Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

clinically stable with no contraindications to contrast enema reduction

1st line – fluid resuscitation + contrast enema reduction

Back
ACUTE
|
clinically stable with no contraindications to contrast enema reduction
1st line – 

fluid resuscitation + contrast enema reduction

Careful monitoring is required during transit to the radiology department, as well as during the procedure. Access to monitoring and resuscitation equipment, and nursing and medical staff capable of managing a child who may become unstable, are essential.

Adequate intravenous access is required and isotonic fluid resuscitation initiated. Contrast enema (air or contrast liquid) should be performed only in patients who are clinically stable. Absolute contraindications include peritonitis, perforation, and hypovolemic shock.[28]

Reduction should be first attempted by contrast enema (air or contrast liquid) which can be both diagnostic and therapeutic.[Figure caption and citation for the preceding image starts]: Site of intussusception as revealed by abdominal x-ray, showing the meniscusFrom the collection of Dr David J. Hackam; used with permission [Citation ends].com.bmj.content.model.Caption@4d725ed9[Figure caption and citation for the preceding image starts]: Abdominal x-ray showing impaired passage of barium at site of obstruction due to intussusceptionFrom the collection of Dr David J. Hackam; used with permission [Citation ends].com.bmj.content.model.Caption@37860a28​​ Pneumatic reduction is considered the method of choice for the treatment of intussusception in stable patients provided there is no indication for surgical reduction.[31][32]​​ Protocols typically vary by institutions but often involve instillation of air and/or contrast at pressures ranging from 80 to 120 mm Hg.[28]​ The patient is kept nil by mouth.

Barium enema: advantages over other types of contrast enema reduction include a long-standing experience in some centers, effective reduction in most cases, good evaluation for residual intussusception, and a low perforation rate. Disadvantages include the need for x-ray exposure, chemical peritonitis in the event of a perforation, and visualization of only intraluminal content. Water-soluble contrast enema has been used to reduce the risk of chemical peritonitis resulting from perforation. Reduction rate and perforation rate are comparable with other contrast agents.

Air enemas: these are noted to require less radiation and offer similar rates of failure, recurrence, and perforation to other agents.

Ultrasound-guided saline enema: excellent results have been described with the use of this modality, which offers the advantage of limiting exposure to radiation.[31][33]​​​ Although there is less experience with this method than fluoroscopic reduction, it is being used with increasing frequency in Europe and elsewhere.[21][22][32][33][34]​[37]​​​​

Consider – broad-spectrum antibiotics

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ACUTE
|
clinically stable with no contraindications to contrast enema reduction
Consider – 

broad-spectrum antibiotics

Treatment recommended for SOME patients in selected patient group

The role of antibiotics is unclear. In some centers they are no longer routinely indicated in children with intussusception. In others, the potential for poorly perfused or dilated bowel to translocate and produce a bacteraemia is seen as an indication. Administration of prophylactic antibiotics before enema reduction does not appear to reduce the risk of postreduction complications.[29]

When indicated, broad-spectrum antibiotics covering intra-abdominal pathogens should be administered.

Administer antibiotics 1 hour before the procedure if possible, and then consider continuing antibiotics after reduction for up to 48 hours if ischemia or significant dilatation is present.

Antibiotic regimens vary according to local protocols; consult local guidance.

Primary options

clindamycin: neonates: consult specialist for guidance on dose; infants and children: 25-40 mg/kg/day intravenously/intramuscularly given in divided doses every 6-8 hours

and

gentamicin: neonates: consult specialist for guidance on dose; infants and children: 2 to 2.5 mg/kg intravenously/intramuscularly every 8 hours

OR

piperacillin/tazobactam: neonates and infants <2 months of age: consult specialist for guidance on dose; children: 2-8 months of age: 80 mg/kg intravenously every 8 hours; children ≥9 months of age and ≤40 kg: 100 mg/kg intravenously every 8 hours

More

OR

cefoxitin: neonates and infants ≤3 months of age: consult specialist for guidance on dose; children >3 months of age: 25 mg/kg intravenously every 4-6 hours

and

vancomycin: neonates: consult specialist for guidance on dose; infants and children: 10 mg/kg intravenously every 6 hours

2nd line – fluid resuscitation + surgical reduction

Back
ACUTE
|
clinically stable with no contraindications to contrast enema reduction
2nd line – 

fluid resuscitation + surgical reduction

Failure of nonoperative reduction strategies requires surgical evaluation and reduction. Factors that suggest a lower reduction rate (as well as higher perforation rate) include patient age <3 months or >5 years, long duration of symptoms (>48 hours), passage of blood via the rectum, significant dehydration, small-bowel obstruction, and visualization of a coiled spring sign.[21]

Traditionally, operative reduction has been performed through an open approach via a right lower quadrant incision. The intussusception is identified and milked out of the intussuscipiens. Successful laparoscopic reduction has been described and is becoming popular;​ the intussusceptum is reduced by applying gentle traction.[29][35][36]

Intestinal resection may be necessary for cases complicated by bowel necrosis and perforation.

Consider – broad-spectrum antibiotics

Back
ACUTE
|
clinically stable with no contraindications to contrast enema reduction
Consider – 

broad-spectrum antibiotics

Treatment recommended for SOME patients in selected patient group

Broad-spectrum antibiotics covering intra-abdominal pathogens should be administered. Antibiotic treatment should be initiated on clinical diagnosis of shock, perforation, peritonitis, or evidence of bowel wall necrosis.

Administer antibiotics 1 hour before the procedure if possible, and then consider continuing antibiotics after reduction for up to 48 hours if ischemia or significant dilatation is present.

