What are the outcomes and management of perforated intussusception in children?

Management and Outcomes of Perforated Intussusception in Children

Perforated intussusception in children requires immediate surgical intervention with bowel resection and carries significant morbidity, with mortality rates of 40-90% in severe cases involving extensive bowel involvement. 1

Clinical Presentation and Diagnosis

• Perforated intussusception presents with signs of peritonitis, hemodynamic instability, and sepsis, often following untreated or delayed diagnosis of intussusception 1
• The classic triad of intermittent abdominal pain, currant jelly stool, and sausage-shaped mass is uncommon, though most patients present with intermittent abdominal pain 1
• CT scan is the preferred imaging modality to confirm perforation, as it is more sensitive than standard abdominal radiographs for detecting free air 2
• Laboratory tests should include white blood cell count and C-reactive protein to assess the severity of inflammation 2

Risk Factors for Perforation and Bowel Resection

• Symptoms lasting at least 2 days before intervention (OR = 6.863) 3
• Long intussusception (OR = 5.088) 3
• Presence of a pathological lead point (OR = 6.926) 3
• Delayed presentation (>24 hours) significantly increases risk of requiring surgery (73% vs 45%) and bowel resection (39% vs 17%) 4

Management Approach

Initial Stabilization

• Fluid resuscitation and broad-spectrum antibiotics should be initiated immediately 5
• Appropriate antibiotic regimens include:
  • Carbapenems (imipenem or meropenem) 5
  • Piperacillin-tazobactam or ticarcillin-clavulanate 5
  • Extended-spectrum cephalosporin (cefotaxime, ceftriaxone, ceftazidime, or cefepime) with metronidazole 5
  • Aminoglycoside-based regimens (gentamicin, ampicillin, and clindamycin/metronidazole) 5

Surgical Management

• Patients with perforations who are hemodynamically unstable or have peritoneal signs require immediate surgical management 5
• Surgery typically involves bowel resection with either primary anastomosis or stoma creation, depending on the extent of contamination 2
• Laparoscopic approach may be considered in stable patients, but conversion to open surgery should be performed if the area of perforation cannot be adequately visualized or managed 5
• Bowel resection is required in approximately 50% of children requiring surgical intervention for intussusception 4

Outcomes and Prognosis

• Length of hospital stay averages 6.1 days when bowel resection is required versus 3.9 days for surgical reduction without resection 4
• Complications occur in approximately 19% of cases requiring surgical intervention 4
• Mortality rates are generally low with prompt intervention but can reach 40-90% in cases with extensive bowel involvement 5
• Intensive care unit admission is strongly associated with need for bowel resection (OR = 11.777) 3

Prevention of Perforation

• Early diagnosis and prompt treatment of intussusception is crucial to prevent progression to perforation 1
• Air-contrasted enema reduction techniques have higher success rates than liquid-contrasted techniques (54% vs 34%) 4
• For failed initial reduction attempts, sedative reduction may be considered, with success rates of approximately 65% 6
• Continuous and strict clinical and biochemical follow-up is recommended for all patients with intussusception 2

Special Considerations

• Immunocompromised patients and transplant recipients with perforated intussusception should receive surgical management regardless of perforation size 2
• Percutaneous needle decompression may be necessary in cases of tension pneumoperitoneum causing hemodynamic instability 7
• Accurate documentation, prompt discussion with family, and reporting to the quality officer and risk management team are essential in cases of perforation 5