Postreduction Management of Intussusception in a Children’s Hospital
Emergency Department
Lalit Bajaj, MD, MPH, and Mark G. Roback, MD
ABSTRACT. Objective. To evaluate the current man-
agement of patients with intussusception who have un-
dergone successful reduction by contrast enema in a ter-
tiary care children’s hospital. To compare differences in
the incidence of recurrence and adverse events between
those patients who were hospitalized after enema reduc-
tion 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 uncompli-
cated enema reduction for intussusception. Hospitaliza-
tion 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 Dis-
eases, 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 obser-
vation was 7.2 hours (range: 0 –21 hours). Eleven recur-
rences 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 recur-
rences (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 oc-
curred in any of the patients who had a successful initial
reduction (95% confidence interval [0%– 4.6%]).
Conclusions. The postreduction management of in-
tussusception is variable at our institution. Previously
healthy patients who have undergone successful enema
reductions are unlikely to have adverse outcomes. Post-
reduction observation in the ED or the hospital does not
seem to affect outcomes in this clinical setting. Pediatrics
2003;112:1302–1307; intussusception, enema reduction,
outpatient management.
From the Section of Emergency Medicine, Children’s Hospital and Univer-
sity of Colorado Health Sciences Center, Denver, Colorado.
This research was presented as a poster at the Annual Pediatric Academic
Societies meeting; May 4, 2002; Baltimore, MD.
Received for publication Oct 21, 2002; accepted Mar 10, 2003.
Reprint requests to (L.B.) Section of Emergency Medicine, Children’s Hos-
pital and University of Colorado Health Sciences Center, 1056 E 19th Ave,
B251, Denver, CO 80218. E-mail: bajaj.lalit@tchden.org
PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad-
emy of Pediatrics.
1302 PEDIATRICS Vol. 112 No. 6 December 2003
Downloaded from http://pediatrics.aappublications.org/ by guest on January 16, 2018
ABBREVIATIONS. PLP, pathologic lead point; ED, emergency
department; LOS, length of stay.
I
ntussusception is the most common cause of in-
testinal 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 sec-
ondary to a pathologic lead point (PLP) such as a
Meckel’s diverticulum or intestinal lymphoma.2 In-
tussusception 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 mar-
ket in 1999.5
Making the diagnosis of intussusception is chal-
lenging because of the wide variety of clinical pre-
sentations and overlap with other conditions.6 – 8 The
reduction of an intussusception with contrast enema
techniques, in particular air enema, has become stan-
dard 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 pa-
tients after a successful enema reduction. Eklof and
Reiter25 published data from a series of patients in
1978 and recommended a 48-hour observation pe-
riod 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 recur-
rence 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 outpa-
tient 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 intussuscep-
tion 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 pa-
tients who were hospitalized postenema reduction
versus 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 intus-
susception identified via International Classification of Diseases,
Ninth Revision code 540.0 from January 1, 1997, to July 31, 2001.
Demographic, historical, physical examination, laboratory, radio-
graphic, 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 med-
ical 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 vom-
iting, 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
Over the 4-year, 7-month study period, 123 pa-
tients were identified with a diagnosis of intussus-
ception. These patients ranged in age from 1.4
months to 12.6 years. Sixty-six percent of these pa-
tients 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 heteroge-
neous population of children who either presented
with acute abdominal symptoms, a mass seen on an
imaging study, or chronic medical problems or re-
ceived a discharge diagnosis of “self-resolved intus-
susception.” 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 pro-
ceeded 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 med-
ical conditions (acute lymphocytic leukemia and He-
noch-Schönlein purpura), and 3 had incomplete
medical records. The remaining 78 patients were in-
cluded in our further analysis (Fig 1).
Downloaded from http://pediatrics.aappublications.org/ by guest on January 16, 2018
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 pa-
tients (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 radi-
ologist as “abnormal.” There were 4 patients who
were diagnosed via ultrasound, and 3 were diag-
nosed 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 ene-
mas (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.
There were no significant differences between the
groups in terms of age, gender, and duration of
symptoms. Historical features such as fever, fussi-
ness, 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 sta-
tistically significant (P ⬍ .001) (Table 1).
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 recur-
rences 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 (perfo-
ration, bowel resection, or sepsis). None of the pa-
tients 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%).
Thirteen patients returned for evaluation of recur-
rent symptoms and did not have a documented re-
currence. Eight of these patients had been observed
in the ED, and 5 had been admitted to the hospital.
DISCUSSION
Although intussusception is relatively common in
pediatrics, significant variability in diagnosis and
treatment modalities exist.1,2,15–24 The manage-
ment 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
ARTICLES 1303
Fig 1. Intussusception patients identified by Interna-
tional Classification of Diseases, Ninth Revision code
540.0 from January 1, 1997, to July 31, 2001.
Fig 2. Postreduction management: hospitalized versus observed
by year.
48-hour observation period after successful reduc-
tion to observe for early recurrence as well as infec-
tious and surgical complications such as perforation
and peritonitis. It is now well-documented that re-
currences 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 in-
creased 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,
1304 POSTREDUCTION MANAGEMENT OF INTUSSUSCEPTION
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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 post-
reduction. 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 Euro-
pean 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 man-
agement of intussusception and have found that the
majority of the patients (65%) were managed as out-
patients 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 ex-
amination features. We also found that hospital ad-
missions at this institution decreased over the time
period studied. Consistent with published studies,
those patients who either did not have an enema
 TABLE 1. Postsuccessful Enema Reduction Patients: Hospitalized Versus Observed
Hospitalized Observed P Value
(n ⫽ 27) (n ⫽ 51)
Mean age (mo) 15.13 (10.2, 20) 21.12 (17, 25.2) NS
Male 17 (63%) 36 (71%) NS
Mean duration symptoms* 1.60 (1.1, 2.1) 1.78 (1.3, 2.3) NS
Vomit history 22 (81%) 32 (63%) NS
Bloody stool history 8 (30%) 19 (37%) NS
Altered mental status 22 (81%) 36 (71%) NS
examination
Dehydration examination 13 (48%) 15 (29%) NS
Heme ⫹ stool 11/19 (58%) 21/37 (57%) NS
Mean LOS (h) 22.7 (19, 26.4) 7.15 (5.8, 8.5) ⬍.001
NS indicates not significant.
* Days (95% confidence interval).

