Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

CASE STUDY
(Intussusception)

Coleen Angelique Q. Montenegro

BSM- 4A (Group 1)

Dr. Jennifer Tam, RN, MAN, PhD

Clinical Instructor
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

A CASE STUDY OF INTUSSUSCEPTION

(Pediatric Case)

INTRODUCTION

Intussusception is a life-threatening illness and occurs when a portion of the intestine folds
like a telescope, with one segment slipping inside another segment. This causes an
obstruction, preventing the passage of food that is being digested through the intestine.

If left untreated, it can cause severe damage to the intestines, intestinal infection, internal
bleedings, and a severe abdominal infection called peritonitis.

Intussusception is the most common cause of intestinal obstruction in children between the
ages of three months and six years.

The first successful surgical correction of intussusception in an infant was described in

1871 by Hutchinson. In 1876, Hirschsprung reported his experience with the treatment of
intussusception by enema. This technique was associated with approximately 35 percent
mortality, better than the mortality rates after surgery. Reduction of intussusception by
fluoroscopy-guided enema was described as early as 1927 and was soon incorporated by
radiologists as part of their expertise. The technique has further evolved to include
ultrasound as an additional imaging option. Reduction was traditionally performed
using barium or other liquid contrast agents (hydrostatic enema), but can also be
performed using air or carbon dioxide (pneumatic enema).

The clinical manifestations, diagnosis, and management of intussusception in infants and

children are discussed below. Intussusception in adults is presented separately.
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

EPIDIMIOLOGY

Intussusception occurs primarily in infants and toddlers. The peak incidence is between 4
and 36 months of age, and it is the most common cause of intestinal obstruction in this age
group. Approximately 1 percent of cases are in infants younger than three months, 30
percent between 3 and 12 months, 20 percent between one and two years, 25 percent
between two and three years, and 10 percent between three and four years. In a population-
wide survey in Switzerland, the yearly mean incidence of intussusception was 38, 31, and 26
cases per 100,000 live births in the first, second, and third year of life, respectively.
Although intussusception is most common in infants and young children, it is important to
consider this diagnosis in children outside this age range. Approximately 10 percent of cases
are in children over five years, and 3 to 4 percent in those over 10 years. When
intussusception occurs outside of the typical age range, it is likely to be associated with a
pathologic lead point, which may include reactive lymphoid hyperplasia.

Most episodes occur in otherwise healthy and well-nourished children. Intussusception has a
slight male predominance, with a male: female ratio of approximately 3:2.

TYPES AND TERMINOLOGIES

Intussusception refers to the invagination (telescoping) of a part of the intestine into a more
distal segment. The proximal segment is known as the intussusceptum, and the distal
segment into which it telescopes is known as the intussuscipiens.
The intussusception is classified by the location:

●Ileocolic intussusception involves the ileocecal junction, and accounts for 90 percent
of all cases [5].
●Ileo-ileal, ileo-ileo-colic, jejuno-jejunal, jejuno-ileal, or colo-colic intussusception
also have been described. Ileo-ileo-colic intussusception refers to an ileo-ileal
intussusception that telescopes further through the ileocecal valve into the right colon.

The intussusception is considered idiopathic if there is no identifiable mass in the

intussusceptum (no "lead point"). The intussusception can be idiopathic even if there was a
likely or possible triggering event, such as viral or other enteric infection.
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

PATHOGENESIS

As the intussusception develops, the mesentery is dragged into the bowel. This leads to the
development of venous and lymphatic congestion with resulting intestinal edema. If
untreated, the process can lead to ischemia, perforation, and peritonitis.

Idiopathic — Approximately 75 percent of cases of childhood intussusception are idiopathic

because there is no clear disease trigger or pathologic lead point. Idiopathic intussusception
is most common in children between three months and five years of age.
Influence of viral factors — An increasing body of evidence suggests that viral triggers may
play a role in some cases, as illustrated by the following observations:

●The incidence of intussusception has a seasonal variation, with peaks coinciding with
seasonal viral gastroenteritis in some populations.
●Intussusception has been associated with some forms of rotavirus vaccine. An early
form of the vaccine (RRV-TV: Rotashield) was removed from the market because of a
22-fold increase in intussusception among vaccinated infants. Providers should be
alert for cases of intussusception that may be associated with rotavirus vaccine and
report all suspected cases to the Vaccine Adverse Event Reporting System (VAERS).
The risk of intussusception associated with currently licensed vaccines is discussed in
a separate topic review.
●Approximately 30 percent of patients experience viral illness (upper respiratory tract
infection, otitis media, flu-like symptoms) before the onset of intussusception.
●A strong association with adenovirus infection has been shown in a variety of
populations. In 30 to 40 percent of cases, there is evidence of recent infection with
enteric and noninterim species of adenovirus. In a prospective case-control study
examining a variety of possible infectious triggers for intussusception in Vietnam and
Australia, infection with adenovirus, species C emerged as the strongest predictor of
intussusception in both populations. In these populations, rotavirus infection
and poliovirus vaccine administration were not associated with intussusception.
Another study found an association with human herpes virus six.

