Authorised by: Clinical Director Paediatric Surgery Ref.0863 January 2015

www.cdhb.health/nz

Antegrade Continence Enema (ACE) Parent/Caregiver Information

What is an ACE?

An ACE is an antegrade continence enema in

which fluid is delivered directly into the colon

to wash out the bowel. The fluid is delivered

through a soft tube (catheter) which is usually

inserted via a small opening (stoma) on the

tummy wall.

Who has an ACE? The ACE procedure aims to help children and

adults with faecal incontinence or severe long

standing constipation. The procedure is

particularly useful in children with poor control

of their bowels such as those with spina bifida.

It is also useful for some children who have

conditions that may result in faecal

incontinence despite successful corrective

surgery such as those with imperforate anus

or Hirschsprung’s disease. There are also a

few children who have severe constipation

who benefit from having an ACE.

Why does my child need an ACE? An ACE is only considered if other simpler

measures such as dietary changes, toilet

training, and laxatives are not effective OR if

your child is requiring regular enemas or rectal

washouts to clear the bowel to the extent that

their quality of life is impaired.

Things to consider before surgery

You will probably have discussed the

procedure with your GP, a paediatrician,

and a paediatric surgeon. You will also

need to see a stomal therapist and it is

recommended that you see a dietitian.

It takes long-term commitment to make the

surgery a success.

The aim is to train the bowel by performing

the irrigation regularly at a similar time

each day. You therefore need to have

appropriate toilet facilities.

Generally, children older than 10 years of

age are able to manage the irrigations by

themselves with encouragement and

supervision from an adult.

Formation and appearance of the stoma No bowel preparation is required before the

surgery takes place.

When possible, the surgery is done via a

laparoscope (key hole surgery). The end of

the appendix is brought out through the wall of

the abdomen on the right side just a little

below the level of the tummy button. The tip of

the appendix is then opened and stitched to

the skin. This creates a small opening called a

stoma. The stoma is usually less than one

centimetre in diameter. It looks red and is

slightly moist. Once the stoma is healed your

child will not feel it, as there are no sensitive

nerve endings in the appendix.

The stoma acts as a porthole through which a

catheter is inserted. The catheter remains in

place for 3-6 weeks after the operation. It is

kept in place by a small balloon on the inside

of the bowel (which cannot be felt).

If your child does not have an appendix,

another part of the bowel can be used or a

permanent tube inserted.

The catheter is kept open by flushing it with 20

mLs of warm tap water the morning after

surgery. The stoma acts as a one-way valve

and usually there is no leakage coming back

from the bowel. There is little risk of water

from the bath, shower or swimming pool

getting into the opening but it is advisable to

cover the stoma with a waterproof dressing

when swimming. There is no restriction on

activities, including sport.

An

teg

rad

e

Co

nti

ne

nc

e

En

em

a (

AC

E)

CH

ILD

HE

ALT

H

2 Authorised by: Clinical Director Paediatric Medicine Ref.0863 December 2014

Establishing the flushing regimen

1. Wash your hands

2. Get your equipment together

3. Prime the connecting tube with the saline

4. Sit your child on the toilet and attach the

connecting tube to the catheter

5. Run in the solution

6. Wait on the toilet until the bowel is completely

empty (usually about 30 minutes)

7. Wash, dry and store your equipment

Step 1

Flush 350 mLs of saline via the catheter 24 hours

after surgery (usually in the afternoon of the day after

surgery). This volume of water usually washes out the

bowel but if it does not produce a bowel action, move

to Step 2.

Step 2

Flush 500 mLs of saline via the catheter as above.

This is usually done in the morning of the second day

after surgery. If this does not produce a bowel action,

proceed to Step 3 in the afternoon.

Step 3

Syringe sodium phosphate enema (as prescribed by a

doctor) into the catheter, wait for 10 minutes, then

flush 500 mLs of saline through the catheter.

Establish a daily saline flush at a similar time each

day.

Saline solution is made by adding 2 level

teaspoons of salt to 500mLs of clean tap water.

Going home

Your specialist will arrange an outpatient appointment

to take the catheter out about 3-6 weeks after

insertion. This is not painful. At this visit you will be

shown how to use an in/out catheter by the outpatient

nurse. Sometimes, a small permanent catheter (called

a Chait tube) is preferred, or the original catheter is

left in place.

Common questions and answers

Q What happens if my catheter falls out before

the doctor removes it?

A If this happens between 8am and 4pm, contact the

Paediatric Outpatient Department (POPD), phone

364 0640, ext.80732. Outside these hours, contact

Children’s Acute Assessment Unit, phone 364

0640, ext.80428.

Telephone first – please do not just appear.

