Pediatric Intussusception Surgery 

Updated: Jul 18, 2019
Author: Amulya K Saxena, MD, PhD, DSc, FRCS(Glasg); Chief Editor: Harsh Grewal, MD, FACS, FAAP 

Overview

Background

Intussusception, which is defined as the telescoping or invagination of a proximal portion of intestine (intussusceptum) into a more distal portion (intussuscipiens), is one of the most common causes of bowel obstruction in infants and toddlers.

Intussusception was first described by Barbette in 1674, and it was first successfully treated surgically by Wilson in 1831. In 1876, Hirschsprung first reported the technique of hydrostatic reduction,[1] and in 1905, after monitoring a series of 107 cases, he reported a 35% mortality attributable to intussusception.

Vascular compromise and subsequent bowel necrosis are the primary concerns with intussusception. Among patients who undergo operative reduction of intussusception, those with long-standing intussusceptions, mostly due to late presentation, bear the risks of resection of affected bowel.

Anatomy

Intussusception is the telescoping or invagination of a proximal portion of intestine into a more distal portion (see the first image below). Intussusception may be ileoileal (see the second image below), colocolic, ileoileocolic, or ileocolic (the most common type; see the third image below).

Diagram illustrating anatomy of intussusception. Diagram illustrating anatomy of intussusception.
Intraoperative appearance of ileoileal intussuscep Intraoperative appearance of ileoileal intussusception.
Intraoperative appearance of ileocolic intussuscep Intraoperative appearance of ileocolic intussusception.

Pathophysiology

Intussusception results in bowel obstruction, followed by congestion and edema with venous and lymphatic obstruction. This progresses to arterial obstruction and subsequent necrosis of the bowel. Ischemia and then necrosis results in fluid sequestration and bleeding from the gastrointestinal (GI) tract. If untreated, the bowel may perforate, resulting in sepsis.

Etiology

Intussusception is ileocolic in 80% of cases but may also be ileoileal, colocolic, or ileoileocolic. Most infants and toddlers (95%) with the condition do not have an identifiable specific lead point. In these idiopathic cases, careful examination may reveal hypertrophied mural lymphoid tissues (Peyer patches), which are due to adenovirus or rotavirus infection. Intussusception has also been found to increase the risk of tonsillar disease (ie, chronic or acute tonsillitis) and tonsillectomy in children.[2]

A specific lead point that draws the proximal intestine and its mesentery inward and propagates it distally through peristalsis is identified in only 5% of cases and is most commonly found in cases of ileoileal intussusception. Specific lead points are more commonly found in children older than 3 years and almost always in adults with intussusception. Meckel diverticulum (see the image below) is the most common lead point, followed by polyps, such as are seen with Peutz-Jeghers syndrome, and intestinal duplications.[3]

Intraoperative appearance of ileocolic intussuscep Intraoperative appearance of ileocolic intussusception due to Meckel diverticulum.

Other lead points described include lymphomas, lymphangiectasias,[4] submucosal hemorrhage with Henoch-Schönlein purpura, trichobezoars with Rapunzel syndrome,[5] caseating granulomas due to abdominal tuberculosis,[6] hemangiomas, and lymphosarcomas. Intussusception associated with pathologic lead points may be more likely to recur.[7]

Children with cystic fibrosis (CF) may present with intussusception due to inspissated meconium in the terminal ileum. Although intussusception is generally observed as a complication in older children with CF, neonatal intussusception with meconium plug syndrome associated with CF has been reported.

Postoperative jejunoileal or ileoileal intussusception, which has no specific lead point in most cases, accounts for approximately 1% of intussusceptions in children of all ages.[8] When a lead point is present with postoperative intussusception, several cases have been reported after appendectomy with stump inversion.[9] Other rare reported types of intussusception include retrograde jejunojejunal intussusception following duodenal atresia repair[10] and an ileoileal type resulting from blunt abdominal trauma.[11]

Although the vast majority of intussusception cases are idiopathic, Oshio et al in Japan reported a familial anatomic tendency that may predispose to the condition in the face of viral infection.[12] Of 554 families who had at furthest a third-degree relative with an idiopathic case of intussusception, the authors found an incidence of approximately 7%, or 1 per 14.2 cases. The family history may help in the workup, and further genetic testing may eventually identify the gene responsible for this predisposition.