Viral infections, including enteric adenovirus, can stimulate lymphatic tissue in the intestinal
tract, resulting in hypertrophy of Peyer patches in the lymphoid-rich terminal ileum, which
may function as a lead point for ileocolic intussusception. Because of this putative
association with lymphoid hyperplasia, treatment with glucocorticoids has been suggested to
prevent recurrence, but this approach is not recommended. Other enteric
infections — Bacterial enteritis is also associated with intussusception. In a series of 1412
cases of bacterial enteritis seen at military treatment facilities, intussusception ensued in 37
patients (comprising 12.6 percent of all intussusceptions seen at these facilities). This
association was noted for
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

infection with Salmonella, Escherichia coli, Shigella, or Campylobacter. Most cases of

intussusception occurred within the first month after the bacterial enteritis.

Lead point — A lead point is a lesion or variation in the intestine that is trapped by peristalsis
and dragged into a distal segment of the intestine, causing intussusception. A Meckel
diverticulum, polyp, duplication cyst, tumor, hematoma, or vascular malformation can act as
a lead point for intussusception.

Underlying disorders — In approximately 25 percent of cases, an underlying disease causes

a pathologic lead point for the intussusception, which may be focal or diffuse. Underlying
disease processes account for a greater proportion of cases of intussusception in children
younger than three months or older than five years. It is important to be vigilant for
pathologic lead points in children of any age.

A variety of conditions have been associated with intussusception, including Meckel

diverticulum, polyps, small bowel lymphoma, duplication cysts, vascular malformations,
inverted appendiceal stumps, parasites (e.g., Ascaris lumbricoides), immunoglobulin A
vasculitis (IgAV; Henoch-Schönlein purpura [HSP]), cystic fibrosis, and hemolytic-uremic
syndrome. Meckel diverticulum is the most common pathologic lead point in most case
series in children, followed by polyps, and then either duplication cysts or IgAV (HSP).

The mechanisms leading to intussusception depend upon the specific cause. As examples:

●Meckel diverticulum, polyps, duplication cysts, lymphomas, areas of reactive

lymphoid hyperplasia, or other focal abnormalities of the intestinal tract function as
lead points for peristalsis advancing the intestine into a distal segment of intestine.
●In patients with IgAV (HSP), a small bowel wall hematoma acts as the lead point.
Intussusception typically occurs after resolution of the HSP-associated abdominal
pain.
●Similarly, in patients with hereditary or acquired coagulopathy (e.g., von Willebrand
disease or anticoagulant therapy), a bowel wall hematoma may act as a lead point.
In other cases, a bowel wall hematoma may mimic the symptoms and ultrasound
findings of intussusception.
●In patients with cystic fibrosis, thick inspissated stool may act as the lead point.
●Celiac disease appears to be associated with a modestly increased risk for
intussusception, as suggested by a large study in Sweden.The proposed mechanism
is that celiac disease may promote enteroenteric (small bowel) intussusception
because of dysmotility and excessive secretions or bowel wall weakness. Subclinical
intussusception has been reported in approximately 25 percent of children with newly
diagnosed celiac disease and typically resolves spontaneously during the first few
days on a gluten-free diet, without radiologic or operative intervention. Conversely, the
 Swedish study found no association between intussusception and future celiac
disease, arguing against the need for routine antibody testing for children with
intussusception.
Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

●Patients with Crohn disease may develop intussusception because of inflammation

and stricture formation.

Postoperative — Small bowel intussusception (usually jejuno-jejunal or ileo-ileal) has been

described in the postoperative setting where it is an uncommon but insidious cause of
intestinal obstruction. Most cases occur after open abdominal surgery (especially
nephrectomies), but there is also a modest increased risk after nonabdominal procedures.
The intussusception is thought to be caused by uncoordinated peristaltic activity and/or
traction from sutures or devices such as a gastrojejunal feeding tube. Affected patients
typically do well for several days and may even resume oral intake before developing
symptoms of mechanical obstruction. In some cases, this is an incidental finding and/or one
that spontaneously resolves, although a single-institution series reported need for operative
reduction in 11 of 12 cases of small bowel postoperative intussusception following
abdominal surgery.

The diagnosis can be difficult to establish because intussusception may be confused with
postoperative paralytic ileus. Evaluation with ultrasonography or computed tomography (CT)
scanning can establish the diagnosis, monitor for spontaneous reduction, and help to predict
which children are likely to need surgical reduction. Because most cases of postoperative
intussusception occur in the small intestine, contrast enemas do not usually contribute to the
diagnosis or treatment.

