general anaesthetic.

Your child feels has tummy ache or feels sick and/or vomitsThere is little or no change in your child’s soilingYour child develops a tummy bug (diarrhoea and vomiting)Your child’s stoma is bleedingYour child’s stoma is sore and oozingBowel contents seem to be leaking from the stoma

• Washouts can cause tummy cramps but these usually stop when the washout has finished.
• Tummy cramps can also occur if the washout solution is too cold.
• If your child feels sick and/or vomits, contact your nurse as the washout solution may need changing.
• You should see some positive changes in the first few weeks following surgery, but it can take six to eight weeks to be free from soiling altogether.
• Do not give your child a bowel washout more than once in 24 hours.
• If this continues, contact your nurse as the washout solution may need adjusting or your child may need more frequent washouts.
• Do not give your child a bowel washout if they are ill.
• Check with your nurse before you start the washouts again.
• Passing the catheter into the stoma can sometimes cause minor bleeding, but this usually stops when the catheter is removed.
• If bleeding continues, please contact your nurse for advice.
• Stoma infections sometimes occur, usually fairly soon after the operation. This will produce redness, swelling and discharge. Contact your GP as your child may need a course of antibiotics.
• In the long term, any weeping from the stoma is likely to be mucous. This is quite usual. You can cover the stoma with a small dressing or plaster if the oozing is affecting your child’s clothes. There may be overgrowth of tissue around the stoma (called granulation) and this may need treatment by your specialist nurse.
• Contact your nurse or doctor as the stoma may need checking or your child may be constipated or the stoma may have stretched.