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PEDIATRICS Vol. 112 No. 6 December 2003, pp. 1302-1307

Postreduction Management of Intussusception in a Children’s Hospital Emergency Department

Lalit Bajaj, MD, MPH and Mark G. Roback, MD

From the Section of Emergency Medicine, Children’s Hospital and University of Colorado Health Sciences Center, Denver, Colorado


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Objective. To evaluate the current management of patients with intussusception who have undergone successful reduction by contrast enema in a tertiary care children’s hospital. To compare differences in the incidence of recurrence and adverse events between those patients who were hospitalized after enema reduction and those who were observed in the emergency department (ED).

Methods. This was a retrospective cohort study of children 0 to 18 years of age who underwent uncomplicated enema reduction for intussusception. Hospitalization versus ED observation management were compared for length of stay, incidence of recurrence, and adverse events.

Results. One hundred twenty-three children were identified with an International Classification of Diseases, Ninth Revision code for intussusception. Of those, 106 patients (86%) had an enema reduction attempted. Three had a normal enema and were given the diagnosis of "resolved intussusception." Eighty-three (80%) of the patients had a successful reduction. Seventy-eight (94%) of those patients had no preexisting condition and had complete medical records. Of those 78 patients, 27 (35%) were hospitalized and 51 (65%) were observed in the ED. The mean length of hospitalization was 22.7 hours (range: 10–50 hours), and the mean length of ED observation was 7.2 hours (range: 0–21 hours). Eleven recurrences were observed in 8 of these 78 patients (10% recurrence rate). Four patients in the hospitalized group and 4 patients in the ED observation group had recurrences (5 hours-10.9 months). Four of the 8 patients had a recurrence within the first 48 hours. All first recurrences occurred after the patient had been discharged from the hospital or ED observation unit. No adverse events occurred in any of the patients who had a successful initial reduction (95% confidence interval [0%–4.6%]).

Conclusions. The postreduction management of intussusception is variable at our institution. Previously healthy patients who have undergone successful enema reductions are unlikely to have adverse outcomes. Postreduction observation in the ED or the hospital does not seem to affect outcomes in this clinical setting.

Key Words: intussusception • enema reduction • outpatient management

Abbreviations: PLP, pathologic lead point • ED, emergency department • LOS, length of stay

Intussusception is the most common cause of intestinal obstruction in infancy and can lead to intestinal necrosis, resection, and even death if not recognized and treated promptly.1 The cause of intussusception in children is idiopathic in 90% of cases and is presumed to be related to intestinal lymphoid hyperplasia. The remaining cases are secondary to a pathologic lead point (PLP) such as a Meckel’s diverticulum or intestinal lymphoma.2 Intussusception has also been reported postoperatively and after blunt abdominal trauma.3,4 The association between intussusception and the rotavirus vaccine prompted the removal of the product from the market in 1999.5

Making the diagnosis of intussusception is challenging because of the wide variety of clinical presentations and overlap with other conditions.6–8 The reduction of an intussusception with contrast enema techniques, in particular air enema, has become standard in many institutions including our own, with success rates ranging from 75% to 85%.9–14 Surgery is reserved for those cases that fail enema reduction, those where a PLP is identified on an imaging study, or in the presence of free air or peritonitis. Long duration of symptoms and small bowel obstruction on plain radiographs are no longer contraindications to an enema reduction attempt.15 A large amount of variability exists in all phases of intussusception management. This includes variability in the use of ultrasound in diagnosis as well as in the monitoring of the reduction attempt.1,2,15–24

An area of intussusception management that has not been well-studied is the management of patients after a successful enema reduction. Eklof and Reiter25 published data from a series of patients in 1978 and recommended a 48-hour observation period postenema reduction to observe for recurrence. The recurrence rate for intussusception is ~10%, with a third of these occurring within the first 48 hours.26–29 The infrequent occurrence of early recurrence and delayed adverse events, as well as the difficulty in predicting which patients will recur,27,30 has most likely led to many modes of management after a successful enema reduction including outpatient management. Parashar et al31 noted that data on hospitalized children with intussusception most likely underestimate the true incidence, because many centers may be managing these patients as outpatients.

