What is the treatment for intussusception?

Treatment of Intussusception

The primary treatment for intussusception is prompt reduction, with the specific approach determined by patient stability, presence of complications, and age group. 1, 2

Diagnostic Approach

• CT scan is the imaging modality of choice for adults to confirm diagnosis and identify potential complications in hemodynamically stable patients 1
• Ultrasound is the diagnostic modality of choice for pediatric patients, with high diagnostic accuracy 2, 3
• Evaluation for signs of peritonitis, strangulation, or bowel ischemia is crucial as these necessitate immediate surgical intervention 1, 4

Treatment Algorithm

Initial Management

• Fluid resuscitation to restore intravascular volume and promote physiological stability 1
• Antimicrobial therapy should be initiated once intussusception is diagnosed or suspected 1
• Surgical consultation should be obtained in all cases, even when considering non-operative management 1, 4

Pediatric Intussusception Management

• In stable pediatric patients without evidence of perforation, non-operative reduction with hydrostatic or pneumatic reduction should be attempted first 2, 3
• Air enema reduction has success rates of approximately 79.5% in pediatric cases 3
• Delay in reduction is associated with higher rates of surgical intervention - time to nonsurgical intervention is positively associated with probability of requiring surgery 5
• Symptoms lasting ≥2 days before intervention significantly increase the risk of requiring bowel resection (OR = 6.863) 6

Adult Intussusception Management

• Surgical exploration is recommended as the primary treatment for adult intussusception due to the high risk of incarceration and strangulation 1
• The high rate of underlying pathology (86-93% of cases have a definable lesion) supports surgical exploration in adults 1
• Delaying intervention beyond 48 hours significantly increases mortality 1

Surgical Approach

• Operative intervention is necessary in patients who are:
  • Hemodynamically unstable 1, 4
  • Showing signs of peritonitis 1, 4
  • Have failed non-operative reduction 2
  • Have a focal lead point identified 2
  • Present with long-standing symptoms (>48 hours) 1, 6
• Surgical options include:
  • Manual reduction of the intussusception 1
  • Resection of the invaginated segment when ischemia or necrosis is present 1
  • Reconstruction of intestinal continuity 1

Non-operative Management

• Non-operative management may be considered only in highly selected cases:
  • Hemodynamically stable patients 1, 4
  • No signs of peritonitis or bowel compromise 1, 4
  • Endoscopic expertise readily available 1, 4
• Endoscopic reduction carries a high recurrence risk and requires close monitoring for at least 24 hours after reduction 1, 4

Special Considerations

Post-Bariatric Surgery Intussusception

• Involves modified intestinal motility, staple lines, and anatomic peculiarities 1
• Treatment options include resection of the invaginated segment, reconstruction of jejuno-jejunostomy, and anchoring techniques 1

Intussusception in Peutz-Jeghers Syndrome (PJS)

• Preventive management includes elective polypectomy for small bowel polyps >1.5-2 cm in size 7
• Symptomatic polyps should be considered for elective resection regardless of size 7
• Options to remove PJS polyps include endoscopy, surgery, or combined approaches based on patient factors, polyp characteristics, and local expertise 7

Pitfalls and Caveats

• Delay in surgical intervention beyond 48 hours significantly increases mortality 1
• Younger pediatric patients can present atypically, including altered mental status or lethargy, which may lead to delayed diagnosis 2
• The classic triad of intermittent abdominal pain, currant jelly stool, and sausage-shaped mass is uncommon in pediatric patients, though most will present with intermittent abdominal pain 2
• Long intussusception (OR = 5.088), pathological lead point (OR = 6.926), and ICU admission (OR = 11.777) are independent predictors of requiring bowel resection 6