From the Guidelines
For a 25-year-old male presenting with acute intestinal obstruction due to intussusception, an endoscopic procedure would be the most appropriate intervention before surgery. This approach is supported by the most recent and highest quality study 1, which suggests that endoscopic reduction can be attempted in adults with intussusception, especially when the diagnosis is clear and there are no signs of peritonitis, perforation, or strangulation. The procedure involves using an endoscope to visualize the intussusception and applying gentle pressure to reduce it.
Key Considerations
- Air enema and hydrostatic reduction techniques (including barium enema) are primarily used in pediatric cases and are generally not recommended for adults due to the higher risk of underlying pathology such as tumors or polyps that often cause adult intussusception.
- Steroid enemas have no role in managing intussusception.
- The rationale for attempting endoscopic reduction first is to potentially avoid surgery and its associated risks, though surgical intervention remains necessary if endoscopic reduction fails or if there are signs of complications.
Management of Intussusception
- Endoscopic reduction is associated with an increased rate of recurrence 1.
- Surgical exploration in laparoscopy or by laparotomy, according to the hemodynamic status of the patient, is recommended because of the high risk of incarceration and strangulation.
- Delay in surgical intervention is associated with a significant increase in mortality especially after 48 h 1.
- Resection of the invaginated segment is the treatment of choice for avoiding recurrences, and laparoscopy or open surgery can be used, depending on the experience of the surgeon and the setting.
Prioritizing Outcomes
The management of intussusception should prioritize reducing morbidity, mortality, and improving quality of life. Given the potential for underlying pathological lead points in adults, a thorough evaluation and potentially definitive surgical management may be necessary even after successful endoscopic reduction. The decision to proceed with endoscopic or surgical intervention should be made based on the individual patient's presentation, the availability of expertise, and the most recent evidence-based guidelines.
From the Research
Pre-Surgical Interventions for Intussusception
Before surgery, several interventions could have been considered for the 25-year-old male presenting with acute intestinal obstruction due to intussusception:
- Air enema: This is a viable option, especially if the intussusception is diagnosed early and there are no signs of complications such as bowel ischemia or perforation 2, 3.
- Steroid enema: There is no direct evidence in the provided studies to support the use of steroid enema as a pre-surgical intervention for intussusception in adults.
- Barium enema: Although traditionally used for diagnostic purposes, barium enema is not commonly recommended for therapeutic reduction of intussusception in adults due to the risk of barium peritonitis if perforation occurs 2, 3.
- Endoscopic procedure: While endoscopy can be diagnostic, its role in the therapeutic reduction of intussusception, especially in acute settings, is limited and not widely recommended as a first-line approach for adults 4.
Considerations for Intervention Choice
The choice of intervention depends on various factors including the duration of symptoms, presence of complications, and the specific characteristics of the intussusception as identified by imaging studies. For instance, the presence of free fluid, small-bowel obstruction, or trapped fluid between the intussusceptum and the colon can predict a lower success rate with air enema reduction 3. In adults, due to the higher likelihood of an underlying malignant lead point, surgical intervention is often necessary for both diagnostic and therapeutic purposes 5, 4.