What is the best treatment approach for an adult patient with transient intermittent enteric intussusception?

Treatment of Transient Intermittent Enteric Intussusception in Adults

For transient intermittent enteric (small bowel) intussusception in adults without signs of obstruction, peritonitis, or hemodynamic instability, conservative management with close observation is appropriate, as these may represent benign physiological phenomena that do not require surgical intervention.

Initial Assessment and Risk Stratification

The critical first step is determining whether this represents a pathologic intussusception requiring surgery versus a transient benign finding 1, 2:

• Obtain CT imaging immediately to confirm the diagnosis and assess for lead points, bowel viability markers (wall thickening, pneumatosis, mesenteric fat stranding), and signs of complete obstruction 1, 3
• Assess for symptoms of complete obstruction: persistent vomiting, inability to pass gas/stool, severe continuous pain, or peritoneal signs 4, 5
• Check hemodynamic stability: tachycardia, hypotension, fever, or signs of sepsis mandate urgent surgical consultation 4, 5
• Age matters for risk stratification: younger patients are more likely to have benign, self-resolving intussusception, while older patients have higher malignancy rates 2

Conservative Management Protocol (For Stable Patients)

When imaging confirms enteric intussusception but the patient is stable without peritonitis or complete obstruction 1, 2:

• NPO status with nasogastric decompression if significant nausea/vomiting is present 5
• IV fluid resuscitation to correct any dehydration or electrolyte abnormalities 5
• Serial abdominal examinations every 4-6 hours to monitor for development of peritonitis or clinical deterioration 5
• Antiemetic therapy with ondansetron if needed (avoid metoclopramide due to risk of extrapyramidal effects) 5
• Observation period of 24-48 hours is reasonable for transient enteric intussusception, as many resolve spontaneously 4, 2

Endoscopic Evaluation

Small bowel enteroscopy or capsule endoscopy should be performed to exclude intrinsic luminal lesions (polyps, tumors, Meckel's diverticulum) even if the intussusception resolves, as approximately 35-48% of adult intussusceptions have an underlying pathologic lead point 3, 6, 2.

Surgical Indications

Urgent surgical exploration is mandatory in the following scenarios 4, 3, 6:

• Failure to improve within 24-48 hours of conservative management 4, 5
• Clinical deterioration with worsening pain, development of peritoneal signs, or hemodynamic instability 4, 5
• CT evidence of complete obstruction, bowel ischemia (wall thickening, pneumatosis, lack of enhancement), or perforation 5, 3
• Persistent symptomatic intussusception where neoplasia is suspected based on imaging characteristics 1, 6
• Recurrent episodes suggesting an underlying structural lesion 7, 3

Surgical Approach

When surgery is indicated 3, 6:

• Resection without reduction is preferred for enteric intussusception when malignancy cannot be excluded, though a more selective approach with attempted reduction may be considered for clearly benign-appearing small bowel cases in younger patients 3, 2
• Laparoscopic exploration is acceptable in stable patients and allows for assessment and potential reduction or resection 2
• Immediate anastomosis is the technique of choice in most cases unless there is perforation with peritonitis 3

Critical Pitfalls to Avoid

• Do not assume all enteric intussusceptions are benign: while small bowel intussusceptions have lower malignancy rates than colonic (approximately 35-48% vs 43-57%), a substantial proportion still harbor malignancy 3, 6
• Do not delay surgical consultation if the patient fails to improve or deteriorates, as early intervention improves outcomes 4, 5
• Do not use prokinetic agents in patients with suspected mechanical obstruction or prior bowel surgery, as this may worsen the condition 4, 5
• Do not skip endoscopic evaluation even if the intussusception resolves, as the underlying lead point may still be present and require treatment 2

Special Consideration: Truly Transient Intussusception

Transient, asymptomatic enteric intussusceptions discovered incidentally on imaging may not require intervention 1. These are increasingly recognized as benign physiological phenomena, particularly in younger patients 2. However, even in these cases, endoscopic evaluation to exclude a lead point is prudent 2.

The key distinction is between intermittent symptomatic intussusception (which requires the workup and potential intervention described above) versus truly transient asymptomatic findings on imaging (which may be observed) 1, 2.