Back into the fray once more we go – or should I say back into the colon goes the ileum… Yes, the third article in the top 10 from the 2014 AAP NCE focuses on intussusception. Back when I was an intern™ after a child was reduced with air contrast enema they were subsequently admitted for 24 hours to the surgery service. Now, we discharge them home form the ED after a much shorter period of observation. Why? Well, you know where this is going. Let’s take a look at Gray et al. from the July 2014 edition of PEDIATRICS.

Recurrence rates after intussusception enema reduction: a meta-analysis

Gray MP, Li SH, Hoffmann RG, Gorelick MH. PEDIATRICS, 2014

The bottom line

The risk of recurrence within 48 hours after successful air contrast enema reduction is low for well appearing children – therefore, consider discharging them home form the ED

What they did

The authors queried PubMed, Cochrane and OVID in an effort to determine the recurrence rate for intussusception after successful reduction. They reviewed 69 studies of children 0 to 18 years that had radiographically proven intussusception reduced by enema and the number of recurrences. To assure validity 10% of the records were reviewed by a second author. There was considerable variability amongst the 69 reviewed studies, with few detailing timing of recurrences exactly. Their analysis was also limited by the fact that most studies on intussusception are retrospective given its relative rarity. Note that the original article’s abstract has an error – the correct values are in the text. This is pointed out in the following errata. A few abbreviations are used: CE contrast enema, UGNCE ultrasound-guided non contrast enema, FGAE fluoroscopy-guided air enema

Ultimately they noted the following:

  • Overall recurrence rates
    • CE 12.7% (95% CI: 11.1%–14.4%, I2 = 28.8%)
    • UGNCE 7.5% (95% CI: 5.7%–9.8%, I2 = 52.4%)
    • FGAE 8.5% (95% CI: 6.9%–10.4%, I2 = 50.1%)
  • Recurrence rates within 24 hours
    • CE 3.9% (95% CI: 2.2%–6.7%, I2 = 47.0%)
    • UGNCE 3.9% (95% CI: 1.5%–10.1%, I2 = 0.0%)
    • FGCE 2.2% (95% CI: 0.7%–6.5%, I2 = 59.8%)
  • Recurrence rates within 48 hours
    • CE 5.4% (95% CI 3.7%–7.8%, I2 = 32.3%)
    • UGNCE 6.6% (95% CI: 4.0%–10.7%, I2 = 0.0%)
    • FGAE 2.7% (95% CI: 1.2%–6.5%, I2 = 73.8%)

What you can do

  • You can safely discharge a well-appearing patient to home after successful intussusception reduction regardless of technique
  • Recognize, and teach that he risk of recurrence in the first 24 hours post reduction is low; 2.2-3.9%
  • Even if you take the 24 hour risk to be the highest value of 3.9%, you would need to hospitalize 26 patients for 24 hours to see a single recurrence
  • Know that serious post-reduction complications are rare
  • Remember that any child that can’t be reduced needs a surgeon