Overview
Definition:
Hydrostatic intussusception reduction is a non-operative therapeutic procedure where saline or air is introduced via the rectum to reduce an intussusception (telescoping of one segment of the bowel into another)
It is the primary treatment for uncomplicated ileocolic intussusception in children
It aims to restore normal bowel patency and prevent complications like ischemia or perforation.
Epidemiology:
Intussusception is the most common cause of bowel obstruction in infants and young children, predominantly affecting those aged 3-36 months
It is more common in males
The ileocolic region is the most frequent site (75-90% of cases)
Recurrence rates vary but are generally low after successful reduction.
Clinical Significance:
Early and accurate diagnosis and timely reduction of intussusception are crucial to prevent bowel ischemia, perforation, and subsequent morbidity or mortality
Hydrostatic reduction, when successful, avoids the risks associated with surgical intervention
Understanding its indications, contraindications, and technique is vital for pediatric surgeons and residents preparing for DNB and NEET SS exams.
Clinical Presentation
Symptoms:
Sudden onset of intermittent, severe, colicky abdominal pain
Child draws legs up during episodes
Vomiting, which may become bilious if obstruction is significant
Stools may be normal initially, then become mucoid and bloody (currant jelly stools) in a later stage
Lethargy or irritability between painful episodes
Fever may be present in advanced cases or if complications arise.
Signs:
Abdominal distension
Palpable sausage-shaped mass in the right upper quadrant or epigastrium (most common)
Tenderness on palpation, which may be diffuse or localized
Signs of dehydration if vomiting is persistent
Rectal examination may reveal blood or currant jelly stool, or the intussusception apex.
Diagnostic Criteria:
Diagnosis is primarily based on clinical suspicion and confirmed by imaging
Classic triad of abdominal pain, palpable mass, and currant jelly stools is pathognomonic but often absent in early stages
Imaging findings of a target sign (ultrasound) or a filling defect with a conical projection (contrast enema) are diagnostic.
Diagnostic Approach
History Taking:
Detailed history of onset, frequency, and severity of pain
Nature of vomiting
Stool characteristics (color, consistency, presence of blood/mucus)
Previous episodes of similar symptoms
Recent viral illness or gastroenteritis
Presence of any chronic medical conditions.
Physical Examination:
Thorough abdominal examination, including inspection for distension, auscultation for bowel sounds, palpation for masses and tenderness, and percussion
Assess hydration status and vital signs
Rectal examination is essential to assess for palpable intussusception, blood, or currant jelly stool.
Investigations:
Abdominal ultrasound is the investigation of choice in most centers due to its safety and accuracy
it typically shows a target sign (concentric rings) or pseudokidney sign
Contrast enema (barium or air) is highly sensitive and specific, demonstrating a filling defect with a convex or concave apex and surrounding contrast
It also serves as a therapeutic modality if reduction is achieved
Plain abdominal X-rays may show signs of obstruction (dilated loops, paucity of gas)
Laboratory investigations typically include CBC, electrolytes, BUN, creatinine, and blood gas analysis for preoperative assessment and to identify complications.
Differential Diagnosis:
Mesenteric adenitis
Gastroenteritis
Appendicitis
Viral illness
Bowel obstruction from other causes (e.g., malrotation with volvulus, adhesions)
Colic
Allergic proctocolitis.
Management
Initial Management:
NPO (Nil per os) status
Intravenous fluid resuscitation to correct dehydration and electrolyte imbalances
Nasogastric tube decompression if significant vomiting or distension is present
Analgesia for pain control
Close monitoring of vital signs and abdominal examination.
Medical Management:
This is primarily a procedural management rather than pharmacological
However, antibiotics are indicated if there is evidence of perforation or sepsis
Pain management with appropriate analgesics is essential.
Surgical Management:
Surgical exploration is indicated for patients with signs of peritonitis, perforation, strangulation, or failed hydrostatic reduction
The goal is to manually reduce the intussusception
If reduction is not possible or if there is gangrenous bowel, resection and anastomosis or stoma formation may be necessary
In children, the ileocecal valve is typically the lead point and may require a gentle manual reduction
Postoperative care includes fluid management, pain control, and gradual resumption of oral intake.
Supportive Care:
Continuous monitoring of hydration status, urine output, and vital signs
Pain management
Nutritional support via parenteral or enteral routes as indicated
Prevention of complications through vigilant observation and prompt intervention.
Complications
Early Complications:
Perforation of the bowel
Hemorrhage
Peritonitis
Sepsis
Recurrence of intussusception (may occur within 24-48 hours if not fully reduced or if lead point remains)
Bowel obstruction from residual edema or incomplete reduction.
Late Complications:
Recurrence of intussusception (weeks to months later)
Adhesions and subsequent bowel obstruction
Short bowel syndrome if extensive resection was required
Malabsorption
Stricture formation at the reduction site.
Prevention Strategies:
Prompt diagnosis and timely hydrostatic reduction can prevent most complications
Identification and management of lead points (e.g., Meckel's diverticulum, lymphoma, polyp) during surgery can reduce recurrence
Careful operative technique during surgical reduction minimizes bowel trauma.
Prognosis
Factors Affecting Prognosis:
Time to diagnosis and treatment
Presence of complications (ischemia, perforation)
Successful reduction (hydrostatic or surgical)
Identification and management of the lead point.
Outcomes:
With timely hydrostatic reduction, the prognosis is excellent with minimal morbidity
Recurrence rates are typically 5-10% but usually manageable with repeat reduction attempts or surgery
In cases requiring resection, outcomes depend on the extent of bowel involved and the presence of complications.
Follow Up:
Close follow-up is recommended for at least 48-72 hours after successful hydrostatic reduction to monitor for recurrence or complications
For surgical cases, follow-up protocols similar to other abdominal surgeries are advised
Patients with identified lead points may require specific long-term follow-up depending on the etiology.
Key Points
Exam Focus:
Hydrostatic reduction is the first-line treatment for uncomplicated ileocolic intussusception in children
Ultrasound is the preferred initial imaging modality
Contrast enema can be both diagnostic and therapeutic
Indications for surgery include peritonitis, perforation, strangulation, and failed reduction
Currant jelly stools and sausage-shaped mass are classic but often late signs
Lead points are important causes of intussusception and recurrence.
Clinical Pearls:
Always perform a gentle rectal examination in suspected intussusception
If performing a hydrostatic reduction, ensure adequate sedation and analgesia
Monitor the child closely during and after the procedure for any signs of compromise
Have surgical backup readily available
Recurrences are common but often manageable non-operatively
Always consider and rule out a lead point, especially in recurrent or atypical cases.
Common Mistakes:
Delaying diagnosis and intervention, leading to bowel ischemia
Performing hydrostatic reduction in the presence of peritonitis or perforation
Inadequate fluid resuscitation and electrolyte correction
Failure to have surgical support readily available during hydrostatic reduction
Over-enthusiastic attempts at manual reduction during surgery leading to iatrogenic perforation.