What is the typical timeline for the management and treatment of intussusception?

Timeline of Intussusception Management

Surgical intervention for intussusception should occur within the first 12-24 hours in stable patients presenting with persistent abdominal pain and inconclusive clinical and radiological findings, with resection of the affected segment strongly recommended to prevent recurrence. 1

Initial Diagnosis and Assessment (0-6 hours)

• Imaging studies:

  • Abdominal plain X-ray as initial imaging (diagnostic in 50-60% of bowel obstruction cases) 1
  • CT scan is the preferred imaging modality for diagnosing intussusception, especially in post-bariatric surgery patients 1
  • Ultrasound may be used for confirmation after reduction attempts 2

• Initial management:

  • Immediate intravenous crystalloid fluid resuscitation
  • Nasogastric tube insertion for decompression
  • Anti-emetics as needed
  • Foley catheter placement to monitor urine output
  • Proton pump inhibitors for gastroduodenal disease
  • Appropriate antibiotic therapy based on patient classification 1

Non-surgical Reduction (6-24 hours)

• Air enema reduction:
  • Most effective when performed within 24 hours of symptom onset 2
  • Air pressure typically maintained between 40-60 mmHg, may temporarily increase to >100 mmHg if needed 2
  • Success rates vary (68-76% reported in different studies) 3, 4
  • Perforation risk is approximately 0.5% 4
  • More commonly used in pediatric cases but can be successful in select adult cases 2

Surgical Intervention (12-24 hours)

• Timing:

  • Exploratory laparoscopy within the first 12-24 hours in stable patients with persistent symptoms 5, 1
  • Delay beyond 48 hours is associated with significantly increased mortality 1

• Surgical approach:

  • Laparoscopic approach for hemodynamically stable patients
  • Open surgery for unstable patients 1

• Intraoperative assessment:

  • Assessment of bowel viability using visual inspection or indocyanine green fluorescence angiography 5, 1
  • Surgical exploration should start from the ileocecal junction toward the jejuno-jejunostomy (in post-bariatric surgery patients) 5

• Treatment based on findings:

  • For viable bowel with intussusception:

    • Resection of the affected segment is recommended to prevent recurrence 5, 1
    • Simple reduction alone has higher recurrence rates 1

  • For non-viable bowel:

    • Resection of the affected segment with primary anastomosis 1
    • In severe peritonitis or hemodynamic instability, consider damage control approach with delayed anastomosis 1

• Location-specific management:

  • Small intestine intussusception:

    • Reduction may be attempted if bowel is viable 6
    • Segmental resection after reduction 6

  • Colonic intussusception:

    • En-bloc resection without reduction due to risk of perforation and potential malignancy 6
    • Higher association with malignancy (33-42% of cases) 6, 7

Post-operative Care and Follow-up

• Nutritional support as needed, especially for patients with gastroduodenal intussusception 1
• Monitor for recurrence, which is more common after reduction alone 1
• In complex cases with recurrent intussusception, consider reversal of gastric bypass or conversion to sleeve gastrectomy (for post-bariatric surgery patients) 1

Important Considerations

• Adult intussusception is rare (1% of all bowel obstructions) and usually has an identifiable lead point (92.3% of cases) 6
• Pediatric intussusception is more commonly idiopathic and amenable to non-operative reduction 7
• Air enema reduction is preferred over barium due to lower radiation exposure and less severe consequences if perforation occurs 3
• The success of non-operative reduction decreases with longer duration of symptoms, with best results when performed within 24 hours of symptom onset 2, 4