Practice Based Learning: Management of recurrent intussusception

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Presented by Hope Arnold MD (PGY1)

Clinical question:

What is the appropriate management of recurrent intussusception? How many times can an air enema be done before considering surgical management?

Intussusception overview:

  • Telescoping of proximal bowel into a distal portion
  • Most common abdominal emergency in early childhood:
    • 60% under the age of 1
    • 80-90% under the age of 2
  • Most cases are idiopathic (75%):
    • If younger than 6 mos or older than 3, most likely has a pathologic lead point (PLP)
  • 1st line treatment: Either hydrostatic (contrast or saline) or pneumatic (air) enema under sonographic or fluoroscopic guidance

When to always do surgery?

Primary intervention for patients who are acutely ill, evidence of perforation, if nonoperative reduction is unsuccessful, or if high suspicion for a pathologic lead point

Recurrence:

  • ~10% of children have recurrence; recurrence is not usually an indication for surgery
  • Our question was when is the number of recurrences (excluding those who warrant immediate surgical intervention) high enough to warrant surgical intervention?

Conclusions:

  • There is good evidence to suggest that treating recurrences of intussusception with repeated air contrast enemas is safe and effective
  • Recurrence was not a risk factor for bowel damage or presence of a lead point
  • However, likelihood of repeat recurrences is very high after the 3rd recurrence, so surgical management could be considered:
    • Risk:benefit ratio of surgical/anesthesia complications, cost of surgery vs. multiple hospitalizations and air contrast enemas (especially those with 4+ recurrences)
    • Parental anxiety cited in both studies as reasons for surgical management

References:

Fisher JG, et al. Operative indications in recurrent ileocolic intussusception. J Pediatr Surg. 2015 Jan;50(1):126-30.

Hsu WL, et al. Recurrent intussusception: when should surgical intervention be performed? Pediatr Neonatol. 2012 Oct;53(5):300-3.

Niramis R, et al. Management of recurrent intussusception: nonoperative or operative reduction? J Pediatr Surg. 2010 Nov;45(11):2175-80.

Pierro A, et al. Indications for laparotomy after hydrostatic reduction for intussusception. J Pediatr Surg. 1993 Sep;28(9):1154-7.

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