Initial stabilisation
Keep nil orally.
Establish IV access.
Provide isotonic fluid for dehydration.
Use analgesia.
Insert nasogastric decompression when there is significant vomiting or obstruction.
A child with shock, peritonitis or perforation should undergo resuscitation and surgery rather than radiological reduction.
Enema reduction
In a haemodynamically stable child without peritonitis or perforation, first line treatment is image guided enema reduction.
Options include:
Pneumatic air reduction under fluoroscopy
Hydrostatic saline or contrast reduction, often ultrasound guided
Both are highly effective.
Recent comparative evidence supports pneumatic reduction as highly effective, while ultrasound guided hydrostatic reduction avoids radiation and also achieves excellent success rates.
For pneumatic reduction, pressures in the range of approximately 80 to 120 mmHg are commonly used with careful imaging control.
Successful reduction is confirmed by:
Do not continue escalating pressure against a fixed nonreducing mass indefinitely.
Contraindications to enema reduction
Proceed directly to surgery with:
Failed reduction
If the child remains stable and partial reduction has occurred, a carefully planned repeat attempt after a short interval can succeed in selected patients.
Surgery is required when:
Operative reduction
At surgery, gently reduce the intussusception by milking the intussusceptum retrogradely from distal to proximal.
Avoid pulling forcefully on the proximal bowel because oedematous bowel can tear.
After reduction assess viability.
Resect when:
Perform primary anastomosis when bowel condition and physiology permit.
Recurrence
Recurrence occurs in approximately 5% to 10% of children after successful nonoperative reduction.
Most recurrent episodes can undergo another enema reduction if no contraindication exists.
Multiple recurrences or recurrence in an older child should increase suspicion for a pathological lead point.
