PEDIATRICS/SYSTEMATIC REVIEW SNAPSHOT

TAKE-HOME MESSAGE
Air enema may be superior to liquid enema for successful reduction of
intussusception, and dexamethasone intramuscularly as an adjuvant therapy may
reduce intussusception recurrence after air or liquid enema. Glucagon with liquid
enema versus liquid enema alone did not result in improved intussusception
reduction.

What Measures Improve Reduction of

METHODS
Intussusception in Pediatric Patients?
EBEM Commentators
DATA SOURCES Brit Long, MD
Michael D. April, MD, DPhil
Two investigators searched the Department of Emergency Medicine
Cochrane Central Register of San Antonio Uniformed Services Health Education Consortium (SAUSHEC)
Controlled Trials, Ovid MEDLINE, Fort Sam Houston, TX
Ovid EMBASE, Science Citation Index
Expanded, and BIOSIS Previews for Results
studies from inception through
Results of included trials.
September 2016. Investigators
examined reference lists of all eligible No. of No. of Risk Ratio Evidence
Intervention Comparison Studies Patients (95% CI) NNTB Quality
trials, contacted content experts,
searched World Health Organization Successful reduction
International Clinical Trials Registry Liquid enema plus glucagon vs 2 218 1.09 (0.94–1.26) —* Low
liquid enema alone1,2
Platform and clinicaltrials.gov, and Enema plus dexamethasone IM 2 356 1.01 (0.92–1.10) — Low
evaluated proceedings from meetings vs enema alone†3,4
from the British Association of Air enema vs liquid enema5,6 2 199 1.28 (1.10–1.49) 6 Low
Paediatric Surgeons, the American Recurrent intussusception
Society of Pediatric Surgery, and the Enema plus dexamethasone IM 2 299 0.14 (0.03–0.60) 13 Low
vs enema alone†3,4
World Congress of Pediatric Surgery. Bowel perforation
Liquid enema plus dexamethasone IM vs 1 75 2.63 (0.11–62.66) — Low
STUDY SELECTION liquid enema alone3

The review included randomized
clinical trials comparing contrast
media, imaging modalities,
pharmacologic adjuvants, protocols
for delayed repeated enema, surgical
approaches, or other curative
techniques for intussusception
management. Included studies
examined patients younger than 18
years with intussusception at any
point of the gastrointestinal tract distal
to the pylorus. Primary outcomes
included number of patients with
successful reduction, patients with
bowel perforation, and patients with
recurrent intussusception. Authors
screened 761 studies, excluding 323
as duplicates and 3 for ongoing trial
NNTB, Number needed to treat for an additional beneficial outcome; IM, intramuscular.
*Dashes indicate that this statistic was not reported in the meta-analysis.
†
The study by Essa et al3 examined liquid enema, whereas that by Lin et al4 examined air enema.
Investigators included 6 random- resulted in no benefit in regard to
ized controlled trials with 822 pa- successful reduction or incidence
tients for analysis. The addition of of bowel perforation, although it
glucagon to liquid enema versus did result in decreased risk of
liquid enema alone did not improve recurrent intussusception (risk
the rate of successful reduction ratio 0.14; 95% confidence interval
of intussusception.1,2 Studies [CI] 0.03 to 0.60), with a number
comparing these 2 interventions needed to treat for an additional
did not report on numbers of beneficial outcome (NNTB) of
children with bowel perforations 13.3,4 Air enema versus liquid
or recurrent intussusception. enema resulted in improved
Air or liquid enema with reduction, with risk ratio 1.28
dexamethasone intramuscularly (95% CI 1.10 to 1.49) and
versus air or liquid enema alone NNTB of 6, although studies

