eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Intussusception: Treatment & Medication

Author: A Alfred Chahine, MD, Associate Professor of Surgery and Pediatrics, The George Washington University School of Medicine; Chief of Pediatric Surgery, Georgetown University Medical Center; Attending Surgeon, Children's National Medical Center
Coauthor(s): Felix C Blanco, MD, Research Fellow, Department of Surgery, Children's National Medical Center
Contributor Information and Disclosures

Updated: Nov 3, 2009

Treatment

Medical Care

Tailor treatment of the child with intussusception to the stage at presentation.

  • For all children, start intravenous fluid resuscitation and nasogastric decompression as soon as possible.
  • The presence of peritonitis and any evidence of perforation revealed on plain radiographs are the only 2 absolute contraindications to an attempt at nonoperative reduction with a therapeutic enema. Therapeutic enemas can be hydrostatic, with either barium or water-soluble contrast, or pneumatic, with air insufflation. Therapeutic enemas can be performed under fluoroscopic or ultrasonographic guidance. The technique chosen is not important as long as the radiologist performing the enema is comfortable with the method. Preferably, the pediatric surgeon involved is present at the reduction.
  • Since the description by Hirschsprung of a systematic approach to hydrostatic reduction of intussusception, the reported success rate of this nonoperative intervention has widely varied (<40% to >90%). This variability in outcome attests to the various factors involved in successful hydrostatic reduction. Among these are factors that are individual to the patient (age, duration of symptoms, presence of lead points) and others that depend on the technique used. Paramount among the latter category is the availability of a team of pediatric surgeons and radiologists with the necessary expertise, determination, and dedication. Even among pediatric radiologists, consensus has been lacking on methodologic issues, including the choice of reducing agent, the type of catheter, the role of the external manipulation of the abdomen, the use of medications, and the establishment of guidelines for pressure limits and number of attempts.
  • Air enema is the treatment of choice in many institutions.
    • The risk of major complications with this technique is small.
    • Its success is decreased, as with other reducing agents, in patients with small bowel intussusceptions and in those with prolapsing intussusceptions.
    • When performing a therapeutic enema, the recommended pressure of air insufflation should not exceed 120 cm of water. When using barium or water-soluble contrast, the column of contrast should not exceed 100 cm above the level of the buttocks.
    • Traditionally, an attempt was not considered successful until the reducing agent, whether air, barium, or water-soluble contrast, was observed refluxing back into the terminal ileum, but new evidence showed that this is not entirely necessary. Most intussusceptions that failed to show reflux into the ileum were due to either an edematous or competent ileocecal valve. When these patients were explored, they displayed a completely reduced intussusception. According to this study, a patient who becomes asymptomatic after nonoperative reduction which fails to show reflux of the reducing agent into the ileum can safely be observed.
  • The value of repeated attempts at nonoperative reduction, if the first attempt is unsuccessful, has not been determined. Some clinicians recommend taking the patient to surgical care if the first attempt fails, and other clinicians advocate 1 or 2 subsequent attempts within a few minutes to a few hours after the first attempt. Delay between the reduction attempts may place the patient in the "window" of spontaneous resolution, which has been reported with an incidence of 5-6%. In addition, the first attempt can reduce the intussusception partially, making the intussusceptum less edematous with improved venous drainage.
  • Some reports have postulated that reduced bowel edema with improved venous drainage is one of the reasons why the success rate of hydrostatic reduction increases with the administration of a second enema. If repeated attempts are unsuccessful, any progress in pushing back the intussusceptum toward the ileocecal valve during operative reduction is advantageous. Delay in performing surgery because of additional attempts at nonoperative reduction has been demonstrated to have no adverse effects on the rates of success of operative reduction and patient morbidity.
  • When therapeutic enema is successful, the results are immediate and extremely gratifying. The infant falls asleep almost immediately, and the obstruction is relieved, allowing the resumption of a normal diet. A short period of overnight observation usually is warranted before discharge.
  • Therapeutic enema is of no value in patients with small bowel–to–small bowel intussusception, which usually occurs in older children who have other associated diseases (eg, Henoch-Schönlein purpura [HSP], hemophilia, Peutz-Jeghers syndrome, malignancies).

