What is the treatment for intussusception?

Treatment of Intussusception

Surgical exploration is the primary treatment for intussusception in adults and should be performed urgently, as delaying intervention beyond 48 hours significantly increases mortality. 1, 2

Pediatric Intussusception

Initial Diagnostic Approach

• Ultrasound is the diagnostic modality of choice in children, with 100% diagnostic accuracy and should be performed first 3
• Look for the classic triad: cramping abdominal pain, bloody diarrhea, and palpable tender mass 4
• Consider lymphoma in older children (median age 87 months vs 18.5 months for idiopathic cases) with prolonged symptoms, mesenteric lymph node enlargement, and distinct intra-abdominal masses on ultrasound 5

Non-Operative Management in Children

• Air or contrast enema reduction is successful in 79.5% of pediatric cases and should be the first-line treatment 3
• Success rates drop significantly when symptoms exceed 24 hours 3
• Complications requiring immediate intervention (perforation, hemodynamic instability) occur in only 1.6% of reduction attempts 6
• On-site surgeon presence during reduction is not mandatory if the attending physician can manage percutaneous needle decompression and hemodynamic instability, with surgical care available expeditiously 6

Surgical Indications in Children

• Failed enema reduction 3
• Symptoms present >24 hours 3
• Signs of peritonitis, strangulation, or bowel ischemia 1, 2
• Suspected lymphoma (older age, prolonged symptoms, failed reduction) 5

Adult Intussusception

Diagnostic Approach

• CT scan is the imaging modality of choice to confirm diagnosis and identify complications in hemodynamically stable adults 1, 7
• Evaluate for peritonitis, strangulation, or bowel ischemia requiring immediate surgery 1, 2
• Assess hemodynamic stability to determine intervention urgency 1, 2
• Note that 86-93% of adult cases have an underlying pathologic lesion (malignancy, inflammatory bowel disease, adhesions, Meckel's diverticulum) 1, 4

Surgical Management (Primary Treatment)

• Formal surgical exploration with bowel resection following oncological principles is recommended due to the high malignancy risk 1, 4
• Resection of the invaginated segment with reconstruction is the standard approach 1, 7
• Reduction without resection may be considered only for confirmed benign lesions to limit resection extent or prevent short bowel syndrome 4
• The 48-hour threshold is critical—mortality increases significantly with delayed intervention 1, 2, 7

Non-Operative Management (Highly Selected Cases Only)

Non-operative management may be attempted only when ALL of the following criteria are met:

• Hemodynamically stable patient 2
• No signs of peritonitis or bowel compromise 2
• Colonic location amenable to colonoscopic reduction 2
• Endoscopic expertise readily available 2

Critical caveats for non-operative approach:

• Endoscopic reduction carries high recurrence rates 1, 2
• Mandatory close monitoring for at least 24 hours after reduction 1, 2
• Surgical consultation must be obtained in all cases, even when attempting non-operative management 1, 2
• Proceed immediately to surgery if reduction is unsuccessful, signs of peritonitis develop, or hemodynamic instability occurs 2

Special Populations

Post-Bariatric Surgery Intussusception

• Classified as Type I (afferent loop), Type II (efferent loop), or Type III (combined) 1
• Immediate surgical intervention is recommended for acute presentations 7
• Treatment options include resection of invaginated segment, reconstruction of jejuno-jejunostomy, anchoring techniques, or conversion to other bariatric procedures 1
• Exploratory laparoscopy is mandatory within 12-24 hours for stable patients with persistent pain and inconclusive findings 8

Peutz-Jeghers Syndrome (PJS)

• Elective polypectomy of small bowel polyps >1.5-2 cm (or smaller if symptomatic) prevents intussusception, which has a 50-68% cumulative risk in childhood 8
• Surveillance with video capsule endoscopy and MRI enterography should begin at age 8 years 8
• For surgical cases, intraoperative enteroscopy with complete "clean sweep" reduces need for subsequent laparotomy 8

Key Pitfalls to Avoid

• Do not delay surgery beyond 48 hours in adults—mortality increases significantly 1, 2, 7
• Do not attempt non-operative management in unstable patients or those with peritoneal signs 2
• Do not assume idiopathic etiology in adults—underlying pathology exists in 86-93% of cases 1
• Do not perform simple reduction in adults without excluding malignancy 4
• In children, do not delay referral to specialized centers for uncertain cases 3