Synopsis
Recognise intermittent bowel ischaemia before classic late signs appear, resuscitate without diagnostic delay and select radiological reduction for stable ileocolic intussusception versus immediate operative care for perforation or volvulus.
- Typical ileocolic intussusception occurs in infancy with episodic crying or drawing up legs, pallor, vomiting and lethargy; a mass or bloody mucus may be absent.
- First-line imaging for a stable suspected intussusception is urgent expert abdominal ultrasound, showing a target or doughnut appearance and assessing perfusion and free fluid.
- Begin surgical involvement and resuscitation before imaging: nil by mouth, IV access, glucose, isotonic fluid, analgesia and nasogastric decompression when vomiting or distension is important.
- Radiological air or hydrostatic enema is both confirmatory and preferred reduction for stable ileocolic disease without peritonitis or perforation, performed with surgical backup.
- Operation is required for instability, peritonitis, perforation, failed enema, non-reducible bowel or a suspected lead point requiring treatment.
- Volvulus often presents with bilious vomiting, but early abdomen and radiograph can be deceptively normal; immediate paediatric surgical contact takes priority.
- Urgent upper gastrointestinal contrast imaging defines malrotation in a stable child, while shock or peritonitis may require direct exploration.
- After successful reduction, observe through the local pathway, restore feeds when safe and provide explicit recurrence advice.
Key red flags
Pain-free intervals do not reassure: intussusception classically produces episodic distress with pallor before continuous pain develops.
Profound lethargy can dominate the presentation in an infant and may be mistaken for sepsis or neurological illness.
Bilious emesis, increasing distension, guarding, shock or acidosis suggests complete obstruction, volvulus or advanced ischaemia.
Red-currant-jelly stool is a late mixture of blood and mucus; waiting for it delays diagnosis.
A pathological lead point is more likely outside the usual infant age, with recurrent episodes or small-bowel rather than ileocolic disease.
Peritonism, free air or cardiovascular instability is a contraindication to routine radiological enema reduction and needs surgery.
Investigation priorities
Confirm intussusception, identify site and assess vascularity, free fluid and a possible lead point.
Management branches
Episodic pain, lethargy, bile or bleeding raises obstruction concern.
- Keep nil by mouth, check glucose, establish IV access and give analgesia and isotonic resuscitation.
- Decompress the stomach when vomiting or distension is significant and contact paediatric surgery.
- Choose urgent ultrasound or contrast imaging from phenotype and stability.
Imaging shows ileocolic disease without peritonitis, perforation or marked instability.
- Correct dehydration and confirm surgical and resuscitation support is available.
- Perform controlled air or hydrostatic enema through the specialist radiology pathway.
- Confirm complete reduction, observe and investigate a lead point when age or recurrence suggests it.