The purpose of this study was to describe the current management of patients with intussusception who have undergone successful reduction by enema in a tertiary care children’s hospital. We also attempted to assess for differences in the incidence of recurrence and adverse events between those patients who were hospitalized postenema reduction versus those who were observed in the emergency department (ED).


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
This was a retrospective cohort study of children 0 to 18 years of age who underwent uncomplicated enema reduction for intussusception identified via International Classification of Diseases, Ninth Revision code 540.0 from January 1, 1997, to July 31, 2001. Demographic, historical, physical examination, laboratory, radiographic, length of stay (LOS), recurrence, and adverse outcome data were abstracted from the charts by using a standardized data-collection sheet. A recurrence was defined as any return to our facility with an intussusception within 1 year of the initial presentation. An adverse outcome was defined as perforation, bowel resection, or sepsis.

The patients in our analysis had to meet the following inclusion criterion: successful enema reduction performed via barium or air contrast enema. Exclusion criteria were: patients who did not undergo an enema reduction attempt, patients with unsuccessful reduction attempts, patients with a normal enema, patients with a preexisting medical condition, and patients with incomplete medical records.

The included study subjects then were analyzed with respect to hospital admission or ED observation. Continuous variables such as age, duration of symptoms, and LOS were analyzed via the Student t test, and categorical variables such as presence of vomiting, fever, and bloody stool were analyzed via the Fisher exact test by using SAS (SAS Institute, Inc). This study protocol was approved by the Colorado Multiple Institutional Review Board.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Over the 4-year, 7-month study period, 123 patients were identified with a diagnosis of intussusception. These patients ranged in age from 1.4 months to 12.6 years. Sixty-six percent of these patients were male.

Of these 123 patients, 106 (86%) had an enema attempt performed. Those 17 patients who did not have an enema performed represented a heterogeneous population of children who either presented with acute abdominal symptoms, a mass seen on an imaging study, or chronic medical problems or received a discharge diagnosis of "self-resolved intussusception." Nine of these patients went to surgery: 5 had an uncomplicated reduction, 2 had a diagnosis of lymphoma, and 2 underwent a bowel resection.

One hundred six patients had an enema attempt. Three patients3 had a normal enema and were given a diagnosis of "resolved intussusception." Twenty patients had unsuccessful enema reductions and proceeded to surgery: 16 had uncomplicated reductions, 2 had a Meckel’s diverticulum (1 also with a bowel resection), and 2 underwent bowel resection.

The remaining 83 patients underwent successful enema reduction. Two patients had underlying medical conditions (acute lymphocytic leukemia and Henoch-Schönlein purpura), and 3 had incomplete medical records. The remaining 78 patients were included in our further analysis (Fig 1).


Figure 1
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  		Fig 1. Intussusception patients identified by International Classification of Diseases, Ninth Revision code 540.0 from January 1, 1997, to July 31, 2001.

 
These 78 patients had a mean age of 19 months, ranging in age from 3.5 months to 6.4 years. Sixty-eight percent of these patients were male. Fifty patients (64%) had either blood tests or a catheter-obtained urine specimen conducted in the process of the diagnostic work-up. There were 81 radiographic studies performed in these 78 patients. Seventy-four patients (95%) had abdominal series performed, and 65 (88%) were read by the attending pediatric radiologist as "abnormal." There were 4 patients who were diagnosed via ultrasound, and 3 were diagnosed by computed tomography scan.

An enema was performed in all patients under fluoroscopy guidance for definitive diagnosis and reduction. The majority of the enemas were air enemas (85%), and the remaining 15% had a barium enema, before universal institution of air enema at our facility. There were no cases of perforation noted in these patients at the time of enema reduction. All study patients had an ileocolic intussusception.

Twenty-seven (35%) patients were admitted to the hospital after the successful enema reduction, and 51 (65%) were observed in the ED. Figure 2 summarizes the pattern of admission versus observation by year for the study period. There was a decrease in hospital admissions over the study period.


Figure 2
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  		Fig 2. Postreduction management: hospitalized versus observed by year.