For patients who undergo resection, use routine intestinal prophylactic regimens. Prolonged antibiotic administration is only recommended in cases of perforation or abscess formation.

Antibiotic regimens vary according to local protocols; consult local guidance.

Primary options

clindamycin: neonates: consult specialist for guidance on dose; infants and children: 25-40 mg/kg/day intravenously/intramuscularly given in divided doses every 6-8 hours

and

gentamicin: neonates: consult specialist for guidance on dose; infants and children: 2 to 2.5 mg/kg intravenously/intramuscularly every 8 hours

OR

piperacillin/tazobactam: neonates and infants <2 months of age: consult specialist for guidance on dose; children: 2-8 months of age: 80 mg/kg intravenously every 8 hours; children ≥9 months of age and ≤40 kg: 100 mg/kg intravenously every 8 hours

More

OR

cefoxitin: neonates and infants ≤3 months of age: consult specialist for guidance on dose; children >3 months of age: 25 mg/kg intravenously every 4-6 hours

and

vancomycin: neonates: consult specialist for guidance on dose; infants and children: 10 mg/kg intravenously every 6 hours

with contraindications to contrast enema reduction and/or clinically unstable (e.g., shock, suspected perforation, peritonitis, evidence of bowel wall necrosis)

1st line – fluid resuscitation + surgical reduction

Back
ACUTE
|
with contraindications to contrast enema reduction and/or clinically unstable (e.g., shock, suspected perforation, peritonitis, evidence of bowel wall necrosis)
1st line – 

fluid resuscitation + surgical reduction

Adequate intravenous access and correction of hypovolemia with isotonic fluid resuscitation is necessary. In cases where there are contraindications to contrast enema reduction, or where the patient is clinically unstable, surgical reduction is required.

Absolute contraindications to contrast enema reduction include: peritonitis, perforation, toxic colitis, and hypovolemic shock.[28]

Relative contraindications include: prolonged symptoms, ultrasound findings of intestinal ischemia or trapped fluid, and marked evidence of bowel obstruction (e.g., abdominal distension, signs on imaging).[28] The procedure requires some cooperation from older children, who may not be able to tolerate the discomfort of the procedure.

Traditionally, operative reduction has been performed through an open approach via a right lower quadrant incision. The intussusception is identified and milked out of the intussuscipiens. Laparoscopic surgical techniques may be considered following surgical assessment, although would not be appropriate in clinically unstable patients.

Intestinal resection may be necessary for cases complicated by bowel necrosis and perforation.

Consider – broad-spectrum antibiotics

Back
ACUTE
|
with contraindications to contrast enema reduction and/or clinically unstable (e.g., shock, suspected perforation, peritonitis, evidence of bowel wall necrosis)
Consider – 

broad-spectrum antibiotics

Treatment recommended for SOME patients in selected patient group

Broad-spectrum antibiotics covering intra-abdominal pathogens should be administered. Antibiotic treatment should be initiated on clinical diagnosis of shock, perforation, peritonitis, or evidence of bowel wall necrosis.

Administer antibiotics 1 hour before the procedure if possible, and then consider continuing antibiotics after reduction for up to 48 hours if ischemia or significant dilatation is present.

For patients who undergo resection, use routine intestinal prophylactic regimens. Prolonged antibiotic administration is only recommended in cases of perforation or abscess formation.

Antibiotic regimens vary according to local protocols; consult local guidance.

Primary options

clindamycin: neonates: consult specialist for guidance on dose; infants and children: 25-40 mg/kg/day intravenously/intramuscularly given in divided doses every 6-8 hours

and

gentamicin: neonates: consult specialist for guidance on dose; infants and children: 2 to 2.5 mg/kg intravenously/intramuscularly every 8 hours

OR

piperacillin/tazobactam: neonates and infants <2 months of age: consult specialist for guidance on dose; children: 2-8 months of age: 80 mg/kg intravenously every 8 hours; children ≥9 months of age and ≤40 kg: 100 mg/kg intravenously every 8 hours

More

OR

cefoxitin: neonates and infants ≤3 months of age: consult specialist for guidance on dose; children >3 months of age: 25 mg/kg intravenously every 4-6 hours

and

vancomycin: neonates: consult specialist for guidance on dose; infants and children: 10 mg/kg intravenously every 6 hours

ONGOING

recurrence

1st line – consideration of evaluation for pathologic lead point + retreatment

Back
ONGOING
|
recurrence
1st line – 

consideration of evaluation for pathologic lead point + retreatment

Most recurrences after successful reduction of intussusception occur soon after reduction. The recurrence rate of intussusception after contrast enema (air or liquid contrast) reduction is approximately 10% and does not significantly differ based on the type of contrast reduction performed.[37] The risk of recurrence within 48 hours is low after enema reduction suggesting that patients who appear well should be considered for outpatient management with follow-up.[38][39]

Surgical reduction has been associated with a recurrence rate of 2% to 5%.[40]

Although suspicion for a pathologic lead point must be increased with a recurrent intussusception, successful contrast enema reduction has been advocated. Surgical intervention is reserved for irreducible recurrences and the presence of an identified pathologic lead point.​[2]​​[37]

After an infant's third episode of intussusception, a pathologic lead point must be considered. Computed tomography may be useful in evaluation for a pathologic lead point.[19]

In older children with intussusception, pathologic lead points must be considered. Diseases such as cystic fibrosis and Henoch-Schonlein purpura can cause bowel-wall abnormalities that function as lead points in intussusception.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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