What is the treatment for intussusception in pediatrics?

Treatment of Intussusception in Pediatrics

Immediate non-operative reduction using pneumatic or hydrostatic enema is the first-line treatment for hemodynamically stable pediatric patients without signs of perforation or peritonitis, with ultrasound as the diagnostic modality of choice. 1, 2, 3

Diagnostic Approach

Ultrasound is the mandatory first diagnostic step, with 98.1% sensitivity for detecting the characteristic target lesion in pediatric intussusception. 1, 4

• Plain abdominal radiographs may show dilated small-bowel loops with air-fluid levels and paucity of colonic gas, useful for evaluating complications such as obstruction or perforation. 1
• Most cases occur between 3 months to 5 years of age, with peak incidence at 5-9 months. 1, 3
• The classic triad (intermittent abdominal pain, currant jelly stool, sausage-shaped mass) is uncommon—most patients present with intermittent colicky abdominal pain alone. 1, 3
• Critical pitfall: Younger patients can present atypically with altered mental status or lethargy without obvious abdominal findings. 3

Treatment Algorithm

Non-Operative Management (First-Line)

For hemodynamically stable patients without peritonitis or perforation:

• Pneumatic or hydrostatic reduction should be attempted immediately as first-line therapy. 3, 4
• Success rate is approximately 79.5% with air enema reduction. 4
• If initial reduction fails, a second or third attempt under sedation with intravenous ketamine, midazolam, and atropine achieves successful reduction in 65.1% of cases, avoiding surgery. 5
• Patients must be monitored for at least 24 hours after successful reduction. 2
• Discharge is appropriate only if the patient tolerates clear fluids, remains asymptomatic, and can return immediately for recurrence. 3

Surgical Management (Immediate Indications)

Proceed directly to surgery when:

• Hemodynamic instability is present. 2, 6
• Signs of peritonitis, bowel perforation, or ischemia are evident. 2, 3
• Non-operative reduction fails after 2-3 attempts. 5, 4
• A pathologic lead point is identified (occurs in 10-25% of pediatric cases). 1, 3

Surgical approach selection:

• Laparoscopic reduction is preferred for patients presenting early (<1.5 days of symptoms) without peritonitis. 7
• Conversion to open surgery occurs in 31.9% of cases and is more likely with: symptom duration >1.5 days, presence of peritonitis, or pathologic lead point. 7
• Resection of the invaginated segment with reconstruction is standard when bowel viability is compromised. 2, 6

Critical Time-Dependent Factors

Duration of symptoms directly impacts outcomes:

• Patients with symptoms >24 hours have significantly higher rates of surgical intervention. 4
• Delayed diagnosis leads to increased need for open surgery rather than laparoscopic approach. 7, 4
• The 48-hour threshold is critical in adults, though less well-defined in pediatrics. 2, 6

Key Pitfalls to Avoid

• Do not delay imaging in children with intermittent abdominal pain, vomiting, or unexplained lethargy—ultrasound should be performed urgently. 1, 3
• Do not assume idiopathic etiology in neonates, older children (>5 years), or those with recurrent intussusception—these groups have higher rates of pathologic lead points requiring surgical exploration. 1
• Do not miss atypical presentations in infants presenting with only altered mental status or lethargy without obvious abdominal findings. 3
• Do not attempt multiple reduction attempts without sedation—if initial reduction fails, sedative reduction (third attempt) significantly improves success rates before proceeding to surgery. 5
• Referred patients and those with prolonged symptoms require heightened suspicion for complications and may need earlier surgical intervention. 4

Special Considerations

• Most pediatric cases (90-75%) are idiopathic, unlike adults where 86-93% have underlying pathology. 1, 2
• Recurrence occurs in 0.1-0.3% of cases, with highest risk in the first 10 days postoperatively. 6
• All mesenteric defects must be closed with non-absorbable sutures after surgical reduction to prevent recurrence. 6