In most cases, the catheter will be replaced.

Q Will it hurt to put in the catheter?

A No – the bowel does not have sensitive nerve

endings. A little lubricant (water or KY Jelly) on the

catheter helps to make the insertion easier.

Q What do I do if I can’t get the in/out catheter in?

A Ensure you/your child is relaxed. Check to see that

the catheter is well lubricated. Gently repeat the

attempt at insertion. If still unable to insert the

catheter, contact your stomal therapist. You may

need a smaller size catheter.

After hours: contact the hospital as above early the

next day.

If the stoma crusts over, contact your stomal

therapist. You may be given a small dilator to

prevent this happening.

Q How long does it take to do the flush?

A Generally it will take about 45 minutes from start to

finish, but it may take longer (or shorter).

Q How much water do I use?

A Warm tap water is used. The amount can vary

from person to person. It is usually between 350

and 500 mLs for a child and up to 1 litre in an

adult.

Q Do I need to add salt to the water?

A Children under 16 years need 2 level

teaspoons of salt added to 500 mLs of water.

3 Authorised by: Clinical Director Paediatric Medicine Ref.0863 December 2014

Q Do I need to use sodium phosphate enema ?

A If required, your Specialist or GP will prescribe it

and you can get it from your pharmacy. Syringe

the prescribed amount of sodium phosphate

through the catheter 10 minutes before the main

irrigation.

Q What time of day is best to do the irrigation?

A Whatever time of the day that suits you and your

child, but it must be at a similar time each day for

the best result. Evenings are often less rushed.

Q What happens if there is no bowel action?

A There are many factors which can cause this. Your

stomal therapist will advise you on the next step.

Q Does my child need a special diet?

A No, but he/she should follow a healthy diet. It is

important to have enough fibre and fluid in the diet.

It is advisable to speak with the dietitian at Nurse

Maude or the hospital .

Q Where do I get the equipment?

A The hospital staff will give you irrigation equipment

prior to discharge. Ongoing products will be

prescribed by the stomal therapist who will explain

your allocation and provide you with a prescription

card. Your products can be either collected from

Nurse Maude or couriered to your house for a

small fee. People from outside Christchurch will be

referred to a stomal therapist in their own area.

There is no charge for equipment used for ACE

irrigations.

Q What happens if my child is away from home, e.g. school camps, sleepovers?

A As mentioned it is important to continue irrigations

at a similar time each day. Some children are able

to do their irrigation every other day once a routine

has been established.

If you are away from home, it is important that you

remember to take all the necessary equipment with

you to do the irrigation. For camps, etc. it is

advisable to check that the bathroom facilities are

suitable.

Q How do I care for the equipment?

A All equipment is cleaned in hot soapy water,

rinsed under hot tap water and kept dry between

each irrigation in order to prevent infections. It

should be clean but is not sterile. It is also

important to wash and dry your hands before

and after each irrigation.

Q The initial catheter has disappeared ‘inside’ -

what do I do?

A At times you may notice that the catheter moves in

and out and this is not a worry. Movement of the

bowel sometimes draws the tube in but if the

catheter disappears completely, contact the

Paediatric Outpatient Department (POPD), phone

364 0640, ext.80732 between 8am and 4pm

weekdays. Outside these hours, contact Children’s

Acute Assessment Unit, phone 364 0640,

ext.80428.

Q What do I use to cover the ACE?

A When you first go home the catheter site is

covered with a gauze dressing. After the catheter

is first removed, the area does not usually need to

be covered (unless bathing or swimming). Should

you have any concerns about this, contact your

stomal therapist.

Q What happens if the skin gets red and sore around the stoma?

A An infection sometimes develops around the

stoma. Please consult your GP or contact the

hospital. Sometimes the skin around the stoma

can become red because of leakage rather than

infection.

Q Can I have a permanent catheter put in?

A Another option for management is a ‘trap door’

tube (a Chait tube). Your surgeon will advise you

on the suitability of this. Your stomal therapist will

assist you in its care.

Q What if my stoma keeps closing over?

A Some people have difficulty inserting the catheter

into the stoma because the skin tends to grow over

it between irrigations. When this occurs, a ‘plug’

made of silicone can be inserted into the stoma.

Alternatively, a catheter or Chait tube can remain

permanently in the stoma. Please consult your

surgeon.

Q Does an ACE have to be permanent?

A No. In some patients, bowel function and faecal

continence can improve over the years and ACE

irrigations are no longer necessary (e.g. some

children with severe constipation). In this case, the

stoma no longer needs to be catheterised and may

close by itself. If not, it can be closed with a minor

operation.

Contact people:

Nurse Maude Stomal therapist 03 375 4289