Epidemiology

The incidence of intussusception ranges from 26 to 38 cases per 100,000 live births in the first 3 years of life.[13] Intussusception typically presents between the ages of 6 and 36 months. Approximately 60% of children with intussusception are younger than 1 year, and 80-90% are younger than 2 years.[14]  Although intussusception is most common in infants and toddlers, it is a diagnosis that should be considered in children outside this age range as well. Approximately 10% of cases occur in children older than 5 years, 3-4% in children older than 10 years, and 1% in infants younger than 3 months.[13]

Prognosis

The following criteria are associated with a higher failure rate for nonoperative reduction:

  • Ileoileocolic intussusception
  • Long duration of symptoms (>24 hours)
  • Raised neutrophil percentage
  • Rectal bleeding
  • Failed reduction with barium enema at another institution
  • Age older than 2 years or younger than 3 months
  • Small-bowel obstruction on radiography
  • Dehydration of greater than 5%
  • Inexperienced radiologist

Factors significantly predictive of bowel perforation are younger age and a longer duration of symptoms.

 

Presentation

History

In 1941, Ladd and Gross described the deceptively healthy appearance of infants with intussusception.[15]  One rarely finds intussusception in a child who is thin, undernourished, and poorly developed. This is evident in that babies with intussusception are usually well nourished and generally above average in physical development.

This fat and healthy appearance is apt to mislead the physician in the early hours of the patient’s illness. Thus, the first visit may leave the physician with the impression that the parent is overanxious, whereas a return visit the next day shows that the child is desperately ill.

Disorders characterized by bowel obstruction, colicky abdominal pain, blood in the stool, an intra-abdominal mass, or a combination of these should be considered in the differential diagnoses of intussusception. These include gastroenteritis, appendicitis, Meckel diverticulum, malrotation with midgut volvulus, or incarcerated hernia.

Most infants with intussusception have a history of intermittent severe cramping or colicky abdominal pain, occurring every 5-30 minutes. During these attacks, the infant screams and flexes at the waist, draws the legs up to the abdomen, and may appear pale. These episodes may last for only a few seconds and are separated by periods of calm normal appearance and activity. However, some infants become quite lethargic and somnolent between attacks.

Early on, the infant may vomit undigested food. As attacks continue, emesis may turn bilious. Stool that appear normal in character early in the course of the illness eventually become dark red and mucoid (resembling currant jelly), a sign of intestinal ischemia and mucosal sloughing.

Physical Examination

Ideally, the dramatic paroxysms that are common in this condition would sufficiently alert the parents to seek medical attention early in the course of the illness. If this is the case, initial inspection may reveal a robust infant who appears healthy. Between attacks, the infant may appear somnolent or quite normal, and findings on examination of the abdomen may be unremarkable. During an attack or spasm, the infant suddenly appears startled or anxious and begins to scream.

Upon initial inspection, the abdomen may appear scaphoid; during paroxysms, it may be rigid; and later in the course of the illness, it may become distended with signs of peritonitis. Careful palpation after an attack has subsided may reveal an ill-defined or sausage-shaped mass.

With early ileocolic intussusception, the mass is typically found in the right upper quadrant (RUQ) of the abdomen. The right lower quadrant (RLQ) may seem empty upon examination, a finding known as the Dance sign. This mass may be difficult to locate in inconsolable infants because of abdominal rigidity from muscle straining. If episodes of cramping are witnessed, the careful examiner may auscultate peristaltic rushes in the area of the intussusception.

The rectal examination should commence with inspection of fecal material in the diaper. Normal-appearing stool should be tested for occult blood. The presence of mucoid or frankly bloody stool supports the diagnosis. Rarely, inspection of the anus reveals the prolapsed tip of the intussusception. A digital rectal examination (DRE) should be performed routinely, looking for blood or a mass higher in the anal canal.

Clinical Diagnostic Criteria

In view of concerns about rotavirus vaccine–associated intussusception, the Brighton Collaboration Intussusception Working Group established a clinical diagnosis using a mix of major and minor criteria. This stratification helps to devise a working model based on three levels of evidence to suggest definite, probable, and possible cases of intussusception.[16]

Major and minor criteria

Major criteria for the clinical diagnosis of intussusception are as follows:

  • Evidence of intestinal obstruction - This criterion consists of a history of bile-stained emesis, along with abdominal distention or abnormal or absent bowel sounds
  • Features of intestinal invagination - This criterion includes at least one of three key findings—abdominal mass, rectal mass, or rectal prolapse—as well as an abdominal radiograph, sonogram, or computed tomography (CT) scan showing visible intussusceptum or a soft-tissue mass
  • Evidence of intestinal vascular compromise or venous congestion - This criterion manifests as rectal bleeding or “red currant jelly” stool or blood on rectal examination

Minor criteria include the following:

  • Male infants younger than 1 year
  • Abdominal pain
  • Vomiting
  • Lethargy
  • Pallor
  • Hypovolemic shock
  • Abdominal radiograph showing nonspecific abnormality

Evidence levels

The likelihood of the diagnosis is stratified on the basis of evidence levels.