TABLE 2. Recurrences After a Successful Enema Reduction

Age Sex Hospitalized/ LOS Time No. of Exploratory PLP
(Months) Observed (Hours) (Postenema) Recurrences Laparotomy
7.3 M O 0 10.9 mo 1 No No
9 M H 24 6.8 mo 1 No No
5 M H 14 10.2 mo 1 No No
7.2 F H 18 43 h/31.5 h 2 No No
4.3 M H 42 2.3 mo 1 No No
31.6 M O 0.75 11 h/5 h/5 h 3 Yes No
15.2 F O 0.67 47 h 1 No No
28 M O 3 5h 1 Yes No

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 ob-
served in either the hospital or the ED at the time of
their initial recurrence. Two of the patients with re-
currences 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 sep-
sis 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 instruc-
tions to return if symptoms recur or any other con-
cerns 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 “appro-
priate observation period following the enema re-
duction” 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 docu-
mented perforations in our series. The risk of bacte-
remia 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 organ-
ism (Staphylococcus aureus) but did not develop clin-
ically evident sepsis. No patient in our series re-
ceived 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 pedi-
atric volume have less operative management and
greater enema reduction success rates.38,39 The prac-
tice of ambulatory management of patients posten-
ema 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 contraindica-
tions 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 unsuccess-
ful to try again in a few hours. It was not possible to
extract from the medical records which patients re-
ceived multiple attempts while in the radiology de-
partment, but this practice did occur. These issues

ARTICLES 1305
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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, how-
ever, is a reliable objective outcome. Inconsistently
documented factors such as ongoing rectal bleeding,
inability to tolerate oral fluids postreduction, fol-
low-up reliability, and availability of transportation
also may have been included in the decision to admit
or observe. The fact that admission rates are decreas-
ing argues against those factors being a strong com-
ponent 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 in-
formed when a patient is undergoing an enema re-
duction attempt. The surgeons will only be contacted
further if the reduction is unsuccessful or complica-
tions 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 per-
ceived parental reliability as well as clinical factors
that we were unable to assess reliably such as ongo-
ing rectal bleeding or need for intravenous hydra-
tion. 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 re-
currence. This may lead to a more directed approach
with which children may benefit from extended ob-
servation.
CONCLUSIONS
The management of patients after successful con-
trast 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 ob-
servation in the ED or the hospital does not seem to
affect outcomes in this clinical setting.
ACKNOWLEDGEMENT
We acknowledge the statistical support of Shayne Bland, MSc,
who unfortunately passed away before the completion of this
manuscript.
1306 POSTREDUCTION MANAGEMENT OF INTUSSUSCEPTION
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878 – 83

A PREGNANT MOTHER’S DIET MAY TURN THE GENES AROUND

“With the help of some fat yellow mice, scientists have discovered exactly how
a mother’s diet can permanently alter the functioning of genes in her offspring
without changing the genes themselves. . . . The research is a milestone in the
relatively new science of epigenetics, the study of how environmental factors like
diet, stress and maternal nutrition can change gene function without altering the
DNA sequence in any way. Such factors have been shown to play a role in cancer,
stroke, diabetes, schizophrenia, manic depression and other diseases as well as in
shaping behavioral traits in offspring. Most geneticists are focusing on sequences
of genes in trying to understand which gene goes with which illness or behavior,
said Thomas Insel, director of the National Institute of Mental Health. ‘But these
epigenetic effects could turn out to be much more important. The field is revolu-
tionary,’ he said, ‘and humbling.’ ”

Blakeslee S. A pregnant mother’s diet my turn the genes around. New York Times. October 6, 2003

Noted by JFL, MD

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 Postreduction Management of Intussusception in a Children's Hospital
Emergency Department
Lalit Bajaj and Mark G. Roback
Pediatrics 2003;112;1302

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
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 Postreduction Management of Intussusception in a Children's Hospital
Emergency Department
Lalit Bajaj and Mark G. Roback
Pediatrics 2003;112;1302

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/112/6/1302

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2003 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
.

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