Management of Suspected Intussusception in a 15-Month-Old
The most important step is barium or air enema reduction (Option D), as this is both diagnostic and therapeutic with high success rates (85-90%) for intussusception, which is the most likely diagnosis given this classic presentation. 1
Clinical Reasoning
This 15-month-old presents with the classic triad of intussusception: abdominal discomfort with apparent colicky pain, vomiting, and bloody mucous per rectum ("currant jelly" stools), in the appropriate age range (peak incidence 3 months to 3 years, most common at 5-9 months but certainly occurs at 15 months). 1
The obstructive pattern on abdominal film is consistent with intestinal obstruction from intussusception and has high sensitivity and specificity for this diagnosis. 1
Why Enema Reduction is the Priority
Enema reduction (air or barium) is both diagnostic AND therapeutic, with success rates of 85-90% in appropriately selected patients. 1, 2, 3
The American College of Radiology specifically recommends enema reduction as the diagnostic and therapeutic approach for intussusception in infants and young children, with a low risk of complications. 1
Immediate resuscitation must occur first (IV access, fluid resuscitation with isotonic crystalloids, nasogastric tube insertion, electrolyte correction), but these are preparatory steps before proceeding to the definitive enema reduction. 1
Why the Other Options Are Incorrect
Option A (Bowel rest and IV hydration):
- While supportive treatment including IV crystalloids, anti-emetics, and bowel rest must begin immediately, these are adjunctive measures, not definitive treatment. 1
- Delaying definitive intervention increases the risk of bowel necrosis and perforation. 1
Option B (IV antibiotics):
- Antibiotics are not indicated for uncomplicated intussusception without evidence of perforation or peritonitis. 4
- This patient shows no signs of peritonitis or free air that would necessitate antibiotics.
Option C (Immediate surgery):
- Surgery is reserved for contraindications to enema reduction, such as free air on imaging, peritonitis on examination, or failed enema reduction (occurs in 10-15% of cases). 1, 2
- Immediate surgery without attempting enema reduction would be inappropriate given the high success rate of non-operative management.
Critical Contraindications to Enema Reduction
You must exclude these before attempting enema reduction:
- Free air on imaging (indicates perforation) 1
- Peritonitis on physical examination 1, 5
- Signs of bowel necrosis or strangulation 5
- Symptoms present for more than 5 days with severe obstruction 5
If any of these are present, proceed directly to surgery. 5
Technical Considerations
- Air enema is preferred over barium due to lower radiation absorption and the relatively inert nature of air if perforation occurs during the procedure. 3
- Success rates are equivalent between air (87-90%) and liquid enema (82-85%) when using proper technique with balloon catheter. 2, 6
- Perforation risk is low (2-3%) with either modality and can be managed with resection and primary anastomosis. 3
- Recurrence after successful reduction occurs in 3-9% of cases. 2, 3