What is the initial recommended treatment for intussusception?

Initial Treatment for Intussusception

The initial recommended treatment for intussusception is non-surgical reduction via air enema under ultrasound or fluoroscopic guidance. 1, 2, 3

Diagnostic Approach

Before proceeding with treatment, proper diagnosis is essential:

• Typical presentation: intermittent crampy abdominal pain, vomiting, and sometimes bloody stools
• Physical examination may reveal a palpable abdominal mass ("olive") in some cases
• Ultrasound is the imaging modality of choice for diagnosis

Treatment Algorithm

First-Line Treatment:

1. Air enema reduction under imaging guidance

   • Success rates of approximately 80-87% have been reported 1, 3
   • Typically performed under fluoroscopic or ultrasound guidance
   • Air pressure should be monitored with a manometer (typically 40-60 mmHg, with temporary increases up to 100 mmHg if needed) 4
   • Average pressure needed for initial movement is around 56.5 mmHg 3

2. Alternative enema media options:

   • Air (preferred due to lower radiation exposure and cleaner in case of perforation)
   • Water-soluble iodinated contrast
   • Normal saline
   • Note: Barium is no longer recommended due to severe complications if perforation occurs 5

When to Consider Delayed Repeat Enema:

• If initial enema partially reduced the intussusception
• If patient remains clinically stable
• Delayed repeat enema can improve overall success rates 5

When to Proceed to Surgery:

Immediate surgical intervention is indicated in cases with:

• Signs of peritonitis
• Prolonged bowel obstruction
• Hemodynamic instability
• Failed enema reduction
• Presence of pathological lead point (more common in older children and adults)
• Perforation

Special Considerations

Pediatric vs. Adult Intussusception:

• In children: Idiopathic intussusception is common, and non-operative reduction is standard first-line treatment
• In adults: Intussusception is rare (1% of bowel obstructions) and often has a pathological lead point requiring surgical intervention 4

Post-Reduction Monitoring:

• Clinical improvement should be observed
• Repeat ultrasound 1 hour after reduction to confirm absence of persistent intussusception 2
• Monitor for recurrence (occurs in approximately 8.5% of cases) 1

Pitfalls to Avoid

1. Delaying treatment (increases risk of bowel ischemia and perforation)
2. Using excessive pressure during enema reduction (risk of perforation)
3. Attempting enema reduction in patients with peritonitis or prolonged obstruction
4. Failing to recognize pathological lead points that require surgical intervention
5. Using barium for enema reduction (contraindicated due to severe complications if perforation occurs)

Air enema reduction is both safe and effective when performed by properly trained clinicians, with lower radiation exposure compared to traditional contrast techniques, and should be the initial treatment approach for intussusception in hemodynamically stable patients without signs of peritonitis or perforation.