Pediatric intussusception: innovative reduction

Introduction

Intussusception, a condition where one segment of the intestine telescopes into another, is a leading cause of acute abdomen in children, particularly those under 3 years old (1). The annual incidence is reported to be 0.33–0.71 per 1,000 (2,3). Timely diagnosis and intervention are essential to prevent severe complications such as bowel ischemia, necrosis, and perforation (4). The initial treatment typically involves non-surgical reduction techniques, most commonly air enema under X-ray guidance or hydrostatic reduction under ultrasound guidance, with early success rates exceeding 85% (5,6). Cases where enema reduction is unsuccessful require surgical intervention, which highlights the urgent need to improve enema success rates, especially in challenging cases. This report highlights the role of sustained intraluminal pressure and external manipulation during air enema reduction.

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the Ethics Committee of the Hainan Women and Children’s Medical Center (HNWCMC MEC No. 85 of 2024) and with the Helsinki Declaration (as revised in 2013). The patient’s legal guardian agreed to the use of the patient’s blood and imaging examinations for clinical research, and provided written informed consent. A copy of the written consent is available for review by the editorial office of this journal.

A 14-month-old boy presented with 8 hours of paroxysmal crying, vomiting of gastric contents, reduced urine output, and 1 episode of bloody stool. Examination revealed decreased skin elasticity, a sunken fontanelle and eye sockets, tearless crying, and a palpable sausage like mass in the abdomen. Ultrasonography confirmed intestinal intussusception (Figure 1). Admission tests showed positive fecal occult blood, white blood cell count of 14.9×10⁹/L, neutrophil count of 11.8×10⁹/L, C-reactive protein at 6.28 mg/L, D-dimer at 546 ng/mL, and prealbumin at 15.7 mg/dL. All other blood biochemistry results were normal. Following fluid resuscitation, air enema reduction was attempted under X-ray guidance, starting at 6.0 kPa. Despite a gradual reduction to the cecum, pulsatile pressure at 12.0 kPa for 5 minutes showed no passage (Figure 2). After a brief pause, during which only a small amount of gas was expelled, deep and repetitive pressure was applied to the right lower abdomen for 30 seconds. A subsequent X-ray showed that the intussusception shadow in the ileocecal region had disappeared (Figure 3). A follow-up ultrasound was conducted 8 hours after the air enema, showing no recurrence of intussusception. The patient began oral liquid feeding, had normal bowel movements, and was discharged after 37 hours in the hospital. In this challenging case, retaining intraluminal gas at a certain pressure for external manipulation was beneficial for successful reduction.

Figure 1 Typical signs of sleeve sheath and concentric circles revealed the presence of intussusception.

Figure 2 X-ray image before applying pressure to the right lower abdomen. The red arrow indicates the location of the intussuscepted bowel.

Figure 3 X-ray image after repeated and deep pressure on the right lower abdomen for 30 seconds. The red arrow shows the successful reduction of the intussusception.

Discussion

Intussusception is a pediatric emergency that demands prompt diagnosis and treatment. In this case, the patient presented with paroxysmal crying, vomiting, and bloody stool—symptoms that strongly indicate intussusception, although not all patients exhibit this classic triad (7,8). Ultrasonography confirmed the diagnosis by identifying the characteristic “sleeve” and “concentric circles” signs, which highlighted that it is a straightforward and effective diagnostic method (9,10). The presence of vomiting and significant dehydration suggested that reduction might be difficult. Initial fluid resuscitation effectively addressed the dehydration and prepared the patient for air enema reduction. Importantly, fluid resuscitation before the procedure does not reduce the likelihood of a successful reduction (11).

Air enema is a primary treatment for pediatric intussusception, with a success rate of over 85% (5,11). However, some cases do not resolve with this method. Improving the success rate of air enema could greatly benefit patients with difficult-to-reduce intussusception. Methods to improve enema success rates include performing repeat air enemas (12,13) or conducting the procedure under sedation (14). For patients with difficult-to-reduce intussusception, these approaches can enhance the likelihood of successful reduction.

In the case presented, reduction failed at 12.0 kPa (15), leading to the use of an innovative approach that combined air enema with external manual manipulation. This technique requires maintaining intraluminal gas pressure while applying progressively deeper and repetitive external pressure to the abdomen, which facilitates successful intussusception reduction. The success of this approach highlights its potential when standard air enema reduction proves challenging. The application of external pressure, in conjunction with sustained intraluminal pressure, can improve reduction efficacy, especially in refractory cases. This method reduces the need for surgical intervention, thereby minimizing associated risks and healthcare costs. A follow-up ultrasound 8 hours post-procedure confirmed no recurrence, further validating the method’s effectiveness.

Studies have shown that external manual reduction of pediatric intussusception has a success rate of up to 80% and is considered safe, with no complications reported during follow-up (16). Our approach, which combines air enema with external manual manipulation, achieved successful reduction in challenging cases, highlighting the feasibility of this method. This case also underscores the potential need for refining non-surgical reduction protocols for intussusception. Incorporating sustained intraluminal pressure and external manipulation in refractory cases could improve non-surgical success rates, although further research and clinical trials are required to confirm this approach.

In summary, this case underscores the potential advantages of innovative non-surgical techniques in managing pediatric intussusception. Ongoing exploration and refinement of these approaches are essential for improving treatment strategies and outcomes in pediatric patients.

Acknowledgments

Funding: This study was supported by the Hainan Provincial Clinical Medical Center (No. QWYH202175).

Footnote

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-24-668/coif). Both authors report that this study was supported by the Hainan Provincial Clinical Medical Center (No. QWYH202175). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the Ethics Committee of the Hainan Women and Children’s Medical Center (HNWCMC MEC No. 85 of 2024) and with the Helsinki Declaration (as revised in 2013). The patient’s legal guardian agreed to the use of the patient’s blood and imaging examinations for clinical research, and provided written informed consent. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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