CLINICAL MANIFESTATIONS

Typical presentation – The classic presentation of intussusception is an infant or toddler

with the sudden onset of intermittent, severe, crampy, progressive abdominal pain,
accompanied by inconsolable crying and drawing up of the legs toward the abdomen, often
with pallor. The episodes usually occur at 15- to 20-minute intervals. They become more
frequent and more severe over time. Vomiting is often a prominent symptom, often starting
shortly after the first episodes of abdominal pain. Initially, emesis may be nonbilious, but it
often becomes bilious as the obstruction progresses. A sausage-shaped abdominal mass
may be felt in the right side of the abdomen. The stool is grossly bloody in up to 50 percent
of cases, and an additional 25 percent have occult blood. In some cases, the stool may be a
mixture of blood and mucous, giving it the appearance of currant jelly, but this is a late
finding and seen in a minority of patients.
Between the painful episodes, the child may behave relatively normally and be free of pain.
As a result, the initial presentation can be confused with that of gastroenteritis. As symptoms
progress, increasing lethargy often develops, which can be mistaken for
meningoencephalitis.

Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

●Atypical presentation – However, the classically described triad of pain, a palpable

sausage-shaped abdominal mass, and currant-jelly stool is seen in less than 15 percent of
patients at the time of presentation. Up to 20 percent of young infants have no obvious pain,
and approximately one-third of patients do not pass blood or mucus, nor do they develop an
abdominal mass. Many older children have pain alone without other signs or symptoms.
Occasionally, the initial presenting sign is lethargy or altered consciousness alone, without
pain, rectal bleeding, or other symptoms that suggest an intraabdominal process. This
clinical presentation primarily occurs in infants and is often confused with sepsis. Thus,
intussusception should be considered in the evaluation of otherwise unexplained lethargy or
altered consciousness, especially in infants.

●Incidental finding or transient intussusception – Enteroenteric (small bowel)

intussusception is sometimes discovered incidentally during an imaging study (most
commonly CT) performed for other reasons or for nonspecific symptoms. The majority of
episodes of transient small bowel intussusception have no clinical significance. If there are
concerns for obstruction or a lead point, short-term follow-up imaging may be obtained to
confirm resolution. If these episodes of intussusception are short in duration and remain
asymptomatic, the patient can be managed with observation alone. Patients with minimal
symptoms may also not require intervention.

EVALUATION

History and physical examination — Because the presentation of intussusception is

variable, a high index of suspicion for intussusception is important, particularly in children
between three months and five years of age, which is the peak age range for idiopathic
intussusception, or those with other risk factors. However, it is important to consider the
possibility of intussusception in children who are younger or older than this age range.

●History – The history is directed to identifying features suspicious for

intussusception, which are detailed above. Although most patients have several of
these features, intussusception should be considered if any of these are present:

•Intermittent, severe, crampy, progressive abdominal pain

•Vomiting
•Rectal bleeding (gross or occult)
•Lethargy (often episodic)
 The history should also solicit information that would suggest a different cause of the
symptoms, including:
•Fever (suggests gastroenteritis, appendicitis, or other infection but also may be a
presenting symptom in children with intussusception)
•Ill contacts (suggests gastroenteritis)
Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

•Exposure to potential toxins (medications, alcohol, or poisons)

●Physical examination – On physical examination, features suspicious of

intussusception include:

•No abdominal tenderness, or only focal tenderness (especially in the right mid or
upper abdomen)
•Abdomen not distended
•Lethargy or altered consciousness (often episodic)
Features that are more specific for intussusception, but are present in a minority of
patients, include:
•Right lower quadrant that is scaphoid (empty; sometimes called Dance sign)
•Palpable "sausage-shaped" mass in the right mid or upper abdomen
•Eversion of bowel and/or the appendix through the anus (in cases of a long
intussusceptum)

Differential diagnosis — The differential diagnosis of intussusception depends on the

presenting symptoms:

●Rectal bleeding and vomiting:

•Meckel diverticulum
•Bacterial or amoebic colitis
•Malrotation with midgut volvulus
These and other causes of rectal bleeding are summarized in separate topic reviews.
●Acute onset of crampy abdominal pain:
•Gastroenteritis
•Appendicitis
•Mesenteric ischemia
•Ovarian torsion
•Malrotation with volvulus
•Incarcerated hernia
•Peritonitis
These and other causes of acute abdominal pain are discussed separately.
●Lethargy and coma:
•Trauma
•Infections, including sepsis
 •Metabolic derangements
•Intoxications
•Seizures (eg, postictal period)
These and other causes of altered consciousness are discussed separately.

Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

Approach to diagnostic testing — The optimal strategy for diagnosis and treatment
depends on the clinical suspicion for intussusception (typical or atypical presentation), and
on the preference and experience of the consulting radiologists.

