What is the initial management for intussusception?

Initial Management of Intussusception

Air enema reduction under fluoroscopic or ultrasound guidance is the initial management of choice for intussusception in hemodynamically stable patients. 1, 2, 3

Diagnostic Approach

1. Clinical Presentation:

   • Typical presentation includes crampy, intermittent abdominal pain
   • May progress to bloody stools and lethargy
   • Uncommon in the first 3 months of life 4

2. Initial Imaging:

   • Abdominal plain X-ray should be performed first
     • Diagnostic in 50-60% of bowel obstruction cases 4
     • Helps determine presence and level of obstruction
   • Ultrasound is highly effective for confirming diagnosis
     • Can visualize the characteristic "target" or "donut" sign

Management Algorithm

Step 1: Supportive Care

• Begin intravenous crystalloid fluid resuscitation immediately
• Insert nasogastric tube for decompression
• Administer anti-emetics as needed
• Place Foley catheter to monitor urine output 4

Step 2: Nonsurgical Reduction

• Air enema reduction is the preferred initial treatment:
  • Success rates of 75-86% reported in studies 2, 5
  • Can be performed under either:
    • Fluoroscopic guidance (traditional approach)
    • Ultrasound guidance (avoids radiation exposure)
  • Air pressure should be monitored (typically maintained between 40-60 mmHg) 6
  • Ultrasound-guided reduction has shown equal or better success rates (100% vs 82% in one study) with no radiation exposure 7

Step 3: Surgical Management

• Indicated when:

  • Nonsurgical reduction fails
  • Signs of peritonitis or perforation are present
  • Patient is hemodynamically unstable
  • Symptoms have been present for >24 hours (significantly lower success rates for nonsurgical reduction - only 33.3%) 5

• Surgical options include:

  • Manual reduction
  • Resection of non-viable bowel segments
  • Treatment of any underlying cause (e.g., lead point) 1

Important Considerations

• Timing is critical: Success rates for nonsurgical reduction decrease significantly with symptom duration:

  • <18 hours: 97.3% success
  • 18-24 hours: 86.4% success

  • 24 hours: 33.3% success 5

• Perforation risk: Though uncommon, perforation can occur during reduction attempts (reported in 1-3% of cases) 2, 5

• Recurrence: Recurrence rates vary between reduction methods:

  • 18% following barium enema reduction
  • 9% following air enema reduction 2

• Ultrasound advantages: Besides avoiding radiation, ultrasound can better visualize potential pathologic lead points 7

Pitfalls to Avoid

• Delaying treatment beyond 24 hours significantly reduces nonsurgical success rates and increases mortality 1, 5
• Failing to recognize signs of peritonitis or perforation, which are contraindications to nonsurgical reduction
• Not maintaining adequate sedation and analgesia during reduction procedures
• Excessive pressure during air enema (>100 mmHg) should only be used briefly and with caution 6

Air enema reduction under either fluoroscopic or ultrasound guidance represents the safest and most effective initial management strategy for intussusception, with ultrasound guidance offering the additional benefit of avoiding radiation exposure while maintaining excellent success rates.