What is the recommended management for a patient with suspected intussusception?

Management of Suspected Intussusception

For suspected intussusception, obtain immediate CT scan in hemodynamically stable patients to confirm diagnosis and identify complications, followed by urgent surgical consultation in all cases, as adults have an 86-93% rate of underlying pathologic lesions requiring surgical exploration. 1, 2

Diagnostic Approach

Imaging Strategy

• CT scan is the imaging modality of choice for confirming intussusception and identifying potential complications in hemodynamically stable patients 1, 2
• Ultrasound has 97.9% sensitivity and 97.8% specificity for diagnosis, making it an excellent alternative, particularly in pediatric cases 3
• Plain radiography has poor diagnostic accuracy (48% sensitivity, 21% specificity) and should only be used to detect pneumoperitoneum or high-grade obstruction 4, 3

Critical Clinical Assessment

• Evaluate immediately for peritonitis, strangulation, or bowel ischemia—these findings mandate immediate surgical intervention 1, 2
• Assess hemodynamic stability to determine intervention urgency 1, 2
• Look specifically for: abdominal pain (present in 72% of adults), nausea (49%), vomiting (36%), and bloody stools 5
• Note that 20% of adult cases are asymptomatic and discovered incidentally, so maintain high clinical suspicion 5

Treatment Algorithm

Immediate Management

• Initiate fluid resuscitation to restore intravascular volume 2
• Start antimicrobial therapy once intussusception is diagnosed or suspected 2
• Obtain surgical consultation in ALL cases, even when considering non-operative management 1, 2

Surgical vs. Non-Operative Decision

Surgical exploration is the primary treatment for adults due to:

• High malignancy risk (86-93% have underlying pathologic lesions including malignancy, inflammatory bowel disease, adhesions, or Meckel's diverticulum) 1, 2
• High risk of incarceration and strangulation 2, 6
• The 48-hour threshold is critical—mortality increases significantly with delayed intervention 1, 2, 6

Non-Operative Management Criteria (Highly Selective)

Non-operative management may be attempted ONLY when ALL of the following are present:

• Hemodynamically stable patient 1, 2
• No signs of peritonitis or bowel compromise 1, 2
• Colonic location amenable to colonoscopic reduction 1
• Endoscopic expertise readily available 2

Important 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 still be obtained 1, 2

Surgical Technique

• Perform formal surgical exploration with bowel resection following oncological principles 1
• Standard approach involves resection of the invaginated segment with reconstruction 1
• Use indocyanine green (ICG) fluorescence angiography to guide resection margins when intestinal perfusion is questionable 2
• Close all mesenteric defects with non-absorbable sutures after reduction to prevent recurrence 2

Special Populations

Post-Bariatric Surgery Patients

• Immediate surgical intervention is recommended for acute presentations 1
• Reduction should begin from the ileocecal valve (distal to obstruction) where bowel is less dilated and safer to handle laparoscopically 2

Peutz-Jeghers Syndrome

• Perform elective polypectomy of small bowel polyps >1.5-2 cm (or smaller if symptomatic) to prevent intussusception 1
• These patients have a 50-68% cumulative risk of intussusception in childhood 1
• Begin surveillance with video capsule endoscopy and MRI enterography at age 8 years 1

Critical Pitfalls to Avoid

• Never delay surgery beyond 48 hours in adults—mortality increases significantly 1, 2, 6
• Do not assume idiopathic etiology in adults—underlying pathology exists in 86-93% of cases 1, 2
• Avoid futile reduction enema attempts in patients with suspicious small bowel intussusception features, as this delays definitive surgical management and increases bowel complications 7
• Do not discharge patients after non-operative reduction without at least 24 hours of close monitoring 1, 2
• In patients presenting to the emergency department with abdominal pain (RR 2.2), nausea (RR 1.7), vomiting (RR 1.4), or bloody stool (RR 1.9), anticipate need for surgical intervention 5