IntussusceptionEdit

Intussusception is a medical emergency in which a part of the bowel folds into an adjacent segment, pulling its blood supply with it and often causing obstruction. It most commonly affects infants and young children, with a peak incidence in the first years of life. The condition can progress rapidly, and prompt recognition and treatment are critical to prevent bowel damage. Most cases are idiopathic, but older children or those with certain conditions may have a lead point such as a Meckel's diverticulum or a polyp. Clinicians increasingly rely on nonoperative techniques to reduce the telescoping when the patient is stable, reserving surgery for cases with perforation, peritonitis, or failed nonoperative reduction. The management approach emphasizes timely care, cost-conscious decision making, and avoiding unnecessary interventions when a conservative route is likely to succeed.

Intussusception occurs when a proximal loop of intestine invaginates into a distal segment, drawing in its mesentery and compromising venous outflow. This leads to edema, ischemia, and potentially bowel necrosis if not resolved quickly. In most pediatric cases, the ileocecal region is involved, and the condition may produce episodes of intermittent crying and drawing up of the legs as the child experiences sharp abdominal pain. Vomiting is common, and as obstruction progresses, stools may become bloody or resemble “currant jelly.” A palpable abdominal mass or sausage-shaped lesion can sometimes be detected. Early recognition hinges on clinical suspicion, supported by imaging and, when appropriate, diagnostic and therapeutic enema procedures. See intussusception for broader context and related pediatric abdominal emergencies.

Epidemiology

Intussusception is the most common cause of intestinal obstruction in infants and toddlers in many parts of the world. It is most frequent in children under 2 years of age, with a slight male predominance. In most cases, there is no identifiable lead point, and the condition is considered idiopathic. Incidence varies by region and diagnostic practices, but timely treatment markedly improves outcomes across settings. In older children, a lead point becomes more likely, prompting different diagnostic and treatment considerations.

Etiology and pathophysiology

Most cases in young children are idiopathic, thought to be related to hypertrophy of lymphoid tissue in the intestinal wall after viral infections, particularly in the region of Peyer's patches. In older children or in cases with a lead point, pathologies such as a Meckel's diverticulum, polyps, intestinal tumors, or other anatomic abnormalities can initiate telescoping. The resultant intussuscepted segment can obstruct the lumen and encroach on its own blood supply, leading to venous congestion, edema, and eventual arterial compromise if not resolved. This pathophysiology underpins the urgency of treatment and the selection of management strategies.

Symptoms and signs

• Sudden, intermittent abdominal pain with crying and drawing up of the legs.
• Vomiting, initially non-bloody, then potentially containing blood as the condition progresses.
• Lethargy or pallor between episodes of pain.
• Palpable abdominal mass in a minority of cases, often described as a sausage-shaped lesion.
• Possible abdominal distension and tender abdomen if the condition has persisted.

Diagnosis

• Ultrasound is the preferred initial imaging modality in most emergency and pediatric contexts, often demonstrating a characteristic target or donut sign when the bowel has telescoped. See ultrasound.
• Plain abdominal X-ray can reveal signs of intestinal obstruction but is less specific for intussusception.
• A contrast enema (hydrostatic or pneumatic) can be diagnostic and often therapeutic, provided the patient is hemodynamically stable and there are no signs of peritonitis. See pneumatic reduction and hydrostatic reduction.
• In atypical presentations or when a lead point is suspected, additional imaging or surgical exploration may be warranted. See Meckel's diverticulum for potential lead points.

Management

Principles of care center on stabilizing the patient, accurately diagnosing, and choosing the least invasive effective method. The prevailing approach in many clinical settings emphasizes nonoperative reduction when feasible, with surgical intervention reserved for select circumstances.

• Nonoperative reduction
  • For stable patients without signs of perforation or peritonitis, a pneumatic (air) or hydrostatic (contrast or saline) enema can be used under imaging guidance. The use of ultrasound guidance for pneumatic reduction is increasingly common, balancing effectiveness with minimal radiation exposure. See pneumatic reduction and hydrostatic reduction.
  • Success rates vary with age, duration of symptoms, and the presence of a lead point but are generally high in typical cases, allowing avoidance of surgery in many children.
  • After a successful reduction, short observation is common to monitor for recurrence and ensure resolution of obstruction. See observation in pediatric care contexts.
• Surgical management
  • Surgery is indicated when nonoperative reduction fails, when there are signs of perforation or peritonitis, or when a lead point is suspected or identified.
  • Intraoperative manual reduction can be followed by resection if a pathologic lead point is found (for example, Meckel's diverticulum, polyp, or tumor). Laparoscopic approaches are increasingly used in suitable cases. See laparoscopy and surgery.
  • In cases with a lead point, addressing the underlying pathology is important to prevent recurrence.
• Recurrence
  • Recurrence after nonoperative reduction occurs in a notable minority of cases, most often within 24 to 48 hours but can occur later. Families are counseled about the risk and the signs that would require medical attention. See recurrence.

The balance between rapid nonoperative reduction and the timely use of surgical intervention reflects broader clinical priorities: minimize anesthesia exposure and hospitalization time while ensuring patient safety and avoiding complications such as perforation or ongoing ischemia. In practice, guidelines emphasize using nonoperative techniques where appropriate, provided there are no contraindications, and escalating to surgery when necessary. See clinical guidelines for standard recommendations in pediatric surgical emergencies.

Complications

• Bowel perforation during reduction is a serious but uncommon complication.
• Inadequate reduction by nonoperative means may necessitate subsequent surgical intervention.
• Prolonged obstruction increases the risk of bowel necrosis and sepsis, underscoring the need for prompt evaluation and treatment.
• Recurrence after initial resolution is possible and informs follow-up planning.

Prognosis

With timely recognition and appropriate treatment, most children recover fully. Mortality is rare in well-resourced settings but can be higher in environments with delayed access to pediatric surgical care or limited imaging and operative capabilities. Early intervention reduces the risk of complications and long-term sequelae.

See also

• pediatric surgery
• ultrasound
• pneumatic reduction
• hydrostatic reduction
• Meckel's diverticulum
• bowel obstruction
• laparoscopy
• surgery