Treatment of Intussusception
Surgical exploration is the primary treatment for adult intussusception due to the high risk of underlying malignancy (86-93% have a definable lesion) and complications including strangulation and bowel ischemia. 1
Initial Management
All patients require immediate stabilization:
- Fluid resuscitation to restore intravascular volume 1
- Antimicrobial therapy initiated once diagnosis is confirmed or suspected 1
- Obtain surgical consultation in all cases, even if considering non-operative approaches 1, 2
- CT scan is the imaging modality of choice in hemodynamically stable patients to confirm diagnosis and identify complications 1, 2
Treatment Algorithm by Patient Population
Adults (General Population)
Proceed directly to surgical exploration as the definitive treatment approach 1, 3:
- Formal bowel resection following oncological principles when malignancy is suspected 3
- Reduction may be considered only for confirmed benign lesions to limit resection extent 3
- Critical timing: Delaying intervention beyond 48 hours significantly increases mortality 1, 4
Non-operative management is reserved only for highly selected cases meeting ALL criteria 1, 2:
- Hemodynamically stable without signs of peritonitis or bowel compromise 1, 2
- Colonic location amenable to colonoscopic reduction 2
- Endoscopic expertise immediately available 2
- Important caveat: Endoscopic reduction carries high recurrence risk 2, 4
- Mandatory close monitoring for at least 24 hours post-reduction 1, 2
Pediatric Patients
Pneumatic or hydrostatic enema reduction is first-line treatment in children without contraindications 5, 6:
- Ultrasound is the diagnostic method of choice with 100% accuracy 5
- Air enema successful in approximately 79.5% of cases 5
- Sedative reduction (ketamine, midazolam, atropine) may be attempted during second or third reduction attempt to improve success rates (65.1% success) and avoid surgery 6
Surgical intervention indicated when 7, 5:
- Enema reduction unsuccessful after appropriate attempts 7
- Peritonitis, bowel perforation, or intestinal damage present 7
- Symptoms present ≥2 days before presentation (OR 6.863 for bowel resection) 7
- Long intussusception segment (OR 5.088 for bowel resection) 7
- Pathological lead point identified (OR 6.926 for bowel resection) 7
Higher surgical rates occur with 5:
Post-Bariatric Surgery Patients
Exploratory laparoscopy is mandatory within 12-24 hours for small bowel obstruction after RYGB with persistent pain and inconclusive findings 8:
- Classification: Type I (afferent loop), Type II (efferent loop), or Type III (combined) 4
- Surgical exploration starts from ileocecal junction toward jejuno-jejunostomy 8
Treatment options include 8, 4:
- Gentle manual reduction if bowel viable 8
- Resection of invaginated segment recommended to reduce recurrence 8, 4
- Reconstruction of jejuno-jejunostomy 4
- Anchoring techniques or conversion to other bariatric procedures in selected cases 1
Peutz-Jeghers Syndrome (PJS)
Elective polypectomy prevents intussusception complications 8:
- Small bowel polyps >1.5-2 cm (or smaller if symptomatic) should undergo elective resection 8
- Median polyp size causing intussusception is 35 mm (range 15-60 mm) 8
- Options include endoscopy, surgery, or combined approaches 8
- For surgical cases, intraoperative enteroscopy with "clean sweep" reduces need for subsequent laparotomy 8
Critical Pitfalls to Avoid
Timing is paramount:
- Never delay surgical intervention beyond 48 hours - mortality increases significantly 1, 4
- Uncertain pediatric cases require urgent referral to specialized centers 5
Assessment errors:
- Evaluate for peritonitis, strangulation, or bowel ischemia before attempting non-operative management 1, 2
- In adults, the high rate of underlying pathology (86-93%) supports surgical exploration over conservative management 1
Procedural complications: