A 2010 retrospective review by Whitehouse et al evaluated kids over a 12-year period (309 total children younger than or equal to 18 years of age) who had been diagnosed with intussusception. They admitted 261 (84.5 percent) and discharged 48 (15.5 percent) from the emergency department. During this period, 138 of 261 children were reduced by enema, and the rest (123/261) were reduced surgically. Recurrence after enema reduction occurred in 10 of 138 (7.2 percent) admitted patients and 4 of 48 (8.3 percent) discharged patients. Of the 14 children overall who had intussusception recurrences, six (42.8 percent) of the recurrences happened within 72 hours. The average LOS was 1.6 days; four of the recurrences happened within this time frame. The remainder of recurrences happened between 10 days and 21 months. There was no significant difference in delayed complications, defined as perforation or intestinal ischemia, between the discharged group and the admitted group.4 In terms of morbidity, the two groups appear similar.
Explore This IssueACEP Now: Vol 35 – No 11 – November 2016
In another, 10-year retrospective study with 568 total children at two tertiary care hospitals, 239 (42 percent) got emergency department “early discharge” where the average LOS was 7.2 hours, while 329 (58 percent) were admitted with an average LOS of 40 hours. The recurrence rate of intussusception was 8.8 percent (21/239) in the discharge group and 8.5 percent (28/329) in those admitted. There was a statistical difference in recurrences that were caught prior to discharge (20 of 28 in the admitted group versus 2 of 21 in the discharge group; P=0.004). There were no significant differences in morbidity between the discharge and admitted groups.5
A 2014 meta-analysis by Gray et al included 69 studies (15,163 total patients) in children. Overall, the recurrence rate of intussusception after enema reduction, whether contrast, ultrasound-guided, or air-contrast, was 12.7 percent (95% CI, 11.1%–14.4%). The recurrence rate within 24 hours was 3.9 percent (95% CI, 1.5%–10.1%); within 48 hours, it was 5.4 percent (95% CI, 3.7%–7.8%). The authors argue that “the vast majority of recurrences will not be identified by overnight hospitalization.”6
Conversely, a more recent 26-year retrospective study including 464 total children by Lessenich et al found a similar recurrence rate (5.6 percent) while noting that 18.5 percent of children required some form of hospital-level intervention defined as imaging/interventions for recurrence or suspected recurrence, or administration of parenteral narcotics or antiemetics.7
Summary: Intussusception recurrence rate after enema reduction, overall, appears to be about 5 to 12 percent. The majority of these recurrences don’t present within the first 24 to 48 hours. It might be reasonable under certain instances (eg, good follow-up, reasonable distance from home, etc.) to discharge these children from the emergency department after a successful enema reduction and appropriate symptom-free observation period. Practitioners should at least recognize that this may be a change in practice when discussing these cases with our surgical colleagues.