Management

Intussusception is potentially lethal. It has been estimated that up to 60% of deaths in intussusception are preventable. The key points for successful management in intussusception are as follows:

• early diagnosis;

• adequate resuscitation;

• effective reduction.

Adequate resuscitation begins with intravenous fluid therapy. Administration of antibiotics and nasogastric aspirations are essential for advanced cases. Reduction of intussusception may be non-operative or operative, depending on the clinical condition. Irrespective of the choice of method of reduction, preparation for surgery is essential as non-operative reduction may fail or result in perforation. Blood is cross-matched. The operating theatre is made available and the aneasthetist is informed. The surgeon is the primary clinician for intussusception and should initiate treatment, decide on the method of reduction and should be present at (non-operative) or carry out (operative) the reduction.

Non-operative reduction should generally be attempted for most cases of acute intussusception. The contraindications are perforation, peritonitis indicating bowel necrosis and profound shock. Non-operative reduction is usually unsuccessful if a pathological lead point is present and the primary pathology usually requires operative treatment. A long history (>48 h), radiological evidence of small bowel obstruction and extremes of age are associated with lower success rates but are not absolute contraindications to nonoperative reduction.

Non-operative reduction can be hydrostatic or pneumatic. The child is sedated with morphia, diazepam or,

Figure 23.3. Intussusception. (a) Ultrasonography: target sign; (b) Ultrasonography: pseudokidney sign; (c) Barium enema: coiled-spring sign.

rarely, general anaesthesia. Traditionally, hydrostatic reduction is achieved with a barium enema. Barium is introduced via a rectal balloon catheter with the buttocks strapped. The hydrostatic pressure should not exceed the equivalence of 1 mH2O for a maximum of 10 min. The procedure is monitored fluoroscopically. Reduction is indicated by a free flow of barium into the terminal ileum, expulsion of faeces and gas with the barium and resolution of symptoms and signs. Alternatively, hydrostatic reduction can be carried out using Hartmann's solution or saline under ultrasonographic guidance, which avoids the risk of irradiation. Successful reduction rates vary between 50% and 90%. Pneumatic reduction is performed with manometric and fluoroscopic control. If perforation occurs, leakage of air, Hartmann's solution or saline is less damaging than leakage of barium (peritoneal reaction) or the hyperosmolar gastrografin although it should not be forgotten that entry of intestinal contents and bacteria into the peritoneal cavity will cause peritonitis, and this will require emergency surgery.

Surgery is undertaken when non-operative reduction is contraindicated or has failed. A right supra- or sub-umbilical transverse incision is made. The intussusception is milked back proximally by progressive compression of bowel just distal to the intussusception. If viability of the reduced bowel is doubtful, warm packs are applied. Bowel resection is carried out for irreducible intussusception, gangrenous bowel and pathological lead points.

With proper management, the mortality rate of intussusception should nowadays be <1%. Recurrent intussusception occurs in about 10% of cases after non-operative reduction and 1-4% of cases after operative reduction, usually within 1-36 months of reduction, peaking at about 8 months. First recurrences can be treated by non-operative reduction. Second recurrences should be managed opera-tively. Multiple recurrences suggest the presence of pathological lead points. Adhesive intestinal obstruction is a late complication (3-6%) of operative reduction.

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