Typical presentation — Patients with a typical presentation (eg, infant or toddler with
sudden onset of intermittent severe abdominal pain with or without rectal bleeding) or
characteristic findings on radiography or ultrasound, may proceed directly to nonoperative
reduction using hydrostatic (contrast or saline) or pneumatic (air) enema, performed under
either sonographic or fluoroscopic guidance. In these cases, the procedure is both
diagnostic and therapeutic.

Atypical presentation — For many other patients, the diagnosis is unclear at presentation,
especially in children who are younger or older than the typical age group for
intussusception. In this case, initial workup may include abdominal ultrasound or abdominal
radiographs, provided that these studies do not significantly delay the definitive treatment of
intussusception. If the ultrasound supports the diagnosis of intussusception, nonoperative
reduction is then performed, provided that the child has normal vital signs and no signs of
peritonitis.

Ultrasonography — Ultrasonography is the method of choice to detect intussusception in

many institutions. The sensitivity and specificity of this technique approaches 100 percent in
the hands of an experienced ultrasonographer. Negative predictive value is also nearly 100
percent, so a negative study by an experienced sonographer can definitively rule out
intussusception. Ultrasound is better able to detect pathologic lead points than fluoroscopic
techniques, can be used to monitor the success of a reduction procedure, and does not
expose the patient to radiation. Ultrasound can also evaluate for several alternative causes
for the child's symptoms, such as appendicitis or hydronephrosis. In other institutions,
fluoroscopy is used as the primary diagnostic and therapeutic procedure for intussusception.

The classic manifestation of intussusception on ultrasound is a "target sign" (also known

termed "bull's eye" or "coiled spring"), representing layers of the intestine within the intestine.
For ileocolic intussusception, which is the most common type, the "target sign" usually is in
the right lower quadrant. Color duplex imaging may reveal a lack of perfusion in the
intussusceptum, indicating the development of ischemia. An advantage of ultrasonography
over fluoroscopy is that it can diagnose the rare ileo-ileal intussusception; ultrasound also
can identify the lead point of intussusception in approximately two-thirds of cases in which
underlying pathology exists.
The possibility of small bowel intussusception (eg, jejuno-jejunal or jejuno-ileal, rather than
ileocolic intussusception) is suggested by location of the intussusception outside of the right
lower quadrant (eg, in the paraumbilical or left abdominal region), and/or lesion size ≤3 cm. If
small bowel intussusception is suspected and the child's symptoms are mild, the first step is
to repeat the ultrasound to see if the finding persists because most small bowel
Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

intussusceptions will spontaneously reduce. If the finding persists, evaluation with a CT scan
may help to confirm the location of the intussusception and whether there is a lead point. In
small bowel intussusceptions, the length of the intussusceptum, as measured by ultrasound
or CT, and the patient's symptoms help to determine prognosis and management.

Abdominal plain film — In patients with suspected intussusception, the initial evaluation
usually should include two-view plain abdominal radiographs. The main purpose of the
radiograph is to exclude perforation, which, if present, requires operative management rather
than nonoperative reduction. They are also useful to screen for other causes of abdominal
symptoms that might be detected by radiography.

Plain radiographs are not sufficiently sensitive or specific to diagnose intussusception, but
may support the diagnosis if one or more of the following findings are present:

●Signs of intestinal obstruction, which may include massively distended loops of bowel
with absence of colonic gas.
●A target sign, consisting of two concentric radiolucent circles superimposed on the
right kidney, represents peritoneal fat surrounding and within the intussusception. In
one report, this finding was present in 26 percent of patients with intussusception.
●A meniscus (or crescent) sign, which is a soft tissue density (representing the
intussusceptum) projecting into the gas of the large bowel.
●An obscured liver margin.
●Lack of air in the cecum, which prevents its visualization.
●Pneumoperitoneum, which suggests that bowel perforation has occurred; this is
rarely seen.

Plain radiographs should not be used to exclude intussusception, particularly in patients with
a high clinical suspicion. The sensitivity for abdominal radiographs to diagnose
intussusception is less than 48 percent while the specificity is 21 percent. In one study, more
than 20 percent of patients with intussusception had negative plain films. In patients with a
low clinical suspicion of intussusception, the presence of air in the cecum or terminal ileum
helps to exclude intussusception. However, ultrasound is far superior to radiography both for
diagnosing and excluding intussusception.

Computed tomography scan — An intussusception can be recognized on CT, which may

also identify the cause. However, CT cannot be used to reduce the intussusception, can be
time-consuming in children who may require sedation, and also exposes the child to
substantial radiation. Thus, CT generally is reserved for patients in whom the other imaging
modalities are unrevealing, or to characterize pathologic lead points for intussusception
detected by ultrasound.

Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

DIAGNOSIS

The diagnosis of intussusception can be made in any of the following ways:

●By diagnostic ultrasound – This is the usual procedure where diagnostic ultrasound
is readily available (eg, in the emergency department), or for patients with atypical
presenting features. Once the diagnosis is established, the patient should proceed
promptly to treatment (typically nonoperative reduction under ultrasonographic or
fluoroscopic guidance).

●By ultrasound or fluoroscopy, as part of an attempt at nonoperative reduction – This

is the usual procedure for patients with typical presenting features. In this case, the
procedure is both diagnostic and therapeutic.

●Incidental finding on ultrasound or CT – In this case, next steps depend upon the
patient's symptoms since incidentally discovered intussusception can be
asymptomatic and often resolves spontaneously.

TREATMENT

The approach to treatment of intussusception depends upon patient characteristics:

●Most patients – Patients with a high clinical suspicion and/or imaging evidence of
ileocolic intussusception, normal vital signs, and no evidence of bowel perforation
should be treated with nonoperative reduction as described below. It is important that
nonoperative reduction be performed at an institution with extensive experience in the
technique and by providers with experience in managing potential complications of
nonoperative reduction, such as tension pneumoperitoneum. Patients presenting to an
institution without this experience should be transferred if this can be done promptly.
●Acutely ill or with perforation – Surgical treatment is indicated as a primary
intervention for patients with suspected intussusception who are acutely ill or have
evidence of perforation. Surgery may also be appropriate when the patient is treated
in a location where the radiographic facilities and expertise to perform nonoperative
reduction are not readily available and if timely patient transfer would not be feasible.
Operative intervention is also indicated for patients in whom nonoperative reduction is
unsuccessful, or for evaluation or resection of a pathologic lead point.
 ●Small bowel intussusception – Patients with intussusception limited to the small
bowel (ileo-ileal, jejuno-ileal, or jejuno-jejunal) are managed differently.

Nonoperative reduction — Nonoperative reduction using hydrostatic or pneumatic

pressure by enema is the treatment of choice for an infant or child with ileocolic
intussusception who is clinically stable and has no evidence of bowel perforation or shock,
when appropriate radiologic facilities are available. Enema reduction has high success rates
in children with ileocolic intussusception. In settings in which nonoperative reduction is not
available (eg, in
Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

resource-limited countries), patients with intussusception usually should be managed with

surgical reduction.

Before attempting reduction by enema, the patient should be stabilized and given
intravenous fluids if there is evidence of volume depletion. The surgical team should be
notified before attempting nonoperative reduction and remain immediately available because
there is a risk of perforation and tension pneumoperitoneum during the procedure (reported
as high as 4 percent). Surgical intervention also may be necessary if nonoperative reduction
fails to reduce the intussusception. Most radiologists perform nonoperative reduction of
ileocolic intussusception without sedation or general anesthesia. However, some institutions
routinely use sedation or general anesthesia and also have high success rates, while
maintaining low complication rates related to the sedation or anesthesia. This experience is
reflected in a large retrospective analysis of more than 3000 patients, in which analgesia and
sedation were not associated with perforation or unsuccessful nonoperative reduction.
Having an anesthesiologist available emergently may be a logistical limitation for some
practices. In our practice we do not routinely utilize sedation or a general anesthetic.

There is no need for prophylactic intravenous antibiotics prior to or during nonoperative

reduction, except for children with hemodynamic instability or critical illness. This is
consistent with recommendations from the American Pediatric Surgical Association, based
on observational evidence summarized in a systematic review. Some institutions give
prophylactic antibiotics because of the potential risk of bacteremia and perforation with these
procedures. However, there is no evidence that this practice is beneficial, likely because
bacteremia and perforation are rare.

Fluoroscopic or sonographic guidance — Reduction of intussusception is most

commonly performed under fluoroscopic guidance, using either hydrostatic (saline or
contrast) or pneumatic (air) enemas. Ultrasound guidance is also an increasingly used
option, and has the advantage of avoiding ionizing radiation, as well as improved detection
of pathologic lead points compared with fluoroscopic technique. As a result, some providers
with expertise in this technique prefer to use ultrasound guidance to reduce ileocolic
intussusception. A disadvantage of ultrasound is that it can only be used for hydrostatic
reduction. Fluoroscopy and ultrasound-guided techniques have comparable success rates
for reduction of intussusception, ranging from 80 to 95 percent.

