Treatment Principles for Suspected HAEC1). A surgical fellow or attending should personally see and evaluate all patients with suspected HAEC at the earliest possible opportunity (within 1 hour) and document exam and treatment plan. 2). A rectal exam should be performed as part of initial exam. If patient is <4 weeks from surgery, rectal exam or dilations should be discussed with the Attending Surgeon prior to performing exam. 3). Rectal irrigations should be initiated at earliest opportunity (within 1 hour) of arrival. Do not delay irrigations to wait for initial abdominal x-ray. Rectal irrigations should be performed by the person most versed in the process; A4S nurses are available to provide support and assistance. Irrigations should be Q8H at minimum (consider more frequent –Q6H or PRN –if severe enterocolitis). 4). Abdominal x-ray should be obtained on arrival and repeated after the initial irrigation and thereafter as needed to demonstrate adequate decompression. 5). Patient should be NPO and started on IVF . If significant abdominal distention, consider replogle. 6). Antibiotics: Any vomiting patients should be on IV antibiotics. 7). Laboratory tests that should be considered include: CBC, renal panel, and a venous blood gas (for any patient with systemic signs). 8). Disposition:•Patients withoutsystemic signs**: Admit to the surgical floor. •Patient withsystemic signs**: Should be evaluated for potential ICU admission. 9). All HAEC patients on the surgical floor should have vitalswith blood pressure measurement every 4 hours. Suspected Hirschsprung’s Associated Enterocolitis (HAEC) Treatment Guidelines Scenario: Patient with known/suspected Hirschsprung’s Disease (HD) presents to the ED with GI complaints* and/or fever . v2 Updated 4/2019 Outpatient:PO metronidazole is sufficient for low suspicion or mild cases Inpatient: WITHsystemic signs**WITHOUT systemic signs** IV broad-spectrum antibiotics, including metronidazole PO or IV metronidazole (low suspicion or mild cases may be managed with PO) *GI complaints may include:Abdominal distention, vomiting, no/minimal stooling, foul-smelling stool, and/or explosive diarrhea Rectal Irrigation Supplies:•Silicone foleycatheter (16 frfor children ≤1 year; 24 frfor children >1 year)•60 cc catheter tip syringe•Lubricant (water soluble)•Saline solution•2 non-sterile basins (e.g. emesis basin)Rectal Irrigation Orderset:Use “Hirschsprung Disease Rectal Irrigation” ordersetto order subsequent irrigations. Rectal Irrigation Video:https://cchmcstream.cchmc.org/MediasiteEX/Play/545154a603a844e8988ef74cd5b4c1c11d **Systemic signs include:Fever, lethargy, age-adjusted tachycardia, hypotension, tachypnea, oliguria
Suspected Hirschsprung's-Associated Entercolitis (HAEC) Treatment Guideline
Guideline · Jul 2019 · 2 min read
In brief
In brief
Clinical management protocol for Hirschsprung's-associated enterocolitis (HAEC) presented by Dr. Meera Kotagal from Cincinnati Children's Hospital. Covers diagnostic approach and treatment strategies for this serious complication in patients with known or suspected Hirschsprung disease.
- Urgent evaluation and rectal irrigation within 1 hour are critical for suspected HAEC; do not delay irrigations for imaging.
- Rectal irrigations should be performed Q8H minimum using appropriate catheter size (16Fr ≤1yr, 24Fr >1yr) with saline.
- IV broad-spectrum antibiotics including metronidazole required for patients with vomiting or systemic signs of sepsis.
- Patients with systemic signs (fever, lethargy, tachycardia, hypotension) require ICU evaluation; others admit to floor.
- Serial abdominal x-rays after initial irrigation confirm adequate decompression; NPO status and Q4H vitals mandatory.
Written by the GCMD Library team from the guideline.
Initial Evaluation and Examination
Surgical fellow or attending must evaluate suspected HAEC patients within 1 hour and document findings. Rectal examination is mandatory as part of initial assessment, though should be discussed with attending surgeon if patient is less than 4 weeks post-operative.
Rectal Irrigation Protocol
Rectal irrigations must be initiated within 1 hour of arrival and should not be delayed for imaging. Irrigations should be performed by experienced personnel at minimum every 8 hours, with consideration for more frequent intervals (every 6 hours or as needed) in severe cases.
Imaging and Monitoring
Abdominal radiograph should be obtained on arrival and repeated after initial irrigation to confirm adequate decompression. Subsequent imaging should be obtained as clinically indicated to assess treatment response.
Supportive Care Measures
Patients should be made NPO and started on intravenous fluids. Nasogastric decompression with Replogle tube should be considered in cases of significant abdominal distention.
Antibiotic Therapy
Intravenous antibiotics are indicated for any patient with vomiting. Outpatient cases with low suspicion may be managed with oral metronidazole, while inpatient cases without systemic signs can receive oral or IV metronidazole, and those with systemic signs require IV broad-spectrum antibiotics including metronidazole.
Laboratory Assessment
Recommended laboratory studies include complete blood count, renal function panel, and venous blood gas for patients exhibiting systemic signs of illness. These tests help assess severity and guide management decisions.
Disposition and Level of Care
Patients without systemic signs should be admitted to the surgical floor with vital signs including blood pressure measured every 4 hours. Patients with systemic signs (fever, lethargy, tachycardia, hypotension, tachypnea, or oliguria) require evaluation for intensive care unit admission.
Rectal Irrigation Technique and Supplies
Irrigation requires silicone Foley catheter (16 Fr for children ≤1 year, 24 Fr for children >1 year), 60 cc catheter-tip syringe, water-soluble lubricant, saline solution, and non-sterile basins. A standardized orderset and instructional video are available to guide the procedure.
Statements in this guideline
A surgical fellow or attending should personally see and evaluate all patients with suspected HAEC within 1 hour and document exam and treatment plan.
A rectal exam should be performed as part of initial exam.
If patient is less than 4 weeks from surgery, rectal exam or dilations should be discussed with the Attending Surgeon prior to performing exam.
Rectal irrigations should be initiated within 1 hour of arrival.
Do not delay irrigations to wait for initial abdominal x-ray.
Irrigations should be Q8H at minimum, with consideration for more frequent Q6H or PRN if severe enterocolitis.
Abdominal x-ray should be obtained on arrival and repeated after the initial irrigation and thereafter as needed to demonstrate adequate decompression.
Patient should be NPO and started on IVF.
If significant abdominal distention, consider replogle.
Any vomiting patients should be on IV antibiotics.
Laboratory tests that should be considered include CBC, renal panel, and a venous blood gas for any patient with systemic signs.
Patients without systemic signs should be admitted to the surgical floor.
Patients with systemic signs should be evaluated for potential ICU admission.
All HAEC patients on the surgical floor should have vitals with blood pressure measurement every 4 hours.
PO metronidazole is sufficient for low suspicion or mild outpatient cases.
Inpatient cases without systemic signs may be managed with PO or IV metronidazole, with PO sufficient for low suspicion or mild cases.
Inpatient cases with systemic signs require IV broad-spectrum antibiotics, including metronidazole.
Use a 16 fr silicone foley catheter for children 1 year or younger and a 24 fr for children older than 1 year for rectal irrigations.
Systemic signs include fever, lethargy, age-adjusted tachycardia, hypotension, tachypnea, and oliguria.
GI complaints may include abdominal distention, vomiting, no or minimal stooling, foul-smelling stool, and explosive diarrhea.