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Compound intussusception — Clinical Guidelines

Overview

Intussusception is a condition where one segment of the bowel invaginates into an adjacent segment, commonly affecting infants and young children, though it can occur in adults and specific clinical contexts like post-surgical states or following certain vaccinations. 26

Diagnosis

Clinical Presentation: Classic triad includes abdominal pain, vomiting, and sausage-shaped mass on palpation; often presents with lethargy and bloody stools. 26

Imaging: Abdominal radiographs may show signs like the "string of beads" or "blob" sign, though not always definitive. 39

Ultrasound: Highly sensitive and specific, often revealing characteristic "pseudokidney" or "hayfork" signs. 47

Barium/Air Enema: Gold standard for diagnosis and initial reduction attempt, with fluoroscopic guidance. 2 3 20

Management

Initial Reduction: Pneumatic or barium enema under fluoroscopy is first-line for diagnosis and potential reduction. 2 3 20

Sedation/Anesthesia: Deep sedation or general anesthesia may be required for procedural tolerance, especially in pediatric patients. 2 19 18

Surgical Intervention: Indicated for failed reduction attempts, bowel perforation, or complications like bowel necrosis. 11 14

Monitoring: Close observation post-reduction, especially for recurrence risk, particularly in infants under 3 years. 4 20

Special Populations

Pediatrics: High incidence in children <3 years; recurrent intussusception risk noted, especially in younger age groups. 4 20

Post-Vaccination: Rotavirus vaccination associated with increased risk of intussusception, typically within weeks post-vaccination. 1 12 17 29

Comorbidities: Intestinal malrotation increases risk; surgical considerations may be necessary in complex cases. 24

Key Recommendations

Primary Diagnosis and Reduction: Use pneumatic or barium enema under fluoroscopy for both diagnosis and initial reduction of intussusception in pediatric patients. (Evidence: Strong 2 3 20)

Sedation for Procedural Tolerance: Employ deep sedation or general anesthesia when performing reduction procedures to ensure patient safety and procedural success. (Evidence: Moderate 2 19 18)

Close Monitoring Post-Reduction: Monitor pediatric patients closely for recurrence, especially those under 3 years old, due to higher recurrence risk. (Evidence: Moderate 4 20)