Level 1 (definite) includes any one of the following:

  • Surgical criteria - Invagination of intestine found during surgery
  • Radiologic criteria - Gas or liquid contrast enema showing invagination or abdominal sonogram with specific features proven to be reduced by enema on postreduction sonogram
  • Autopsy criteria - Invagination of the intestine

Level 2 (probable) includes either of the following:

  • Two major criteria (see above)
  • One major criterion and three minor criteria (see above)

Level 3 (possible) includes the following:

  • Four or more minor criteria (see above)

The relevance of this definition was clinically tested in Switzerland, where it correctly identified 86 of 96 confirmed episodes, 82 of which met level 1 evidence.[17] Regarding sensitivity in comparison to this level 1 evidence, level 2 (probable) had a sensitivity of 65%, whereas level 3 (possible) had a sensitivity of only 30%.

A 2011 prospective study by Weihmiller et al focused on establishing predictive clinical criteria to risk stratify patients while performing a workup for intussusception.[18]  The three strongest clinical predictors for high risk were as follows:

  • Male sex ( = .007)
  • Age >5 months ( = .04)
  • Report of lethargy ( = .001)

If a patient is older than 5 months, then he or she may be considered low-risk if the abdominal radiograph is negative and there is diarrhea with no bilious emesis.

This study also recommended plain abdominal radiographs for all patients suspected of having intussusception.[18]  An abnormal abdominal plain film had a P value of .0001. Their definitions for an abdominal radiographs were classified as either (a) negative, with no intussusception suspected, or (b) positive or possibly positive for intussusception, which led to more testing using either ultrasonography (US) or air enema.

Of note, this study identified 38 intussusceptions out of 310 pediatric patients and did not find abdominal pain, abdominal mass, or guaiac-positive stools to be significant.[18]  However, these clinical findings are classic for intussusception on the basis of prior research; therefore, the presence of these symptoms and signs should still raise clinical suspicion for intussusception.

In a study of 379 patients, Fallon et al concluded that significant predictors for operative treatment included abdominal symptoms for more than 2 days, age younger than 1 year, multiple findings on US, and failure of initial enema reduction.[19]

In a 7-year multicenter retrospective study of intussusception in 153 pediatric patients aged 12 years or younger, Banapour et al found that children older than 5 years were significantly more likely to have a pathologic lead point, which suggested that early surgical intervention should be considered.[20]  In this age group, enema reduction, though safe, yielded only minimal benefit.

 

Workup

Laboratory Studies

Obtain a complete blood count (CBC) with differential and chemistry profile. Blood chemistry abnormalities are not specific for intussusception. Depending on the duration of illness and associated vomiting and blood loss, laboratory investigations may reflect dehydration, anemia, leukocytosis, or a combination of these.

Plain Radiography

Early in the course of the illness, findings on plain radiographic examination of the abdomen (supine and upright) may be unremarkable. Findings suggestive of intussusception include dilated loops of small bowel with or without air-fluid levels, an airless or opacified right lower quadrant (RLQ; see the image below), or both. Occasionally, the intussusceptum is apparent on plain abdominal radiography.

Abdominal plain radiograph of 14-week-old patient Abdominal plain radiograph of 14-week-old patient with intussusception. Note nonspecific appearance of bowel obstruction.

In order to increase the diagnostic accuracy, a left-side-down decubitus radiographic view of the abdomen can be helpful. Hooker et al found that the diagnostic value of kidney-ureter-bladder (KUB) radiography increased from 60.3% to 74.1% after a decubitus view was added.[21]  With the addition of the decubitus view, the exclusion value was also increased, from 25.6% to 58.1%.

