These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

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To guide PCH Emergency Department (ED) staff with the assessment and management of intussusception.


Intussusception occurs when a section of bowel invaginates into the lumen of the immediately distal bowel, resulting in ischaemia and gangrene of the inner bowel. It most commonly occurs at the ileocaecal junction.


  • Peak age 5-10 months (may occur from 3 months to 5 year old)
  • Most common cause of acute intestinal obstruction in children 6-36 months
  • 60% of cases are < 1 year old and 80-90% are < 2 year old.


  • Perforation of bowel, with peritonitis
  • Necrosis of bowel requiring bowel resection
  • Shock and sepsis
  • Re-intussusception after spontaneous or active reduction.



  • Typically, episodes of sudden intense pain with screaming and flexion of the legs, often associated with pallor
    • Episodes last several minutes and recur at 5-20 minute intervals
    • Episodes may be associated with vomiting (bilious or non-bilious) and/or blood in stools
    • The infant usually looks relatively well between episodes
  • Less commonly, episodes of lethargy, irritability, altered mental status
    • May be mistaken for a child presenting with convulsions or sepsis/meningitis – the child appears floppy and semi-conscious
  • The classical TRIAD of pain, abdominal mass and red currant jelly stool is only seen in < 15% of cases
  • On third of cases present with a history of recent viral illness
  • Recent rotavirus vaccination (there is a small risk of intussusception in infants following the rotavirus vaccination).3,4


  • The child can present as:
    • Pale, lethargic and hypovolemic
    • Abdomen may be distended and tender
    • Palpable abdominal mass (sausage shaped) in the right upper quadrant.
    • The mass can be difficult to palpate
    • Dehydration or shock develops as symptoms progress
    • Vomiting (may become bile-stained if bowel obstruction has occurred)
    • 'Red currant jelly' stool (blood and mucous in stool) is a late sign.


Abdominal X-ray

  • Mainly to look for signs of bowel obstruction or perforation
  • It may be normal
  • Signs of intussusception are:
    • paucity of bowel gas on the right side of the abdomen
    • distended loops of small bowel with air/fluid filled level
    • look for obscured liver edge, crescent sign and target signs
    • free gas if perforated.

Ultrasound (US)

  • Diagnostic investigation of choice – highly sensitive and specific for intussusception (a ‘target’ or ‘doughnut’ sign is classic).

Blood tests

  • If shocked or unwell looking
  • Electrolytes, urea, creatinine, blood gas
  • Full blood count
  • Cross match to be arranged in all circumstances in case surgical intervention becomes urgent.


  • Insert IV cannula and obtain blood tests if required
  • If shocked, correct using IV boluses of 20 mL/kg of sodium chloride 0.9%
  • Nil by mouth
  • If signs of bowel obstruction insert nasogastric tube and leave on free drainage
  • Analgesia:
    • IV morphine. Refer to Morphine Monograph – Medication Management Manual (internal WA Health only)
  • Arrange for an urgent abdominal ultrasound, and urgent surgical review
    • If the abdominal ultrasound is positive:
      • Follow directly by attempted non-operative reduction by means of an air enema unless the surgeon and radiologist agree that air reduction is unsafe and operative treatment is required.
  • Air enema1
    • Contraindications: signs of peritonitis/perforation
    • Antibiotics must be administered prior to the air enema or surgical reduction
    • ED nurse +/- ED doctor should accompany child to radiology to administer IV morphine for analgesia prior to attempted reduction
    • Surgical registrar must be in attendance
    • Performed by an experienced radiologist (up to 95% success rate).
  • Surgical reduction is necessary if there are signs of peritonitis / perforation, or if air enema fails to reduce the intussusception or leads to iatrogenic perforation during the procedure.


  • Complete and record a full set of observations on the observation and response tool and record additional information on the Clinical Comments Chart.
  • Complete a full set of neurological observations if clinically indicated.
  • Minimum of 1 hourly observations should be recorded whilst in the ED
  • Any significant changes should be reported immediately to the medical team
  • Ensure appropriate medication, monitoring, observations, suction, oxygen and emergency equipment is available for patient transfer and reduction procedure
  • Fluid input/output is to be monitored and documented.


  1. Vo N and Sato T (2021) Intussusception in children. UpToDate. Accessed at
  2. Jones' Clinical Paediatric Surgery 7thEdition By: John M. Hutson (Editor), Michael O'Brien (Editor), Spencer W. Beasley (Editor), Warwick J. eague (Editor), Sebastian K. King (Editor) 2015
  3. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook, Australian Government Department of Health, Canberra, 2018,
  4. Health (Notification of Intussusception) Regulations 2007 – Repealed 20 Sept 2017 - HealthNotfctnOfIntussusceptionRegs2007_00-e0-00.docx (

Reviewer/Team: ED HOD, ED Consultants, Consultant General Paediatric Surgery, ED CNM, ED CNS
Last reviewed: Jan 2022

Review date: Sep 2025
Endorsed by:
Nurse Co-director, Surgical Services Date:  Apr 2022

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