The techniques are performed as follows:

●Sonographic guidance – Sonographic guidance requires a hydrostatic technique

(saline enema) to provide retrograde pressure because use of air would interfere with
 ultrasound visualization. Sonographic signs of successful reduction include the
disappearance of the intussusception and the appearance of water and bubbles in the
terminal ileum.
●Fluoroscopic guidance – Under fluoroscopy for a typical ileocolic intussusception,
the intussusceptum appears as a filling defect within the bowel lumen. This is seen as
either a low density filling defect when contrast is used for hydrostatic reduction, or a
higher density filling defect when air is used as a negative contrast with pneumatic
reduction techniques. The intussusception can be found in any part of the large bowel,

Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

even the rectum. Occasionally, contrast may coat the outer surface of the
intussuscipiens, resulting in a coiled spring pattern.
Successful reduction is indicated by the free flow of contrast or air into the small
bowel. Reduction is complete only when a good portion of the distal ileum is filled with
contrast or air, thus excluding ileo-ileal intussusception. Other indications of successful
reduction include relief of symptoms and disappearance of the abdominal mass.
Occasionally, the contrast material does not reflux freely into the small bowel even
after a complete reduction; however, a successful reduction is suggested by lack of a
filling defect in the cecum (apart from the ileocecal valve), and clinical resolution of
symptoms and signs. A post-reduction filling defect in the cecum is commonly seen,
probably the result of residual edema in the ileocecal valve. However, this finding
cannot be distinguished from a focal lead point by radiologic examination alone. As a
result, a repeat contrast study or even surgery may be indicated if there is any
concern for a focal lead point.

Hydrostatic or pneumatic reduction — Either pneumatic (air) or hydrostatic (saline or

contrast) technique is acceptable for reduction of intussusception in stable children. The
choice of technique depends primarily upon the expertise and comfort level of the
radiologist, and availability of the necessary equipment.
In our institution, pneumatic reduction is the method of choice, rather than hydrostatic
reduction. This is because pneumatic reduction of intussusception has somewhat higher
success rates and no increased risk of perforation. This was shown in a meta-analysis,
which reported a success rate of 83 percent for pneumatic reduction, and 70 percent for
hydrostatic reduction. There was no difference in rate of perforation (0.39 and 0.43 percent,
respectively), or of early recurrence within the first 48 hours. In addition, pneumatic reduction
may be advantageous if perforation occurs. Finally, pneumatic reduction typically requires a
lower overall radiation exposure dose compared with hydrostatic enema, which is
independent of the fluoroscopy time required for the procedure. This is likely because air has
a lower density than the contrast that is typically used for hydrostatic reduction, and thus
reduces the exposure required for generating the image with fluoroscopy.

In other institutions the hydrostatic enema technique is used, either because it is the primary
nonoperative method available, or if ultrasound guidance is used.

The techniques are performed as follows:

●Hydrostatic technique – The standard method of reduction is to place a reservoir of

contrast 1 meter above the patient so that constant hydrostatic pressure is generated.
With experience (and depending upon the clinical status of the patient), a clinician may
 undertake a more aggressive reduction (ie, increase the hydrostatic pressure by
raising the reservoir higher above the patient).
•When hydrostatic reduction is performed under fluoroscopic guidance, a water-
soluble contrast enema is preferred because of the risk of perforation before or
during the procedure. Water-soluble agents reduce the risk of electrolyte
disturbances and peritonitis in patients in whom perforation has occurred.
Traditionally, barium was used as the contrast agent in most North American and
European centers.
•When hydrostatic reduction is performed under ultrasonographic guidance,
normal saline is used for the enema.
Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

●Pneumatic technique – Pneumatic (air reduction) techniques are now generally

preferred to the hydrostatic methods if fluoroscopy is used for guidance. The
pneumatic technique cannot be used with ultrasonography, because the air interferes
with ultrasound visualization.

The technique begins with insertion of a Foley catheter (or equivalent) or rectal tube
into the rectum. A tight anal seal is formed around the catheter or tube, typically using
tape; a good seal is critical as a means to minimize air leak and maintain adequate
pressure for reduction throughout the procedure. If a Foley catheter is utilized, the
balloon may be inflated with up to 30 mL of air to further help maintain air retention
during reduction; this is done under real-time fluoroscopy to ensure appropriate
degree of inflation within the rectal ampulla. Inflation of Foley balloon should not be
done in children 10 months or younger, to minimize risk of bowel perforation during the
pneumatic reduction procedure. Fluoroscopy is used to monitor the procedure. Air is
then instilled until the intussusceptum is pushed back gently, taking care to avoid
excessive pressure. A sphygmomanometer can be used to monitor colonic
intraluminal pressure (typically not to exceed 120 mmHg) to aid in reduction. Carbon
dioxide can also be used instead of air. It has the advantage of being absorbed rapidly
from the gut, is associated with less discomfort, and is less dangerous than air, which
potentially could cause an air embolism (although air embolisms have not been
reported).
A successful reduction of the intussusception is indicated by a rush of air reflux into
the terminal ileum, a sudden drop in the intraluminal pressure, and the disappearance
of the mass at the ileocecal valve. Water-soluble contrast material can be instilled to
confirm the reduction, or the air reduction can be repeated if the completeness of
reduction is questioned.

