Patient in ED with history suggestive of intussusception Surgical Consult (if not previously obtained) Surgery must be aware of patient prior to air enema; in-person evaluation can occur before or after enema if patient clinically stable Ultrasound Need for urgent surgery consult? Yes No Negative Positive Air Enema Return to ER for further work-up/observation To OR if indicated Reduced Completely? Yes Observation in ED x 4 hours then PO Trial Discharge No Can repeat Q1H x 3 times with monitoring between attempts as long as intussusceptum continues to reduce, no free air, and patient stable. Reduced Completely? No (Fellow or Attending should be notified) Indications for urgent surgery consultation: • Acute abdomen • Abnormal vital signs • Ill-appearing • Other concerns per ED provider Surgical Consult Sources: • Applegate KE, et al. Intussusception in children: evidence-based diagnosis and treatment. Pediatr Radiol 2009;39:S140-143. • Navarro OM, et al. Intussusception: the use of delayed, repeated reduction attempts and the management of intussusceptions due to pathologic lead points in pediatric patients. Am J Roentgenol 2004;182:1169-1176. • Daneman A, et al. Intussusception. Part 1: a review of diagnostic approaches. Pediatr Radiol 2003;33(2): 79-85. • Daneman A, et al. Intussusception. Part 2: An update on the evolution of management. Pediatr Radiol 2004;34(2):97-108. • Sujka JA, et al. Emergency department discharge following successful radiologic reduction of ileocolic intussusception in children: A protocol based prospective observational study. J Pediatr Surg 2018; epub ahead of print print. Updated 2/2019 v1.0
Intussusception Management
Guideline · Nov 2018 · 1 min read
In brief
In brief
Clinical pathway for evaluating and managing pediatric intussusception, covering diagnostic imaging, air enema reduction techniques, indications for surgical consultation, and criteria for safe emergency department discharge following successful non-operative reduction.
- Surgery must be notified before air enema reduction attempt, even if patient is clinically stable
- Air enema can be repeated up to 3 times at 1-hour intervals if intussusceptum continues to reduce and patient remains stable
- After successful complete reduction, observe patient in ED for 4 hours with PO trial before discharge
- Urgent surgical consultation required for acute abdomen, abnormal vitals, or ill-appearing patients
- Ultrasound is the initial diagnostic modality; air enema serves as both diagnostic and therapeutic intervention
Written by the GCMD Library team from the guideline.
Initial Assessment and Surgical Notification
All patients with suspected intussusception require surgical consultation prior to air enema reduction, though in-person evaluation timing depends on clinical stability. Urgent surgical consultation is indicated for patients with acute abdomen, abnormal vital signs, ill appearance, or other concerning features identified by the ED provider.
Diagnostic Ultrasound
Ultrasound is the initial diagnostic modality to confirm intussusception before proceeding to therapeutic intervention. Negative ultrasound prompts return to ED for further workup and observation, while positive findings lead to air enema reduction.
Air Enema Reduction Protocol
Air enema is the primary therapeutic intervention for confirmed intussusception. Up to three repeat reduction attempts can be performed at one-hour intervals if the intussusceptum continues to reduce, no free air is present, and the patient remains clinically stable, with fellow or attending notification required for repeat attempts.
Post-Reduction Management for Successful Cases
Patients with complete reduction undergo four hours of ED observation followed by oral trial. Successful tolerance of oral intake allows for discharge home.
Management of Failed Reduction
Patients with incomplete reduction after maximum reduction attempts proceed to operating room for surgical management. This pathway is also followed for patients who develop complications during reduction attempts or remain clinically unstable.
Statements in this guideline
Surgery must be aware of the patient prior to air enema.
In-person surgical evaluation can occur before or after enema if the patient is clinically stable.
Indications for urgent surgery consultation include acute abdomen, abnormal vital signs, ill-appearing patient, or other concerns per ED provider.
Ultrasound should be performed in patients with history suggestive of intussusception.
Air enema is performed for ultrasound-confirmed intussusception.
If the intussusception is completely reduced by air enema, the patient should be observed in the ED for 4 hours then given a PO trial.
Air enema can be repeated every 1 hour up to 3 times with monitoring between attempts as long as the intussusceptum continues to reduce, there is no free air, and the patient is stable.
A fellow or attending should be notified if the intussusception is not completely reduced after repeated attempts.