What is the treatment for bowel intussusception?

Treatment of Bowel Intussusception

Surgical exploration with formal bowel resection is the definitive treatment for adult intussusception, and should be performed within 12-24 hours of diagnosis in stable patients, as 86-93% of adult cases have an underlying pathological lesion requiring oncologic resection. 1, 2

Immediate Management

Initial Stabilization

• Fluid resuscitation to restore intravascular volume and achieve hemodynamic stability 1
• Antimicrobial therapy should be initiated immediately once intussusception is diagnosed or suspected 1
• Obtain surgical consultation in all cases, even when considering non-operative approaches 1, 2
• CT scan is the imaging modality of choice in hemodynamically stable patients to confirm diagnosis, identify complications, and detect lead point lesions 1, 2

Critical Time Threshold

• The 48-hour window is critical—delaying surgical intervention beyond 48 hours significantly increases mortality 1, 2
• Prompt treatment after diagnosis is mandatory to prevent progression to bowel ischemia, perforation, and peritonitis 3, 2

Surgical Management (Primary Treatment)

Standard Approach for Adults

• Formal surgical exploration with bowel resection following oncological principles is recommended due to the high malignancy risk in adults 2, 4
• Resection of the invaginated segment with reconstruction is the standard approach 2
• The high rate of underlying pathology (86-93% have a definable lesion including malignancy, inflammatory bowel disease, adhesions, or Meckel's diverticulum) supports immediate surgical exploration 1, 2, 4

Surgical Technique

• Begin exploration from the ileocecal junction (distal to obstruction) where bowel is less dilated and safer to handle laparoscopically 5, 1
• Assess intestinal viability—if ischemia is present, perform surgical resection 5
• Indocyanine green (ICG) fluorescence angiography can guide resection margins when intestinal perfusion is questionable 5, 1
• Close all mesenteric defects with non-absorbable sutures after reduction to prevent recurrence 5, 1

Decision: Reduction vs. Immediate Resection

• Resection of the affected segment is recommended as it results in fewer recurrences compared to simple reduction 5
• Reduction before resection may be considered only if the small bowel is viable and the lesion appears benign, but this approach is controversial, especially in colonic cases 5, 6
• In cases where malignancy is suspected, never attempt reduction—proceed directly to oncologic resection 2, 4

Non-Operative Management (Highly Selected Cases Only)

Strict Criteria for Non-Operative Approach

Non-operative management may be considered only when ALL of the following criteria are met:

• Hemodynamically stable patient with no signs of peritonitis (no guarding, rigidity, or rebound tenderness) 3, 2
• No bowel compromise or ischemia (normal lactate, no severe continuous pain, no bloody stools) 3
• No radiological evidence of perforation (no pneumoperitoneum) 3
• Endoscopic expertise readily available 1
• Colonic location amenable to colonoscopic reduction 2

Post-Reduction Protocol

• Mandatory close monitoring for at least 24 hours after successful reduction to detect early recurrence 1, 3, 2
• Endoscopic reduction carries a high recurrence risk 1, 3, 2
• If reduction fails, proceed immediately to surgical exploration without further delay 3

Special Populations

Post-Bariatric Surgery Intussusception

• Immediate surgical intervention is recommended for acute presentations 2
• Classification includes Type I (afferent loop), Type II (efferent loop), or Type III (combined) 1
• Treatment options include resection of invaginated segment, reconstruction of jejuno-jejunostomy, and anchoring techniques 1
• In stable patients with persistent abdominal pain and inconclusive findings, exploratory laparoscopy is mandatory within 12-24 hours 5

Peutz-Jeghers Syndrome Patients

• Elective polypectomy of small bowel polyps >1.5-2 cm (or smaller if symptomatic) prevents intussusception 2
• These patients have a 50-68% cumulative risk of intussusception in childhood 2
• Surveillance with video capsule endoscopy and MRI enterography should begin at age 8 years 2

Critical Pitfalls to Avoid

• Never delay surgery beyond 48 hours in adults—mortality increases significantly with delayed intervention 1, 2
• Do not assume idiopathic etiology in adults—86-93% have underlying pathology requiring oncologic resection 1, 2, 4
• Avoid bowel resection in patients with preexisting diarrhea or incontinence when treating rectal intussusception, as these symptoms worsen postoperatively 1
• Do not attempt non-operative reduction when any signs of peritonitis, hemodynamic instability, perforation, or bowel ischemia are present 3
• Nasogastric decompression is supportive only—it does not reduce intussusception and should not delay definitive surgical treatment 3