Roskind et al used three radiographic views (supine, prone, and left decubitus) and found a sensitivity of 100% when these three showed air in the ascending colon, but a specificity of only 18.4%. The sensitivity went to 96% and specificity to 41% when at least two views revealed air in the ascending colon.[22]

 

Ultrasonography

First reported as a useful diagnostic tool in intussusception by Burke in 1977, ultrasonography (US) has been shown by a number of authors to be helpful in the diagnosis of intussusception.[23]  Studies advocating its use for diagnosis have reported sensitivities of 98.5-100%, specificities of 88-100%, and negative predictive values of 100%. US has been described as being the imaging method of choice for ileocolic intussusception in children.[24]

Characteristic findings on US include a target sign (see the first image below) visible on transverse section and a pseudokidney sign (see the second image below) viewed on longitudinal section.

Transverse ultrasonographic view (target sign) of Transverse ultrasonographic view (target sign) of intussusception.
Longitudinal ultrasonographic view (pseudokidney s Longitudinal ultrasonographic view (pseudokidney sign) of intussusception.

US has also been studied as a tool for helping to differentiate the types of intussusception.[25]  Park et al reported that a transient small-bowel intussusception is most likely characterized by the following[26] :

  • Location in the RLQ or periumbilical region
  • Smaller anteroposterior diameter (1.38 cm vs 2.53 cm)
  • Thinner outer rim (0.26 cm vs 0.53 cm)
  • Absence of lymph nodes, in contrast to ileocolic intussusception

A study by Munden et al supported these findings, with a mean anteroposterior diameter of 1.5 cm in ileoileal intussusceptions and 3.7 cm in ileocolic intussusceptions and mean lengths of 2.5 cm and 8.2 cm, respectively.[27]

With small-bowel intussusception, the length may be helpful in determining the necessity of surgery. Munden et al found that an intussusception length of more than 3.5 cm independently predicted the likelihood of surgery being performed, with a sensitivity of 93% and a specificity of 100%.[12]

US is best employed as a diagnostic tool of exclusion when the index of suspicion for intussusception is lower.

Computed Tomography

The evaluation of abdominal pain often leads to examination with computed tomography (CT). Although CT is not indicated for the diagnosis of intussusception, intussusception can be found incidentally on CT scans (see the image below).

Appearance of intussusception on CT scan. Appearance of intussusception on CT scan.

Procedures

Diagnostic and therapeutic enema

Ladd first used barium enema as a diagnostic tool in 1913.[28]  Since that time, enemas, with either air or barium, have become a mainstay in both diagnosis and therapy, replacing surgery as the initial management of stable patients. Knowledge of the basic technique and potential complications of contrast enemas in intussusception is important for all clinicians involved in the management of these patients.

A discussion of the choice between air (see the first image below) or barium (see the second image below) in contrast enemas is beyond the scope of this article, and the reader is referred to a number of reviews discussing the advantages and disadvantages of both techniques.[24]   Perforation is a risk with either barium or air but poses less of a problem with air, in that the combination of barium and feces may result in severe peritonitis with wide peritoneal soilage.

Ileocolic intussusception is observed by using air Ileocolic intussusception is observed by using air-contrast enema. Intussusception has been reduced to level of cecum.
Ileocolic intussusception is observed by using bar Ileocolic intussusception is observed by using barium contrast enema. Intussusception has been reduced to level of proximal transverse colon.

Once the diagnosis of intussusception is entertained, surgical personnel should be notified, and an intravenous (IV) line should be placed. The author prefers to have a nasogastric tube in place, though this is not a universal practice. Furthermore, sedation may be helpful while the examination is being conducted.

Preferably, the surgeon should be present in the radiology suite at the time of contrast enema examination. The diagnostic enema is therapeutic in 80-90% of patients. Thus, treatment is usually concluded in the radiology suite, and some surgeons elect to observe these patients in the hospital until they can tolerate an oral diet.

A successful therapeutic reduction must demonstrate free flow of contrast (air or barium series) proximal to the ileocecal valve. Historically, patients in whom enema reduction was unsuccessful were taken immediately to the operating room for laparotomy and manual reduction. However, in patients who are clinically stable, second and third attempts at pneumatic or hydrostatic reduction have proven effective.

Pneumatic reduction is also successful in ileoileal intussusceptions with signs of bowel viability. It should be attempted with caution in patients with jejunojejunal or ileoileal small bowel intussusceptions and in those patients with pathologic lead points or bowel ischaemia.[29]

Technique

A lubricated straight catheter is placed into the rectum and secured by taping the buttocks together tightly. Although many radiologists prefer a balloon-tipped catheter, laceration or perforation of the rectum is a risk with balloon inflation.

