Air Enema is the First-Line Treatment Before Surgery
For acute intestinal obstruction due to intussusception in hemodynamically stable patients without signs of peritonitis or bowel ischemia, air enema reduction should be attempted first before proceeding to surgery. 1, 2
Why Air Enema (Option 1) is Correct
Evidence Supporting Air Enema
- Air enema achieves successful reduction in 66-88% of cases, avoiding the need for surgery and its associated morbidity 2, 3
- The procedure has an extremely low complication rate of only 0.5% for bowel perforation, making it remarkably safe 2, 4
- Success rates are consistent across multiple large series: 66% (UK tertiary center, 290 cases), 68% (Thailand, 737 cases), and 88% (with pressure-controlled devices) 2, 4, 3
- Non-operative reduction reduces morbidity and shortens hospitalization compared to immediate surgery 5
Technical Considerations
- Air enema should be performed under fluoroscopic guidance with pressure not exceeding 120 mmHg to minimize perforation risk 4, 3
- The procedure can be repeated 2-3 times if initial attempt is unsuccessful, with 36% of successful cases requiring a second insufflation 3
- Recurrence rate after successful air enema is approximately 9%, which is acceptable given the avoidance of surgery 2
Why Other Options Are Incorrect
Steroid Enema (Option 2)
- No evidence supports steroid enema for acute intussusception treatment in any of the available guidelines or research
- This is not a recognized therapeutic modality for this condition
Barium Enema (Option 3)
- While historically used, barium enema has been largely replaced by air enema since the 1990s 4
- Air enema is preferred because it provides equivalent or better reduction rates with less radiation exposure and easier cleanup if perforation occurs 2, 4
Endoscopic Procedure (Option 4)
- Endoscopy is not indicated for ileocolic intussusception, which is the most common type causing acute obstruction 2
- Endoscopy is only recommended for proximal small bowel obstruction after bariatric surgery or when bezoar is suspected in the stomach 6
- Endoscopic reduction carries a high recurrence risk and is not standard practice for typical intussusception 1
Critical Caveats
Absolute Contraindications to Air Enema
- Signs of peritonitis (guarding, rigidity, rebound tenderness) mandate immediate surgery 1, 7
- Hemodynamic instability despite resuscitation requires emergency surgical exploration 1, 7
- Radiological evidence of perforation (pneumoperitoneum) is an absolute surgical indication 7
- Clinical signs of bowel ischemia (markedly elevated lactate, severe continuous pain, bloody stools) necessitate immediate operation 7
Timing Considerations
- Delay beyond 48 hours significantly increases mortality, so air enema should be attempted promptly after diagnosis 1
- If air enema fails, surgical exploration should proceed without further delay 1, 2
- Patients require close monitoring for at least 24 hours after successful reduction to detect early recurrence 1
Special Population: Adults
- In adults, 90% of intussusception cases have an underlying pathological lead point (often malignancy), making surgical exploration more commonly indicated 1, 8
- The question context suggests a pediatric scenario where air enema is most appropriate, but adult intussusception typically requires surgery for both diagnosis and treatment of the underlying cause 1, 8