236 Annals of Emergency Medicine Volume 71, no. 2 : February 2018


status, followed by screening 435
abstracts. Investigators excluded 87
abstracts because of nonrandomized
study, 330 because of inappropriate
population, and 6 for inappropriate
intervention. Authors assessed the full
text of 12 studies for eligibility and
excluded 1 for no translation available
and 4 for not being randomized
controlled trials. Two of the 7
remaining studies included duplicate
information, and authors included
these as one trial.
DATA EXTRACTION AND
SYNTHESIS
Two review authors independently
extracted data and assessed risk of
bias with the Cochrane Collaboration
risk-of-bias tool, with disagreement
resolved by consensus or third author
involvement if required. Investigators
used funnel plots and Egger’s linear
regression to assess for publication
bias. They evaluated evidence quality
through the Grading of
Recommendations Assessment,
Development and Evaluation
approach, with disagreements
resolved through consensus.
Investigators conducted the following
head-to-head comparisons of the
primary outcomes according to
patient interventions: liquid enema
plus glucagon versus liquid enema
alone, air or liquid enema plus
dexamethasone intramuscularly
versus air or liquid enema alone, and
air enema versus liquid enema.
Authors presented results for
dichotomous data as summary risk
ratios and as number needed to treat
for an additional beneficial outcome.
They used mean differences for
continuous data, standardized mean
differences to combine studies
measuring the same outcome with
different methods, hazard ratios for
survival data, and rate ratios for rate
data. Authors conducted subgroup
analyses and assessed heterogeneity
with I2 and c2.
Volume 71, no. 2 : February 2018
Systematic Review Snapshot
comparing these interventions reduction and reduce recurrence
did not report on numbers and risk of perforation. Previous
of children experiencing narrative reviews combined previ-
recurrent intussusception or ous study data evaluating treat-
5,6
bowel perforation (Table). ments for intussusception,
Investigators downgraded quality although without pooling of results
of trial evidence because of by meta-analysis.7,8,12 This meta-
concerns about imprecision, wide analysis suggests air enema may
CIs, or high risk of bias. This be more effective at reducing
limited conclusion strength intussusception in children, with
and the ability to evaluate clinical a NNTB of 6. Glucagon with
and statistical heterogeneity. liquid enema did not improve
All examined outcomes intussusception reduction, and
demonstrated a Grading of dexamethasone intramuscularly as
Recommendations Assessment, an adjunct may reduce rates of
Development and Evaluation recurrent intussusception, with a
assessment of low quality. NNTB of 13.
Commentary Evidence quality for all findings was
low because of imprecision, wide
Intussusception is an emergency
CIs, and high risk of bias, limiting
occurring primarily in pediatric
conclusions. Consequently, more
patients, in which one part of the
study is necessary for confirmation
bowel folds into another
of these results. Such future in-
(commonly the ileum and cecum),
vestigations would benefit from
which may lead to perforation and
standardization of outcomes and
peritonitis. It is one of the most
uniform collection of data about
common abdominal emergencies
treatment safety and harms. Future
in patients younger than 3 years,
studies should take measures to
with boys affected more
minimize bias by seeking strategies
commonly.7-10 Most cases are
to achieve investigator and subject
idiopathic, although other
blinding. Moreover, such in-
conditions may result in
vestigations would ideally include
pathologic lead points that are
examination of understudied in-
associated with worse
terventions such as surgical man-
outcomes.8-11 The classic triad of
agement strategies.
vomiting, colicky abdominal pain,
and bloody stool occurs in less Editor’s Note: This is a clinical
than half of patients who receive synopsis, a regular feature of the
a diagnosis of intussusception. Annals’ Systematic Review Snapshot
(SRS) series. The source for this
Once the disease is diagnosed, air
systematic review snapshot is:
or liquid enema is the standard Gluckman S, Karpelowsky J,
treatment,7,8,10-12 which involves Webster AC, et al. Management for
introducing a substance into the intussusception in children.
bowel through the rectum to Cochrane Database Syst Rev.
produce pressure and reduce the 2017;(6):CD006476.
bowel into normal position.7,8,11,12
1. Franken EA, Smith WL, Chernish SM, et al.
The use of glucagon in hydrostatic
Enemas can be completed with air
reduction of intussusception: a double-
or liquid contrast, and adjuvants blind study of 30 patients. Radiology.
may facilitate intussusception 1983;146:687-689.
Annals of Emergency Medicine 237
Systematic Review Snapshot

2. Mortensson W, Eklof O, Laurin S. management of intussusception: a Geneva, Switzerland. Vaccines Biologicals;

Hydrostatic reduction of childhood
intussusception. The role of adjuvant
glucagon medication. Acta Radiol Diagn
(Stockh). 1984;25:261-264.
3. Essa AE, Eltayeb AA, Mansour E. Evaluation
of the role of dexamethasone in decreasing
early recurrence of intussusception: using
ultrasound-guided saline enema for
reduction. Surg Pract. 2011;15:114-119.
4. Lin SL, Kong MS, Houng DS. Decreasing early
recurrence rate of acute intussusception by
the use of dexamethasone. Eur J Pediatr.
2000;159:551-552.
5. Hadidi AT, El Shal N. Childhood
intussusception: a comparative study of
nonsurgical management. J Pediatr Surg.
1999;34:304-307.
6. Meyer JS, Dangman BC, Buonomo C, et al.
Air and liquid contrast agents in the
controlled, randomized trial. Radiology.
1993;188:507-511.
7. Applegate KE. Intussusception in children:
evidence-based diagnosis and treatment.
Pediatr Radiol. 2009;39:140-143.
8. Ko HS, Schenk JP, Tröger J, et al. Current
radiological management of
intussusception in children. Eur Radiol.
2007;17:2411-2421.
9. Loukas M, Pellerin M, Kimball Z, et al.
Intussusception: an anatomical perspective
with review of the literature. Clin Anat.
2011;24:552-561.
10. Bines JE, Ivanoff B. Acute intussusception
in infants and children: a global
perspective. A report prepared for the
Steering Committee on Diarrhoeal Disease
Vaccines, Vaccine Development, Vaccines
and Biologicals, World Health Organization,
2002. WHO V & B:02.19.
11. Blanch AJ, Perel SB, Acworth JP. Paediatric
intussusception: epidemiology and
outcome. Emerg Med Australas.
2007;19:45-50.
12. Daneman A, Navarro O. Intussusception,
part 1: a review of diagnostic approaches.
Pediatr Radiol. 2003;33:79-85.
This review does not reflect the views or
opinions of the US government,
Department of Defense, US Army, US
Air Force, or SAUSHEC EM Residency
Program.
Michael Brown, MD, MSc, Jestin N.
Carlson, MD, MS, and Alan Jones, MD,
serve as editors of the SRS series.

Images in Emergency Medicine

The Annals Web site (www.annemergmed.com) contains a collection of
hundreds of emergency medicine-related images, complete with brief
discussion and diagnosis, in 18 categories. Go to the Images pull-down menu
and test your diagnostic skill today. Below is a selection from the
Trauma Images.

“Child With Dinner Fork Deformity” by Kardouni, February 2016, Volume 67, #2,
pp. 165, 188.

238 Annals of Emergency Medicine Volume 71, no. 2 : February 2018