Background Contrast enema (CE) in Hirschsprung's disease (HD) provides a road map to surgeons by ascertaining the transition zone (TZ) and helps in pre-surgical planning. In our institute, we use CE as the initial investigation for HD and carry on till the whole colon is fully distended, followed by a 24-hour abdominal film which is also a part of the international protocol. The main aim of this study was to evaluate the usefulness of this 24-hour delayed film in detecting HD, compare it with gold-standard biopsy results, and to evaluate other imaging features of contrast enema for diagnosis of HD in our tertiary-care hospital in Pakistan.  Methods This retrospective study was conducted at the Department of Radiology, Aga Khan University Hospital, Karachi. Records of pediatric patients referred for radiological evaluation of symptoms and signs suspicious of HD during the years 2007-2017 were reviewed. A delayed film was labeled positive if the contrast was not completely evacuated when the residual contrast was present till transverse colon and not beyond. Specificity and sensitivity along with positive and negative predictive values were calculated for each finding according to rectal biopsy, taken as the gold standard. Results In all, 82 patients met the inclusion criteria out of 111 cases, as they had both biopsy results and delayed 24-hour films. HD was confirmed using rectal biopsy in 56 (43 patients were males and 13 were females) of 82 cases. The most sensitive radiological finding was the transition zone with a sensitivity of 91.07%. The rectosigmoid index was the second most common finding on contrast enema with a sensitivity and specificity of 91.07% and 83.93%, respectively. In all, 59% patients had a positive delayed 24-hour film and were confirmed with having HD on biopsy. The sensitivity, specificity, and positive predictive value of delay in contrast evacuation after 24 hours in our study was 81.25%, 90.91%, and 97.50% respectively. Conclusion Contrast enema examinations along with the 24-hour delayed film with mid transverse colon cut-off are optimal for initially investigating HD in a developing nation, and our results show that it correlates well with biopsy. However, rectal biopsy still remains the gold standard for diagnosis.