What is the approach to diagnosing and treating intussusception (a medical condition where a part of the intestine slides into an adjacent part of the intestine)?

From the Guidelines

Intussusception is best diagnosed using abdominal ultrasound as the initial imaging study due to its high sensitivity and specificity, particularly in the pediatric age group. The diagnosis of intussusception typically involves a combination of clinical evaluation and imaging studies. Clinical presentation may include abdominal pain, vomiting, and bloody stools, although these symptoms are not always present.

Key Diagnostic Steps

• Physical examination to identify signs of abdominal distress or the classic triad of symptoms
• Abdominal ultrasound as the preferred initial imaging study, given its high accuracy in evaluating intussusception, especially in children, as noted in studies such as 1
• Consideration of abdominal X-rays, which may show suggestive signs but are less sensitive and specific than ultrasound

Treatment Approach

• Non-surgical reduction using air enema is the first-line treatment, preferred for its lower risk of perforation and reduced radiation exposure, with success rates ranging from 70-90%
• Surgical intervention is reserved for cases where non-surgical reduction fails or when there are signs of complications such as peritonitis, bowel perforation, or shock
• Post-reduction monitoring is crucial for detecting recurrence, which occurs in approximately 10% of cases, most frequently within the first 24 hours, as part of managing the condition effectively.

From the Research

Diagnosis of Intussusception

• Intussusception is a medical condition where a part of the intestine slides into an adjacent part of the intestine, representing the most common abdominal emergency in infancy 2.
• The classical clinical triad of abdominal colics, red jelly stools, and a palpable mass is only present in approximately 50% of cases, while 20% of patients are symptom-free at clinical presentation 2.
• Primary imaging modality of choice is ultrasound scanning, which enables the diagnosis or exclusion of an intussusception at a sensitivity of 98-100%, specificity of 88%, and a negative predictive value of 100% 2.

Treatment of Intussusception

• Non-surgical reduction (NSR) is used once the diagnosis of an intussusception is established, with a surgical approach chosen in patients with signs of perforation, shock, or peritonitis 2.
• Different contrast media are used for NSR, including barium suspension or air with fluoroscopic guidance, or saline only or mixed with water-soluble contrast under sonographic guidance 2.
• NSR is an effective technique, being successfully employed in more than 90% of cases, with sonography and fluoroscopy being equally effective in the non-surgical management of childhood intussusception 2, 3.
• The use of sonography is preferred due to the absence of ionizing radiation and better visualization of possible pathologic lead points 3.

Confirmation of Reduction

• Confirmation of reduction can be obtained with a single abdominal radiograph, which can help detect false-positive reduction results after ultrasound-guided hydrostatic intussusception reduction 4.
• The use of water-soluble contrast material in the enema fluid can help confirm the reduction and decrease the false-positive reduction rate and early recurrence 4.

Clinical Presentation and Diagnosis

• Intussusception may be difficult to diagnose due to the non-specific symptoms, with the classical triad of symptoms evident at the time of presentation in only about 20% of cases 5.
• The most common presenting features are colicky abdominal pain, vomiting, pallor, lethargy, and listlessness, with clinical suspicion playing a crucial role in diagnosis 5, 6.
• Ultrasonography has replaced routine plain abdominal X-ray as the primary imaging modality, with gas largely replacing barium for enema reduction 5.