What is the best non-surgical method for reducing intussusception?

Best Non-Surgical Method for Intussusception Reduction

Air enema is the best non-surgical method for reducing intussusception, having replaced barium enema as the treatment of choice due to its lower radiation exposure, relatively inert nature if perforation occurs, and equivalent success rates. 1, 2

Primary Treatment Approach

• Air enema reduction should be attempted first in hemodynamically stable patients without signs of peritonitis or bowel ischemia before proceeding to surgery. 1
• Success rates for air enema reduction range from 76-85.5%, comparable to barium enema (71.7-75%), but with superior safety profile. 2, 3
• The procedure should be performed promptly after diagnosis, as delays beyond 48 hours significantly increase mortality. 1, 4

Why Air Enema Over Barium Enema (Option B)

While barium enema was historically used and achieves similar reduction rates, air enema has become preferred because:

• Air is relatively inert compared to barium if perforation occurs during reduction - barium peritonitis carries significant morbidity, while air is better tolerated. 2
• Air provides lower radiation absorption, reducing patient exposure. 2
• Both modalities show similar perforation rates (2-3 perforations per 100 cases), but air-related perforations are less morbid. 2
• Recurrence rates are actually lower with air enema (9%) compared to barium enema (18%). 2

Why Not Manual Reduction Per Rectum (Option A)

• Manual reduction per rectum is not a standard treatment for intussusception and is not mentioned in any current guidelines. 1, 4, 5
• This approach would not address ileocolic intussusception, which is the most common type in children.
• Gentle manual reduction is only mentioned in the context of intraoperative surgical management, not as a primary non-surgical approach. 6

Why Not Nasogastric Tube Decompression (Option C)

• Nasogastric decompression is a supportive measure for bowel obstruction but does not reduce intussusception. 6
• NG tube placement may be used for gastric decompression in the perioperative period but has no role in definitive treatment of intussusception. 6

Absolute Contraindications to Non-Operative Reduction

Non-surgical reduction should not be attempted when:

• Signs of peritonitis are present (guarding, rigidity, rebound tenderness). 1, 4
• Hemodynamic instability persists despite resuscitation. 1, 4
• Radiological evidence of perforation (pneumoperitoneum) exists. 1
• Clinical signs of bowel ischemia are present (markedly elevated lactate, severe continuous pain, bloody stools). 1

Post-Reduction Management

• Patients require close monitoring for at least 24 hours after successful reduction to detect early recurrence. 1, 5
• If air enema fails, surgical exploration should proceed without further delay. 1
• Multiple interval attempts may improve success rates - delayed interval enema reduction can increase reduction rates by 61%. 7

Important Caveats

• In adults, 86-93% of intussusception cases have an underlying pathological lead point (often malignancy), making surgical exploration more commonly indicated rather than non-operative reduction. 4
• Failure of reduction shows high association with presence of a lead point or ileoileal/ileoileocolic intussusception. 2
• Ultrasound guidance during reduction avoids radiation exposure entirely and achieves success rates of 85.5%. 3