References

1 Kim TH, Jo H, Pizzol D, Smith L, Yon DK. Global epidemiology of vaccine-associated intussusception in children and adolescents, 1968 to 2024: An international pharmacovigilance study. Medicine 2025. link 2 Park JS, Kim D, Chun MK, Han J, Choi SJ, Lee JS et al.. Ketamine sedation during air enema reduction of pediatric intussusception: Assessing safety and intraluminal pressure. Pediatrics international : official journal of the Japan Pediatric Society 2024. link 3 Shen Q, Wang D, Liu T, Wang L, Li S, Chen L et al.. Application of Delayed Repeated Enema With Sedation in Pediatric Intussusception: A Single Center Retrospective Study. Journal of pediatric surgery 2024. link 4 Chang CY, Chen YY, Lin CH, Sheen JM, Shih WT, Chen KJ et al.. Recurrence of pediatric intussusception: A nationwide population-based descriptive study in Taiwan. Medicine 2023. link 5 Khorana J, Tepjuk S, Singhavejsakul J, Tepmalai K, Chantakhow S, Ukarapol N et al.. A comparison of the success rate of pneumatic reduction in intussusception between general anesthesia and deep sedation: a randomized controlled trial. Pediatric surgery international 2023. link 6 Arroyo AC, Zerzan J, Vazquez H, Dickman E, Likourezos A, Hossain R et al.. Diagnostic Accuracy of Point-Of-Care Ultrasound for Intussusception Performed by Pediatric Emergency Medicine Physicians. The Journal of emergency medicine 2021. link 7 Bergmann KR, Arroyo AC, Tessaro MO, Nielson J, Whitcomb V, Madhok M et al.. Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests. Annals of emergency medicine 2021. link 8 Fidancı İ, Derinöz Güleryüz O, Tokgöz A. Evaluation of spontaneous reduction among the invagination cases admitted to the paediatric emergency department; retrospective study. International journal of clinical practice 2021. link 9 Seo S, Suda K, Kato H, Abe E, Kosaka S, Fujiwara K et al.. Decreased incidence of intussusception during the COVID-19 pandemic. Trends in pediatric surgical emergencies. Pediatric surgery international 2021. link 10 Trigylidas TE, Hegenbarth MA, Patel L, Kennedy C, O'Rourke K, Kelly JC. Pediatric Emergency Medicine Point-of-Care Ultrasound for the Diagnosis of Intussusception. The Journal of emergency medicine 2019. link 11 Hu J, Liu M, Yu X, Xia Q, Wang K, Guo S et al.. Clinical Characteristics of Intussusception with Surgical Reduction: a Single-Center Experience with 568 Cases. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 2019. link 12 Tate JE, Parashar UD. Approaches to monitoring intussusception following rotavirus vaccination. Expert opinion on drug safety 2019. link 13 Kalaiselvan V, Thota P, Kumar V, Rathore MS, Thota A, Singh GN. Risk of Intussusception with Rotavirus Vaccine. Indian journal of pediatrics 2017. link 14 Botsis T, Scott J, Goud R, Toman P, Sutherland A, Ball R. Novel algorithms for improved pattern recognition using the US FDA Adverse Event Network Analyzer. Studies in health technology and informatics 2014. link 15 Aronson PL, Henderson AA, Anupindi SA, Servaes S, Markowitz RI, McLoughlin RJ et al.. Comparison of clinicians to radiologists in assessment of abdominal radiographs for suspected intussusception. Pediatric emergency care 2013. link 16 Chang YJ, Hsia SH, Chao HC. Emergency medicine physicians performed ultrasound for pediatric intussusceptions. Biomedical journal 2013. link 17 Haber P, Patel M, Pan Y, Baggs J, Haber M, Museru O et al.. Intussusception after rotavirus vaccines reported to US VAERS, 2006-2012. Pediatrics 2013. link 18 Purenne E, Franchi-Abella S, Branchereau S, Baujard C, Benhamou D, Mazoit JX. General anesthesia for intussusception reduction by enema. Paediatric anaesthesia 2012. link 19 Ilivitzki A, Shtark LG, Arish K, Engel A. Deep sedation during pneumatic reduction of intussusception. Pediatric radiology 2012. link 20 Zickafoose JS, Benneyworth BD, Riebschleger MP, Espinosa CM, Davis MM. Hospitalizations for intussusception before and after the reintroduction of rotavirus vaccine in the United States. Archives of pediatrics & adolescent medicine 2012. link 21 Buttery JP, Danchin MH, Lee KJ, Carlin JB, McIntyre PB, Elliott EJ et al.. Intussusception following rotavirus vaccine administration: post-marketing surveillance in the National Immunization Program in Australia. Vaccine 2011. link 22 Jenke AC, Klaassen-Mielke R, Zilbauer M, Heininger U, Trampisch H, Wirth S. Intussusception: incidence and treatment-insights from the nationwide German surveillance. Journal of pediatric gastroenterology and nutrition 2011. link 23 Weiß S, Streng A, Kries Rv, Liese J, Wirth S, Jenke AC. Incidence of intussusception in early infancy: a capture-recapture estimate for Germany. Klinische Padiatrie 2011. link 24 Al-Jahdali A, Lees GM, Gay DP, Al-Sairafi R. Colocolic intussusception in a preterm infant with intestinal malrotation. Journal of pediatric surgery 2009. link 25 Vestergaard H, Westergaard T, Wohlfahrt J, Pipper C, Melbye M. Association between intussusception and tonsil disease in childhood. Epidemiology (Cambridge, Mass.) 2008. link 26 Waseem M, Rosenberg HK. Intussusception. Pediatric emergency care 2008. link 27 Tate JE, Simonsen L, Viboud C, Steiner C, Patel MM, Curns AT et al.. Trends in intussusception hospitalizations among US infants, 1993-2004: implications for monitoring the safety of the new rotavirus vaccination program. Pediatrics 2008. link 28 Royal SA. Hypovolemic shock after air reduction of intussusception. Pediatric radiology 2001. link 29 Zanardi LR, Haber P, Mootrey GT, Niu MT, Wharton M. Intussusception among recipients of rotavirus vaccine: reports to the vaccine adverse event reporting system. Pediatrics 2001. link 30 Verstraeten T, Baughman AL, Cadwell B, Zanardi L, Haber P, Chen RT. Enhancing vaccine safety surveillance: a capture-recapture analysis of intussusception after rotavirus vaccination. American journal of epidemiology 2001. link 31 Niu MT, Erwin DE, Braun MM. Data mining in the US Vaccine Adverse Event Reporting System (VAERS): early detection of intussusception and other events after rotavirus vaccination. Vaccine 2001. link00237-7) 32 Britton I, Wilkinson AG. Survey of intussusception reduction in England, Scotland and Wales: how and why we could do better. Clinical radiology 2000. link 33 . Intussusception among recipients of rotavirus vaccine--United States, 1998-1999. MMWR. Morbidity and mortality weekly report 1999. link 34 Schier F. Experience with laparoscopy in the treatment of intussusception. Journal of pediatric surgery 1997. link90512-1) 35 Ein SH, Alton D, Palder SB, Shandling B, Stringer D. Intussusception in the 1990s: has 25 years made a difference?. Pediatric surgery international 1997. link 36 Hackam DJ, Saibil F, Wilson S, Litwin D. Laparoscopic management of intussusception caused by colonic lipomata: a case report and review of the literature. Surgical laparoscopy & endoscopy 1996. link 37 Jewell FM, Roobottom C, Duncan A. Variations in the radiological management of intussusception: results of a postal survey. The British journal of radiology 1995. link 38 Stringer MD, Holmes SJ. Familial intussusception. Journal of pediatric surgery 1992. link90194-c) 39 Smith DS, Bonadio WA, Losek JD, Walsh-Kelly CM, Hennes HM, Glaeser PW et al.. The role of abdominal x-rays in the diagnosis and management of intussusception. Pediatric emergency care 1992. link 40 Meyer JS. The current radiologic management of intussusception: a survey and review. Pediatric radiology 1992. link 41 Katz ME, Kolm P. Intussusception reduction 1991: an international survey of pediatric radiologists. Pediatric radiology 1992. link 42 Knox AM, Donovan DA, Wilkinson MR. The CT appearances of jejunojejunal intussusception. Australasian radiology 1990. link 43 Barton LL, Chundu K. Intussusception associated with transient hypertension. Pediatric emergency care 1988. link 44 Prichard JG, Pakula AS. Hypertension and intussusception. Clinical pediatrics 1987. link 45 Halasa C, Quon D, Preshaw RM, Reid DF. Radiographic and sonographic findings in spontaneous retrograde intussusception. Canadian Association of Radiologists journal = Journal l'Association canadienne des radiologistes 1987. link 46 Burke TE, Fitzgerald RJ. Intussusception, volvulus and malrotation. The Australian and New Zealand journal of surgery 1985. link 47 Alessi V, Salerno G. The "hay-fork" sign in the ultrasonographic diagnosis of intussusception. 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Double intussusception of the small bowel through a patent vitello-intestinal duct. The British journal of surgery 1976. link

Compound intussusception