 
There were no significant differences between the groups in terms of age, gender, and duration of symptoms. Historical features such as fever, fussiness, and vomiting did not differ between the 2 groups. Recorded physical examination features such as altered mental status, level of hydration, and abnormal abdominal examination also did not differ between the 2 groups. The hospitalized group had a mean LOS of 22.7 hours (range: 10–50 hours), and the ED observation group had a mean LOS of 7.15 hours (range: 0–21 hours). This difference was statistically significant (P < .001) (Table 1).


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  		TABLE 1. Postsuccessful Enema Reduction Patients: Hospitalized Versus Observed

 
Eight (10.3%) of these 78 patients had recurrences, with a total number of 11 events. These patients are shown in Table 2. Four of the patients had recurrences within the first 48 hours (range: 5–47 hours). None of these patients had their initial recurrence under medical supervision. Two of the patients who had recurrences underwent exploratory laparotomy, and neither had a PLP or any adverse event (perforation, bowel resection, or sepsis). None of the patients who underwent a successful reduction and were otherwise healthy had an adverse outcome, including those who returned with a recurrence (95% confidence interval: 0%–4.6%).


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  		TABLE 2. Recurrences After a Successful Enema Reduction

 
Thirteen patients returned for evaluation of recurrent symptoms and did not have a documented recurrence. Eight of these patients had been observed in the ED, and 5 had been admitted to the hospital.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Although intussusception is relatively common in pediatrics, significant variability in diagnosis and treatment modalities exist.1,2,15–24 The management of children after a successful enema reduction is an area that has not been well studied. Eklof and Reiter25 published a study of patients in 1978 who had recurrent intussusception and recommended a 48-hour observation period after successful reduction to observe for early recurrence as well as infectious and surgical complications such as perforation and peritonitis. It is now well-documented that recurrences of intussusception can be reduced safely with enema techniques with a success rate of up to 95%,27,28 and that the incidence of PLPs is not increased until the patient has >1 recurrence.28

Jinzhe et al32 published in 1986 a study of patients in China who underwent enema reduction, 87% of which were treated as outpatients. No follow-up data were given, and it appeared that outpatient management was common practice in China. In 1988, Bonadio33 published a study of 88 children with intussusception. Forty-eight of these patients had successful enema reductions, and 7 were treated as outpatients. Bonadio stated that patients could be followed safely as outpatients if they had a normal physical examination and tolerated oral fluids postreduction. This series of patients had a very low reduction success rate (55%), and a recurrence was considered an adverse outcome.

In 1999, Le Masne et al34 published, in the European literature, data from a series of patients who underwent an uncomplicated enema reduction. They were either discharged from the hospital after 8 hours of observation, if the parents could return quickly and could be reached by telephone, or were admitted to the hospital. They found no difference in the incidence of recurrence between the 2 groups. They did not, however, provide any data on adverse events.

We report our experience with postreduction management of intussusception and have found that the majority of the patients (65%) were managed as outpatients after a variable time of observation. The remaining 35% of the patients were hospitalized postreduction. These patients did not differ in age, duration of symptoms, or historical or physical examination features. We also found that hospital admissions at this institution decreased over the time period studied. Consistent with published studies, those patients who either did not have an enema attempt or had an unsuccessful enema were more likely to have a PLP or bowel necrosis compared with those patients with an uncomplicated enema reduction.9,10

The recurrence rate in our population was 10% (8 of 78 patients), which is consistent with previous data.26–29 Four of the 8 patients had recurrences within the first 48 hours and are considered "early recurrences." None of these patients were being observed in either the hospital or the ED at the time of their initial recurrence. Two of the patients with recurrences underwent exploratory laparotomy for evaluation for a PLP, and in neither patient was a PLP detected. No child had an adverse event such as perforation, bowel necrosis, or clinically evident sepsis in our series.

The observation period recommended by Eklof and Reiter of 48 hours is not being practiced at our institution. In addition, the majority of the patients are being observed in the ED observation unit rather than being admitted to the hospital. Patients then are discharged from the hospital with specific instructions to return if symptoms recur or any other concerns arise. It was not possible to determine from the medical records if the decision to admit was based on the availability of transportation or any other social factor.