Surgical Care

If nonoperative reduction is unsuccessful or if obvious perforation is present, promptly refer the infant for surgical care.

  • Traditional entry into the abdomen is through a right paraumbilical incision. Deliver the intussusception into the wound and attempt nonoperative reduction. Milking the intussusceptum out of the intussuscipiens is important. Sustain gentle manual pressure rather than pulling out the intussusceptum to avoid risk of iatrogenic perforation. If operative reduction is successful, appendectomy is often performed if the blood supply of the appendix is compromised. A cecopexy is not necessary. Risk of recurrence of the intussusception after operative reduction is less than 5%.
  • If manual reduction is not possible or perforation is present, perform a segmental resection with an end-to-end anastomosis. A diligent search for any lead points is warranted, especially if the patient is older than 2-3 years.
  • Recently, laparoscopy has been added to the surgical armamentarium in the treatment of intussusception.9,10 Laparoscopy can be performed in all cases of intussusception. Reduction of the intussusception, confirmation of radiologic reduction, and detection of lead points have all been reported.
  • Laparoscopy is associated with faster recovery times, decreased length of stay, decreased time to full feeds, and lower requirements of pain medication.

Consultations

  • Involve a pediatric surgeon as early as possible to help coordinate the care and resuscitation of the infant.
  • The availability of a pediatric radiologist enhances the chances of successful nonoperative reduction.

Diet

  • A few hours after nonoperative reduction, start the infant on a regular age-appropriate diet as tolerated.
  • If operative reduction was performed, advance the diet as with any postoperative patient.

Activity

  • The only limitations on activity after the treatment of intussusception are those imposed by the postoperative state.

Medication

  • Drug therapy is not currently a component of the standard of care for intussusception.
  • Some investigators have advocated the use of steroids in intussusception secondary to Henoch-Schönlein purpura (HSP) and lymphoid hyperplasia with varied results.

More on Intussusception

Overview: Intussusception
Differential Diagnoses & Workup: Intussusception
Treatment & Medication: Intussusception
Follow-up: Intussusception
Multimedia: Intussusception
References
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References

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Further Reading

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Keywords

intussusception, bowel obstruction, bowel torsion, abdominal pain, Henoch-Schönlein purpura, HSP, cystic fibrosis, hematologic dyscrasias, idiopathic intussusception, enteroenteral intussusception, jejunojejunal intussusception, jejunoileal intussusception, ileoileal intussusception, peristalsis

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Contributor Information and Disclosures

Author

A Alfred Chahine, MD, Associate Professor of Surgery and Pediatrics, The George Washington University School of Medicine; Chief of Pediatric Surgery, Georgetown University Medical Center; Attending Surgeon, Children's National Medical Center
A Alfred Chahine, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Pediatric Surgical Association, and International Pediatric Endosurgery Group
Disclosure: Nothing to disclose.

Coauthor(s)

Felix C Blanco, MD, Research Fellow, Department of Surgery, Children's National Medical Center
Felix C Blanco, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Hisham Nazer, MB, BCh, FRCP, DCh, DTM&H, Professor of Pediatrics, Consultant in Pediatric Gastroenterology, Hepatology and Clinical Nutrition, Bushnaq Medical Centre, University of Jordan
Hisham Nazer, MB, BCh, FRCP, DCh, DTM&H is a member of the following medical societies: Royal College of Paediatrics and Child Health, Royal College of Physicians, Royal College of Surgeons in Ireland, Royal College of Surgeons of Edinburgh, and Royal Society of Tropical Medicine and Hygiene
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

B UK Li, MD, Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin
B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
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