Risk and complications — The main risk of hydrostatic or pneumatic reduction is

perforation of the bowel, which occurs in 1 to 4 percent of patients. The perforation usually
occurs on the distal side of the intussusception, often in the transverse colon, and commonly
where the intussusception was first demonstrated by radiographic studies. Risk factors for
perforation include age younger than six months, long duration of symptoms (eg, three days
or longer), and evidence of small bowel obstruction; use of higher pressures during the
reduction is a contributing factor in some patients. Nonoperative reduction should not be
attempted in patients with any signs of peritoneal irritation or free peritoneal air.
The pneumatic reduction technique provides an advantage if perforation occurs because air
is generally less harmful than other contrast materials in the peritoneal cavity. When
perforation is noted with air reduction, the colonic wall tears are smaller than those observed
with the hydrostatic contrast techniques, and peritoneal pathology tends to be minimal.
Needle decompression of the abdomen may be necessary if the excess air in the peritoneal
cavity compromises the patient's respiratory status.

Success rate — In institutions with extensive experience, nonoperative reduction using

hydrostatic or pneumatic techniques is successful in approximately 70 to 85 percent of
patients with ileocolic intussusception. Success is more likely to be achieved in patients with
idiopathic intussusception (ie, no identifiable lead point), although it also can be
accomplished in patients with a recognized lead point. The supplemental use
of glucagon or atropine to relax colonic smooth muscle had no benefit in a double-blind
study and a subsequent observational study. lleo-ileo-colic intussusception may be more
difficult to reduce because the contrast often
Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

percolates along the loops of small bowel in the colon, reducing the effective pressure of the
enema.

Delayed repeat enema — If the nonoperative reduction is partly successful (ie, the
intussusception moved but was not completely reduced) and the patient remains stable, it is
reasonable to perform repeated attempts at nonoperative reduction, often referred to as
delayed repeat enema. The time gap or delay between nonoperative enema attempts varies
from 30 minutes to a few hours. There is some evidence that this approach is successful and
avoids surgery for some patients who would have otherwise required surgical reduction
following initial unsuccessful reduction attempts.
Delayed repeat enema should not be attempted in patients in whom the initial attempt at
nonoperative reduction was completely unsuccessful (ie, the intussusception did not move),
or in those who are unstable. Such patients should proceed promptly to surgery.

Post-procedure management — There are no compelling data or widely used guidelines

for clinical care after successful nonoperative reduction of an ileocolic intussusception. Our
own practice is as follows:

●Antibiotics – We do not routinely give intravenous antibiotics after a successful

nonoperative reduction; we give antibiotics only if there are progressive symptoms and
signs of sepsis, or if there is a suspicion of intestinal perforation despite successful
nonoperative reduction. A low-grade fever (temperature higher than 38 to 39°C [100.4
to 102°F]) is often noted during the first few hours after the procedure, probably
because of the systemic inflammatory response associated with transient bowel
ischemia.
●Diet – We offer clear fluids as soon as the patient is awake and alert, and advance
the diet as tolerated. We place a nasogastric tube only if the patient has recurrent
vomiting or clinical evidence of bowel obstruction.
●Disposition – If patients are well-appearing and tolerating clear fluids within two
hours after nonoperative reduction, we typically discharge the patient as long as they
are able to return to the hospital promptly for recurrent symptoms.
At many institutions, it has been common practice to admit the patient for 12 to 24
hours of observation, primarily to monitor for early recurrence. The duration of the
observation is guided by monitoring symptoms and vital signs, physical examination,
the distance the family lives from the hospital, and tolerance of a diet. However, the
utility of routine inpatient observation has been questioned because only
 approximately 4 percent of patients experience recurrence within 48 hours and
recurrence rates of intussusception do not differ between children observed in the
hospital and those discharged home. A meta-analysis and observational studies have
concluded that children who had uncomplicated enema reduction and are afebrile,
hemodynamically normal, asymptomatic, and tolerating a diet can be safely
discharged home. For children with these characteristics, outpatient management is
associated with no increase in the rate of return to the emergency department,
recurrence, need for operation, or mortality compared with inpatient observation.
●Imaging – No routine imaging is required for patients that remain asymptomatic.
Should symptoms develop that are suspicious for recurrent intussusception, an
ultrasound study is warranted. If there is concern for perforation, the patient should be
evaluated with conventional radiographs.

Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

●Consultations – We consult the pediatric surgical service promptly if there is

suspected intestinal perforation or incomplete reduction of intussusception.
●Follow-up – When the patient is discharged, we give instructions to call promptly if
symptoms recur, and plans for follow-up by a clinician within one to two days.

