What is the management approach for gastroduodenal intussusception?

Management of Gastroduodenal Intussusception

Gastroduodenal intussusception requires prompt surgical intervention, with the specific approach determined by the patient's hemodynamic status, underlying cause, and presence of complications.

Diagnostic Approach

• Clinical presentation: Typically presents with:

  • Epigastric pain
  • Nausea and vomiting (often persistent)
  • Possible palpable epigastric mass
  • Potential signs of gastric outlet obstruction

• Imaging studies:

  • CT scan is the preferred initial diagnostic modality
  • Endoscopy to identify potential lead points (tumors, polyps)
  • Abdominal ultrasonography may suggest intussusception

Management Algorithm

1. Initial Assessment and Stabilization

• Fluid resuscitation
• Nasogastric tube placement for decompression
• Correction of electrolyte abnormalities
• Assessment of hemodynamic status

2. Surgical Management

• Timing: Prompt surgical intervention is necessary as delay beyond 48 hours is associated with significantly increased mortality 1

• Approach based on patient classification:

  Class A patients (hemodynamically stable):

  • Laparoscopic or open surgical reduction
  • Identification and treatment of underlying cause (usually tumor resection)
  • If minimal contamination: primary repair may be considered 2

  Class B and C patients (moderately to severely unstable):

  • Open surgical approach preferred
  • Damage control procedure should be considered regardless of patient class if severe hemodynamic instability exists 2
  • Delayed bowel anastomosis may be necessary 2

3. Specific Surgical Interventions

• Manual reduction of the intussusception when possible 1
• Resection of the underlying lesion (most commonly a tumor)
  • For gastric GIST causing intussusception: wedge resection or partial gastrectomy 3, 4
  • For benign polyps: endoscopic resection may be sufficient in select cases 5
• Assessment of bowel viability using visual inspection or indocyanine green fluorescence angiography 2
• Resection of non-viable segments when necessary 1

4. Post-operative Management

• Proton pump inhibitors for gastroduodenal disease 2
• Appropriate antibiotic therapy based on patient class:
  • Class A: Short course perioperative antibiotics
  • Class B/C: Extended antibiotics based on clinical response 2
• Nutritional support as needed

Special Considerations

• Underlying etiology: Most adult gastroduodenal intussusception cases are caused by lead point lesions:

  • Gastrointestinal stromal tumors (GISTs) 3, 4
  • Hyperplastic polyps 5
  • Other submucosal tumors (schwannomas, etc.) 6

• Endoscopic management: May be appropriate in select cases:

  • For small, benign polyps causing intussusception 5
  • As a diagnostic tool prior to surgery
  • Not recommended for suspected malignancy or large lesions

• Recurrence prevention: Consider anchoring techniques in selected cases to prevent recurrence 1

Pitfalls and Caveats

• Gastroduodenal intussusception is rare but should be considered in patients with persistent vomiting and epigastric pain
• Pre-operative diagnosis can be challenging; high index of suspicion is needed 3
• Delay in surgical intervention beyond 48 hours significantly increases mortality 1
• Partial endoscopic resection may resolve the intussusception in select cases with benign polyps, avoiding the need for surgery 5
• Always evaluate for underlying malignancy as the lead point

Remember that gastroduodenal intussusception represents a surgical emergency requiring prompt diagnosis and intervention to prevent complications such as bowel ischemia, perforation, and peritonitis.