A manometer and a blood pressure cuff are connected to the catheter, and air is insufflated slowly to a pressure of 70-80 mm Hg (maximum, 120 mm Hg) and followed fluoroscopically as it percolates proximally through the colon. The column of air stops at the intussusception, and a plain radiograph is taken.

If no intussusception exists or if the reduction is successful, air is observed to pass rapidly into the small bowel. Another radiograph is taken at this point, and the air is allowed to escape before removal of the catheter.

At the completion of the procedure, postreduction radiography (in supine and decubitus/upright views) should be performed to confirm the absence of free air.

Difficult reductions may require several attempts. The use of glucagon (0.5 mg/kg) for facilitating relaxation of the bowel has yielded mixed results and is not routine.

Success rates of 80-90% for pneumatic reduction have been reported. In the stable patient, suggestion of a recurrence following enema reduction necessitates a repeat enema examination.

Ultrasonographically guided hydrostatic reduction

The role of US in the diagnosis of intussusception is well established; however, experience with US-guided hydrostatic reduction of intussusception is limited in the Western hemisphere.

In a 1997 study from Hong Kong, Chan et al compared the efficacy of US-guided versus fluoroscopically guided hydrostatic reduction in 46 patients with intussusception.[30]  The US-guided reduction group had three recurrences (11.5%), one lead point (4.4%), and 19 successful reductions (73%). Only one recurrence (4.2%), one lead point (4.4%), and 12 successful reductions (50%) occurred in the same number of patients undergoing hydrostatic reduction with barium.

No complications occurred in either group, and the accuracy rate of diagnosing a complete reduction was 100% with both forms of reduction.[30]  Hence, the authors concluded that US-guided hydrostatic reduction for childhood ileocolic intussusception is preferred because it is safe, accurate, has a higher success rate, and can avoid radiation exposure risk.

In a 2006 study from China that assessed hydrostatic reduction in 5218 patients, Bai et al reported a 95.5% rate of success and a colonic perforation rate of only 0.17%.[31]  In Europe, successful reduction has been reported in 76-95% of cases, with only one case of perforation in 825 cases. As hydrostatic reduction of intussusception has proved effective in Europe and Asia, it has come into increasing use at some US centers.

Histologic Findings

Resected specimens show varying degrees of ischemia, necrosis, or both. Benign reactive lymph node hyperplasia and Peyer patch hyperplasia is common. Resected specimens should be carefully examined for potential lead points (eg, Meckel diverticulum, polyps, lymphoma).

 

Treatment

Approach Considerations

Stable patients in whom the index of suspicion for intussusception is high but who do not have evidence of ischemic bowel, perforation, or sepsis may undergo immediate contrast enema for diagnosis and treatment of suspected intussusception. Contraindications for enema reduction include evidence of bowel perforation and peritonitis.

Immediate surgery is indicated for unstable patients, patients who have peritonitis, and patients with bowel perforation during attempted enema reduction. Elevated temperature and white blood cell (WBC) counts have also served as relative indicators for surgery. Patients requiring surgery must be aggressively resuscitated with fluids, and care must be taken to preserve body temperature preoperatively, intraoperatively, and postoperatively.

Medical Therapy

Expeditious diagnosis and management are essential for achieving successful outcomes in infants with intussusception. Once the diagnosis is entertained, surgical personnel should be notified, an intravenous (IV) line inserted, and IV hydration started. A nasogastric tube should be inserted and placed to suction. If there is marked distention or a dilated bowel loop, an abdominal radiograph should be obtained. Antibiotics should be administered if there is clinical suspicion of peritonitis or infection (sepsis) or if the WBC count is markedly elevated.

In the United States, if the intussusception can be reduced with an enema, the hospital stay typically lasts 3 days. However, one small retrospective study in Canada evaluated 96 patients with a successfully reduced ileocolic intussusception and determined that a short observational stay in the emergency department could be used safely in 90% of patients.[32] This approach would prevent an admission and save on costs; however, more evidence-based criteria must be developed before it can become common practice.

Surgical Therapy

Preparation for surgery

Preoperatively, IV crystalloid resuscitation is begun (10 mL/kg × 2, plus 1.5 × maintenance fluid). A Foley catheter is placed to guide fluid resuscitation. A nasogastric tube is placed. Broad-spectrum IV antibiotics are administered. Body temperature must be preserved in the operating room. A type and screen of the patient's blood should be obtained. As in any patient with a bowel obstruction, careful rapid sequence induction of anesthesia should be carried out because of the risk of regurgitation and aspiration.

