Suspected Hirschsprung's-associated enterocolitis (HAEC) Treatment Guideline...

Hi, this is Todd Ponsky. A lot of you have asked us to release more treatment guidelines. So we have decided to create videos highlighting the most important treatment guidelines. Today, we have Dr. Mira Kodagali, one of my colleagues, who is going to be talking to us about Hirschsprung's associated enterocolitis. Hi there. My name is Mira Kodagali and I'm a pediatric surgeon here at the Colorectal Center at Cincinnati Children's. Today we're talking about Hirschsprung's associated enterocolitis. As you all know, it's a controversial topic and it's hard to figure out how best to manage it. There are a couple of great papers out there by Pastor at al and Gosain at al that outline some frameworks and some clinical guidelines for management of enterocolitis. We use those papers and our own practice in order to make a guideline here at Cincinnati Children's. So these guidelines are most appropriate for patients with either known or suspected Hirschsprung's who present with GI symptoms and or fever. Those GI symptoms might include abdominal distension, vomiting, no or minimal stool, foul smelling stool, or explosive diarrhea. And we have to be particularly concerned about patients who present with systemic signs, so fever, lethargy, age-adjusted tachycardia, tachypnea, hypotension, or oliguria. So the most important thing about the guideline is that there are eight key steps that need to be followed. The first is that the patients should be seen and evaluated as soon as possible, ideally, within one hour by someone with some clinical expertise. In our case, a surgical fellow or an attending. That exam should include a rectal exam. If the patient is less than four weeks out from surgery, we ask that our fellows discuss the rectal exam with one of the attending surgeons prior to performing the exam. So irrigations are the key to treatment for these patients. Here at Cincinnati Children's, we like to call that lifesaving saltwater. Irrigations should not be delayed for patients to get an x-ray, and they should be repeated as frequently as eight hours, but even every Q6 or Q4 hours as needed for sicker patients. Abdominal films should be obtained upon arrival and then repeated again after an irrigation to demonstrate adequate decompression. They can be repeated throughout the course of the hospitalization as clinically necessary as well. Number five, patients should be NPO and started on IV fluids to assist with resuscitation and hydration. And then number six is antibiotics. So patients who are do not have systemic signs and are mostly clinically well can be maintained on either IV or oral flagyl during their hospitalization, although all patients who are vomiting should be on IV antibiotics. Those patients with systemic signs who are sicker need broad spectrum antibiotics. In our case, we use Zosyn and flagyl. Number seven, laboratory tests. All patients should get a CBC and a basic metabolic panel, but we also get a Venus blood gas for patients who are sicker in order to help us evaluate their resuscitation needs. And lastly, number eight, disposition. Patients with systemic signs should be evaluated for potential admission to the ICU. After an admission for enterocolitis, we continue these patients on metronidazole and irrigations for a few weeks and then slowly taper them in order to make sure that the patients continue to do well. If there's an underlying anatomic issue such as a stricture or a transition zone pull through, that has to be addressed as well in order to make sure that these patients don't have a recurrent bout of enterocolitis. All right, so in summary, number one, patients need to be evaluated as soon as humanly possible. Number two, they should get a rectal exam unless they're less than four weeks out from surgery, in which case it should be discussed with an attending. Number three, irrigations or lifesaving saltwater. Number four, all patients should have an abdominal film and that should be repeated during their hospitalization. Number five, patients should be made NPO and should be on IV fluids. Number six, antibiotics. All patients need antibiotics, the sicker patients need broad spectrum antibiotics. Number seven, patients need lab tests including potentially a Venus blood gas. And number eight, disposition. Patients should be evaluated for admission to the ICU if they're sick enough to warrant it. As we know, enterocolitis is complicated and this guideline may not apply to all patients. If you have any questions or we can be of any help, please don't hesitate to contact us.