What is the initial treatment for pediatric intussusception?

Initial Treatment for Pediatric Intussusception

The initial treatment for pediatric intussusception is non-operative enema reduction (air or liquid) under ultrasound or fluoroscopic guidance, which has a success rate of approximately 82% in cases without signs of perforation or peritonitis. 1

Diagnosis and Initial Assessment

Imaging

• Ultrasound is the modality of choice for diagnosis of intussusception 1
• Abdominal radiography's primary role is to detect complications such as pneumoperitoneum or high-grade bowel obstruction 1
• CT scan may be used in certain cases but is not the first-line imaging modality for children due to radiation exposure concerns 2

Clinical Presentation

• Classic triad (present in only ~20% of cases):
  • Intermittent abdominal pain
  • Vomiting
  • Bloody stools ("currant jelly" stools)
• Other symptoms: lethargy, palpable abdominal mass

Treatment Algorithm

Step 1: Stabilization

• Intravenous fluid resuscitation
• Nasogastric tube placement for decompression if significant vomiting
• Correction of electrolyte abnormalities
• Pain management

Step 2: Non-operative Reduction

• Contraindications to enema reduction:

  • Signs of peritonitis
  • Perforation
  • Hemodynamic instability
  • Sepsis

• Enema reduction techniques:

  1. Air enema (preferred by many centers)

     • Average pressure needed for initial movement: 56.5 mmHg
     • Average maximum pressure for complete reduction: 97.8 mmHg
     • Lower radiation dose than hydrostatic enema
     • Success rate up to 87% 3

  2. Hydrostatic/liquid contrast enema

     • Can be performed under fluoroscopic or ultrasound guidance
     • Ultrasound-guided reduction has 95% success rate in experienced hands 4

Step 3: Management After Initial Reduction Attempt

• If successful reduction:

  • Observe for 12-24 hours
  • Monitor for recurrence (occurs in 5-10% of cases)
  • Repeat ultrasound 1 hour after reduction to confirm success 4

• If unsuccessful first attempt:

  • Consider delayed repeat enema after 30 minutes to several hours
  • Success rate of repeat enemas: 31-52% 5
  • Implementation of a delayed repeat enema protocol can significantly reduce the need for surgical intervention 5

Step 4: Surgical Management (if non-operative reduction fails)

• Indications for surgery:

  • Failed enema reduction (after repeated attempts)
  • Signs of peritonitis
  • Perforation
  • Hemodynamic instability

• Surgical approaches:

  • Laparoscopic or open surgical reduction for stable patients
  • Open surgical approach for unstable patients 6
  • Resection with primary anastomosis if bowel is non-viable 6

Special Considerations

• Complete reduction criteria: Traditionally, reflux of contrast into the terminal ileum was considered necessary to confirm complete reduction. However, research shows that symptomatic improvement without contrast reflux into the terminal ileum may still indicate successful reduction 7

• Predictors of failed enema reduction:

  • Longer symptom duration
  • Younger age
  • Presence of lethargy, fever, or bloody diarrhea
  • Unfavorable radiologic findings (small bowel obstruction, trapped fluid, ascites)
  • Pathological lead points 1

Follow-up

• Monitor for 24-48 hours after successful reduction
• Educate parents about signs of recurrence
• No dietary restrictions necessary after successful reduction and return of normal bowel function

By following this structured approach to the management of pediatric intussusception, clinicians can achieve high success rates with non-operative treatment while minimizing the need for surgical intervention.