Operative details

The abdomen and bowel are typically explored through a transverse incision in the right lower quadrant (RLQ), though some advocate a right transverse supraumbilical or even an upper midline incision. After inspection for signs of perforation, the intussusception is identified and delivered into the wound. First, an attempt is made at manual reduction by retrograde milking of the intussusceptum. Although gentle pulling may aid in reduction, avoid vigorous pulling apart of the intussuscepted segment of bowel.

If manual reduction is unsuccessful, if a mass or pathologic lead point is present, or if perforation has occurred, segmental bowel resection is necessary. Bowel resection is more likely to be required in older children and those with longer duration of symptoms.[33] After resection, a primary anastomosis may be performed

After successful manual reduction, the involved bowel segment may appear edematous, hyperemic, or ischemic, but such findings do not necessarily mandate resection. An incidental appendectomy is often done, particularly if an RLQ incision was made for access to the abdomen; it may be presumed that the patient has had an appendectomy.

Laparoscopy in the management of intussusception was initially limited to a diagnostic role. It was used to confirm unreduced bowel following an enema, with prompt conversion to an open procedure. The laparoscope allowed the surgeons to avoid unnecessary open procedures in cases of spontaneous reduction following enema and enhanced the efficacy of hydrostatic or pneumatic reductions, reducing the need for an open procedure in approximately 30% of cases.

Continued experience with laparoscopy and improved technology has led some centers to successfully utilize the technique for therapeutic reduction in confirmed cases of pediatric intussusception. Several small series have been published demonstrating the laparoscopic approach as safe, effective, and cost efficient when compared to the open technique.[34]

In a retrospective analysis at the University of Michigan comparing laparoscopic treatment of intussusception with the open technique, intraoperative complications occurred only when bowel necrosis was present and resulted in a 12.5% (2/18) conversion-to-open rate.[35]  Postoperative complication rates were not significantly different in the open and laparoscopic groups. The open group experienced one wound infection and one recurrence (2/25), and the laparoscopic group experienced one urinary tract infection and one recurrence (2/18).

A major concern regarding the laparoscopic approach is the inability to reduce the intussusception in the standard retrograde fashion characteristic of the open technique. Some authors voice concern that a surgeon reducing an intussusception laparoscopically must apply pull and tension on an often friable segment of bowel, increasing the risk of bowel perforation.

Additionally, because most cases of intussusception in older children and adults are secondary to a pathologic lead point, the laparoscopic technique may not be appropriate in these patients. In order to minimize the rate of conversion to the open approach, the patient should be seen within 36 hours of the onset of symptoms and should have no peritoneal signs.[36]

The compromised tactile feedback for identifying a lead point laparoscopically and the potential need for an extended bowel resection for malignancy support an open approach in older children and adults. However, advances in laparoscopy have made intussusception reduction more safe and effective.

Chui et al developed a “Chinese fan spread” technique that utilizes an intracorporeal fulcrum to distribute the distraction forces more evenly as the surgeon does a push-pull on the intussusception.[37]  Overall, 12 of 14 intussusceptions were reduced successfully without a concurrent enema, and in the two cases where laparoscopic reduction failed, open manual reduction failed as well, thus necessitating right hemicolectomy. Of the 12 reductions, five had lead points that were managed laparoscopically or through a transumbilical incision.

The role of laparoscopy in intussusception is evolving and will be better defined as technology progresses and experience with the minimally invasive approach to this disease grows.[38]

There are differences in ileocolic and small bowel intussusception  with regard to spontaneous reductions, and bowel resection, and age with regard to surgery and bowel resection. Treatment efficacy depends on time of presentation, intussusception type, pathologic lead points, US/color Doppler interpretation, and expertise in reduction techniques.[39]

Postoperative Care

IV fluid resuscitation is continued and calculated, with consideration given to maintenance requirements and third-space losses. Upon resolution of ileus, diet is advanced at the discretion of the surgeon.

Complications

Intussusception results in bowel obstruction; thus, complications such as dehydration and aspiration from emesis can occur. Ischemia and bowel necrosis can cause bowel perforation and sepsis. Necrosis of a significant length of intestine can lead to complications associated with short bowel syndrome. Whether treated by operative or radiographic reduction, late stricture (4-8 weeks) may occur within the length of intestine involved.

Long-Term Monitoring

In older children and in cases of recurrent intussusception (three or four episodes) successfully reduced with an enema, consider evaluating the patient for a lead point (eg, upper gastrointestinal [GI] series, Meckel scan).