Adverse events did not occur in our population of patients with an uncomplicated reduction, but case reports do exist in the literature. In 2001, Royal35 published a case report of a previously healthy 7-month-old girl who received an uncomplicated air enema reduction of an ileocolic intussusception. She was admitted and 1 hour later became highly febrile and hypotensive. After receiving intravenous fluids and antibiotics overnight, she became afebrile, alert, and active. Blood cultures were negative. The cause of her hypotensive episode was not elucidated. Based on this patient, Royal recommends an "appropriate observation period following the enema reduction" to observe for hypovolemic shock.

Perforation has been reported to occur in ~1% of patients and has been found to occur at the time of the initial reduction attempt.36 There were no documented perforations in our series. The risk of bacteremia postenema reduction has also been postulated. In 1996, Somekh et al37 performed 81 blood cultures on 27 patients before and after enema. One patient had a positive blood culture for a pathogenic organism (Staphylococcus aureus) but did not develop clinically evident sepsis. No patient in our series received a postenema blood culture, and no preenema blood culture collected grew an organism.

There are important limitations to this study. The institution at which this study was performed is a tertiary care pediatric facility. Recently published work has noted that children with intussusception who are cared for at institutions with greater pediatric volume have less operative management and greater enema reduction success rates.38,39 The practice of ambulatory management of patients postenema reduction may reflect a greater comfort and experience with pediatric patients. All the reductions were performed by pediatric radiologists who have experience in the technique as well as identifying potential adverse events and possible contraindications to proceeding if concerns arise. Patients are not sedated at this institution before enema reduction. It is also not the practice of the radiologists to return the patient to the ED if the reduction was unsuccessful to try again in a few hours. It was not possible to extract from the medical records which patients received multiple attempts while in the radiology department, but this practice did occur. These issues could affect the generalizability of this study if it is the practice of the institution to admit patients if they have been sedated or underwent multiple attempts.

Retrospective design limits this study. Multiple providers were involved in the documentation of historical and physical examination information. The admission-observation status of the patient, however, is a reliable objective outcome. Inconsistently documented factors such as ongoing rectal bleeding, inability to tolerate oral fluids postreduction, follow-up reliability, and availability of transportation also may have been included in the decision to admit or observe. The fact that admission rates are decreasing argues against those factors being a strong component in the decision. The decision to admit or observe early in the study period was often made by the consulting surgeon. This practice changed during the study period, and the surgical staff is now informed when a patient is undergoing an enema reduction attempt. The surgeons will only be contacted further if the reduction is unsuccessful or complications arise. The disposition decision is then left to the pediatric emergency medicine attending physician.

There is also the possibility that a patient returned to another facility with a recurrence or adverse event. As the only academic tertiary care children’s hospital in the state, it is unlikely that a patient would have returned to another facility. However, the possibility still exists.

Local practices to admit or observe these patients may depend on transportation, geography, and perceived parental reliability as well as clinical factors that we were unable to assess reliably such as ongoing rectal bleeding or need for intravenous hydration. Additional prospective research in the safety of ambulatory management of patients postsuccessful enema reduction would be useful in ensuring the reliability of the clinical information collected as well as the subsequent follow-up. Research investigating inflammatory plasma cytokines in children with acute intussusception is ongoing40 and may become useful in identifying children at higher risk for recurrence. This may lead to a more directed approach with which children may benefit from extended observation.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
The management of patients after successful contrast enema reduction was variable at our institution. The majority of the patients were observed in the ED and then discharged; this approach increased over time. The patients discharged after ED observation did not have an increased incidence of recurrence of intussusception compared with those admitted to the hospital. There were no adverse outcomes in our study population of otherwise healthy children who had a successful enema reduction. Postreduction observation in the ED or the hospital does not seem to affect outcomes in this clinical setting.


   ACKNOWLEDGMENTS
 
We acknowledge the statistical support of Shayne Bland, MSc, who unfortunately passed away before the completion of this manuscript.


   FOOTNOTES
 
Received for publication Oct 21, 2002; Accepted Mar 10, 2003.

Reprint requests to (L.B.) Section of Emergency Medicine, Children’s Hospital and University of Colorado Health Sciences Center, 1056 E 19th Ave, B251, Denver, CO 80218. E-mail: bajaj.lalit{at}tchden.org

This research was presented as a poster at the Annual Pediatric Academic Societies meeting; May 4, 2002; Baltimore, MD.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics



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