The first therapeutic measure is the fluid resuscitation of the baby together with nasogastric tube placement if there is vomit. The intussusception can be reduced by radiologic contrast enema or by intervention. The removal of the PLP is required in case of “secondary forms.” Medical treatment can be used before, along with, and after radiologic reduction, and it consists of steroid administration in case of lymphoid hyperplasia and Schonlein-Henoch purpura. Steroids seem to modulate intestinal immunological activity and reduce the bowel edema in acute forms.

Patients who do not need immediate surgery (signs of intestinal perforation, peritonitis, or free intra-abdominal air) are eligible for enema reduction (hydrostatic or pneumatic). Radiologic reduction is effective in 90 % of cases [4, 5]. Pneumoenema is safe, quick, and easy to perform and should be attempted in all children with intussusception. It is performed with a Foley catheter inserted into the rectum with the balloon inflated. The buttocks are taped, and air is used to create a pressure of 120 mmHg for 5 min. The procedure has been effective where the air fills into the terminal ileum even if sometimes the passage of air is not associated with complete reduction. Hydrostatic barium enema reduction under fluoroscopic guidance is the preferred option in many centers. Barium enema shows the “crab’s claw sign” related to the passage of contrast between the layers of the intussusception. Once again, the column of barium exerts a pressure of 120 mmHg that is held for 3–5 min. The passage of barium in the terminal ileum indicates successful reduction. The risk of intestinal perforation exists for both the procedures (<1 %) with the difference that barium in the peritoneal cavity leads to intense inflammatory response. After the reduction, the baby should be kept for observation in hospital for some time with intravenous fluids. Antibiotics should be continued in case of difficult reduction or fever. When there is intestinal obstruction, the nasogastric tube is kept until gas passes freely through the intestine.

Recurrent intussusception is described in 5–10 % of cases after enema reduction, mostly within 72 h [4]. Some authors suggest performing maneuvers to improve radiologic reduction rates: steroid administration, smooth muscle relaxants and sedation, transabdominal manipulation, and delayed repeat enema. The rationale for repeat enema lies in the evidence that 10 % have already been reduced at surgery and 40 % are easily reduced. Criteria for delayed enema (after 2–4 h) are onset of symptoms <36 h, temperature <38°C, pulse rate <150/min, the movement of the intussusception, and asymptomatic patients.

Surgery is required when enema reduction fails. Classical operation is performed by laparotomy (small right-sided transverse incision). The intussusception mass is palpated and is brought outside the wound, and the reduction is attempted by exerting gentle and persistent pressure at its distal end (constant pinching, squeezing like a tube of toothpaste, or milking backward in retrograde fashion through the wall of the intussuscipiens) (Fig. 21.3). The index finger can be inserted into the intussusception to enlarge the space between the intussuscipiens and intussusceptum. The intestine appears edematous, but its aspect improves with irrigation with warm saline solution. Ischemic segments should be removed avoiding long resections (reduction should be always attempted as much as possible). Some colleagues at the end of the manual reduction perform appendectomy. Laparoscopic reduction has been described as an effective alternative with reduced scarring, adhesions, pain, and hospitalization length although its role is still questioned (Fig. 21.4) [6, 7]. Feeding is resumed shortly after surgery in cases without resections. Antibiotic prophylaxis is recommended. Surgical complications are described in 14 % of cases: wound infection and dehiscence, intestinal obstruction for adhesions, and perforation. Delay in diagnosis is the main factor related to morbidity and mortality. The latter has rapidly declined to less than 1 % in developed countries.