Recurrence — Intussusception recurs in approximately 10 percent of children after

successful nonoperative reduction. Approximately 4 percent have a recurrence within the
first 48 hours after nonoperative reduction (perhaps because of residual bowel edema or
inflammation, which may act as a lead point), and the remainder of the recurrences occur
weeks or months later.

Management of recurrent intussusception depends upon the patient's individual

characteristics. Recurrence is not necessarily an indication for surgery. In general, each
recurrence should be handled as if it were the first episode, provided that each attempt at
nonoperative reduction is successful and the patient remains stable. However, imaging
studies should be reviewed carefully for the possibility of a pathologic lead point. If a lead
point is identified, the patient may still be treated with nonoperative reduction, particularly if
the lead point is diffuse (eg, immunoglobulin A vasculitis [IgAV; Henoch-Schönlein purpura
(HSP)]).

Surgical exploration should be performed for any patient who is unstable, and should also be
considered for those with a focal lead point or multiple recurrences.
The risk for recurrence is associated with patients older than one year of age, but not the
duration of symptoms at the initial presentation. The rate is similar for the different
nonoperative techniques of reduction described above. Multiple recurrences of
intussusception are associated with the presence of a pathologic lead point, but may also
occur in those with "idiopathic" intussusception. In one series, 19 percent of children with two
or more episodes of intussusception had a pathologic lead point, whereas 4 percent of
children without a recurrence had a pathologic lead point.

Surgery — Indications for urgent surgical intervention include:

●Unstable patient – In this case, initiate resuscitation, consult surgeon, and stabilize
the patient before proceeding to the operating room.
●Peritonitis or intestinal perforation.
 ●Nonoperative reduction is completely unsuccessful. If the reduction attempt was
partially successful, it may be repeated.

Surgery is also indicated when imaging reveals a persistent focal filling defect, indicating a
mass lesion. However, not all filling defects are indications for surgery:
●If the patient has undergone successful nonoperative reduction (as indicated by relief
of symptoms) and there is a residual filling defect that is consistent with an edematous
ileocecal valve, the patient can be safely observed. However, repeat evaluation with
ultrasound or contrast study within 12 to 24 hours is appropriate to confirm successful
reduction.
●If the patient has a filling defect that appears diffuse and has a suspected or a known
explanation (eg, IgAV [HSP]), the patient can be managed with repeated nonoperative
reduction, provided that each attempt is successful.

Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

Children needing operative management require adequate intravenous fluid resuscitation

and prophylactic intravenous antibiotics covering enteric flora prior to skin incision. Patients
presenting with clinically significant nausea and emesis may require nasogastric tube
decompression until their bowel obstruction is resolved by the definitive surgical intervention.

Contemporary operative management of childhood intussusception by pediatric surgeons

uses a minimally invasive approach via laparoscopy in most cases. Laparoscopy allows for
accurate diagnosis, as well as reduction of intussusception and, if necessary, bowel
resection and anastomosis. Successful laparoscopic approaches to childhood
intussusception have been demonstrated in several series worldwide to be safe, effective,
and may be associated with a more rapid recovery of intestinal function with less need for
postoperative narcotic analgesia.

Reduction of intussusception during operation is attempted in most cases, but resection with
primary anastomosis is performed if manual reduction is not possible or if a pathologic lead
point is seen. The risk of recurrence is approximately 1 to 8 percent after manual reduction
and virtually nonexistent after surgical resection.

Small bowel intussusception — Patients with intussusception limited to the small bowel
are managed somewhat differently. Compared with ileocolic intussusception, small bowel
intussusception is more likely to reduce spontaneously (provided that the intussusceptum is
short) and less likely to respond to nonoperative reduction.

Patients with small bowel intussusception are managed in one of two ways, depending on
the clinical circumstances:

●If a short ileo-ileal intussusception is detected incidentally on a radiographic

examination in a patient with mild or no symptoms, the intussusception often resolves
spontaneously, during the imaging procedure or shortly thereafter.
●If the patient has symptoms consistent with intussusception or if the intussusceptum
is long on initial imaging studies, nonoperative reduction may be attempted, but is
rarely successful. If nonoperative reduction is unsuccessful or is not attempted,
surgery is often necessary.
Spontaneous reduction of intussusception — Intussusception that is detected
incidentally by imaging in a patient with mild or no symptoms often resolves spontaneously
(termed spontaneous reduction of intussusception [SROI]), typically during the imaging
procedure or shortly thereafter. In this case, the patient does not require further evaluation or
intervention if no lead point is identified. Other radiographic criteria suggesting a transient
process include normal bowel wall thickness, no proximal dilatation, and no colonic
involvement.

These cases of SROI are increasingly recognized, probably because ultrasound is frequently
used for evaluation of patients with nonspecific abdominal symptoms and may detect
transient intussusceptions. In one series from a single institution, 17 percent of children with
an intussusception experienced SROI and approximately one-half of these were
asymptomatic.