Use of an enterocolitis triage and treatment protocol in children with Hirschsprung disease reduces hospital admissions

Background: While a consensus for the definition of Hirschsprung associated enterocolitis (HAEC) is lacking, the mainstay of treatment includes rectal irrigations with or without antibiotics. This treatment is often effective when initiated as an outpatient. Our institution implemented a triage algorithm in an effort to standardize care thus providing more timely treatment and preventing unnecessary hospital admissions. We sought to review our short-term experience.

Methods: A retrospective review was performed of all Hirschsprung (HD) patients <6 years old over two distinct time periods from May 2016-2017 (pre-protocol, group A) and June 2017-2018 (post-protocol, group B). Patients with a colostomy were excluded. Primary end point was hospital admission. Presenting symptoms were categorized as moderate or severe, with patient triage based on number and quality of symptoms.

Results: Eighty-seven total patients were included. Rectosigmoid transition zone was most common (75%) and 20% of patients had trisomy 21. HAEC occurred in 22% of patients in the preprotocol group (group A, n = 78, 27 episodes) and 20% of patients in the post-protocol group (group B, n = 87, 32 episodes). In group A, 78% of episodes required an unplanned visit and 74% resulted in admission. In group B, 81% of episodes required an unplanned visit and 50% resulted in admission (33% reduction in hospital admission, p = 0.06). Irrigations only, without antibiotics, were used in 30% of episodes in group A versus 41% in group B. Of patients who initially contacted the office by phone (group A = 7 episodes, group B = 6 episodes), outpatient management was successful in 43% versus 100% respectively (p = 0.07). No patient experienced increased morbidity in group B.

Discussion: Implementation of a HAEC treatment algorithm shows promise in improving the management and resource utilization of this complex patient population. It is anticipated that continued education of caregivers and the treatment team will result in a greater effect. A multi-institutional implementation of this algorithm is needed to characterize risk factors associated with failure of outpatient management.

Level of evidence: III, Treatment Study.