What is the management for ileal intussusception?

Management of Ileal Intussusception

For ileal intussusception, surgical intervention with resection of the affected segment is recommended as it results in fewer recurrences than simple reduction alone. 1

Diagnosis and Initial Assessment

• Imaging: CT scan is the preferred diagnostic modality for adults with suspected intussusception, showing the characteristic "bulls-eye" or "target" appearance 2, 3
• Clinical presentation: Often presents with:
  • Abdominal pain (intermittent or constant)
  • Nausea and vomiting
  • Signs of bowel obstruction
  • In some cases, a palpable abdominal mass 3, 4

Management Algorithm

1. Initial Stabilization

• Intravenous fluid resuscitation
• Nasogastric tube insertion for decompression
• Foley catheter placement to monitor urine output
• Appropriate antibiotic therapy if peritonitis is suspected 2

2. Surgical Approach

For Hemodynamically Stable Patients:

• Exploratory laparoscopy is recommended within the first 12-24 hours in patients with persistent abdominal pain and inconclusive findings 1
• Begin surgical exploration from the ileocecal junction and work proximally 1
• Assess the entire small intestine to identify the intussusception and any potential lead point 1

For Hemodynamically Unstable Patients:

• Open surgical approach is indicated 2
• Damage control procedure may be necessary in severe cases 2

3. Intraoperative Management

• Assessment of bowel viability is crucial using visual inspection or indocyanine green (ICG) fluorescence angiography when available 1, 2

• For viable bowel with intussusception:

  • While simple reduction is possible, resection of the affected segment is strongly recommended to prevent recurrence 1, 2, 4

• For non-viable bowel:

  • Resection of the affected segment with primary anastomosis is necessary 1
  • In cases of severe peritonitis or hemodynamic instability, damage control approach with delayed anastomosis may be considered 1

Special Considerations

Lead Point Pathology

• In adults, intussusception is often associated with a lead point (tumor, polyp, Crohn's disease, etc.) 4
• Resection is particularly important when a lead point is identified 3, 4
• Histopathological examination of the resected specimen is essential to identify potential malignancy 3

Post-Bariatric Surgery Patients

• Intussusception is a recognized cause of small bowel obstruction after bariatric surgery 2
• Retrograde (anti-peristaltic) intussusception is most common after laparoscopic Roux-en-Y gastric bypass 2
• In recurrent cases, consider reversal of gastric bypass or conversion to sleeve gastrectomy 2

Pitfalls to Avoid

• Delay in surgical intervention: Mortality increases significantly if surgery is delayed beyond 48 hours 2
• Endoscopic reduction alone: Associated with high recurrence rates and should be avoided as definitive treatment 2
• Missing underlying pathology: Always search for a lead point, as adult intussusception is rarely idiopathic 4
• Inadequate resection margins: When resecting, ensure adequate margins to prevent recurrence 1, 2

By following this management approach, the risk of complications such as bowel ischemia, necrosis, and perforation can be minimized, improving patient outcomes in cases of ileal intussusception.