Pneumatic Reduction for Intussusception 
Muse Freneh, Jason Axt 
 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Ileocolic intussusception is one of the most 
common causes of intestinal obstruction in infants 
and toddlers. It occurs when a segment of the bowel 
(intussusceptum) telescopes into an adjacent distal 
segment (intussuscipiens), leading to progressive 
obstruction. 
As the intussusceptum advances further into 
the intussuscipiens through peristalsis, it becomes 
thickened, edematous, and swollen. This process first 
obstructs the lumen, then causes venous congestion, 
followed by arterial compromise, ultimately leading 
to ischemia and necrosis if untreated. 
Primary intussusception—the most common 
form—occurs in the absence of a pathological “lead 
point.” Cases have a seasonal variation, often 
correlating with an increase in viral upper respiratory 
infections and viral gastroenteritis. Some studies 
suggest that up to 50% of cases are linked to prior 
Rotavirus infection. 
Secondary intussusception, which accounts 
for 1.5% to 12% of cases, arises due to an underlying 
pathological lead point. The most common cause is 
Meckel’s diverticulum, though other potential lead 
points include polyps, hemangiomas, ectopic 
pancreatic tissue, the appendix, or other lesions. In 
rare cases, an intestinal tumor serves as a lead point, 
with incidence increasing with patient age. 
 
Clinical presentation 
Intussusception primarily affects children 
between 3 months and 3 years of age, with peak 
incidence occurring between 5 and 9 months. 
The typical presentation includes sudden 
onset of intermittent, crampy abdominal pain, often 
accompanied by leg flexion toward the chest and 
episodes of vomiting that last for a few minutes. 
These symptoms alternate with periods where the 
child appears normal. 
If left untreated, progressive obstruction 
leads to dehydration and lethargy. The classic triad 
of intermittent abdominal pain, a palpable “sausage-
shaped” mass, and “currant jelly” stools is seen in 
less than 25% of cases, primarily in patients with 
delayed presentation. Given this, clinicians must 
maintain a high index of suspicion even in the 
absence of all three signs. 
 
Stool mixed with blood and mucus gives the appearance of 
“currant jelly.”  
 
A less common presentation involves 
transanal protrusion of the intussusceptum, which 
can be mistaken for rectal prolapse. Differentiation is 
simple: inserting a lubricated tongue depressant or an 
examining finger next to the prolapsed tissue. If the 
instrument can be advanced more than 2 cm, 
transanal protrusion of the intussusceptum should be 
strongly suspected. 
Pneumatic Reduction for Intussusception 
Muse Freneh, Jason Axt 
 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Trans-anal protrusion of the intussusceptum results when the 
process of intussusception proceeds far enough that the process 
continues out the anus. Source: 
https://doi.org/10.1016/j.epsc.2020.101405  
 
In resource-limited settings, children often 
present late, frequently with overwhelming sepsis 
and severe electrolyte imbalances, which require 
urgent correction before attempting reduction. 
 
Diagnosis 
Intussusception is primarily a clinical 
diagnosis, based on characteristic symptoms and 
signs. 
However, 
imaging 
is 
essential 
for 
confirmation. 
• Abdominal ultrasound is the gold standard for 
diagnosis, with near 100% sensitivity. The 
hallmark finding is the “target sign”, representing 
concentric layers of bowel within bowel. 
• Additional investigations may be warranted to 
evaluate for electrolyte imbalances, dehydration, 
or sepsis, particularly in cases of delayed 
presentation. 
 
Ultrasound image demonstrating target sign. Source: 
https://radiopaedia.org/articles/target-sign-intussusception  
 
Initial management 
Early and aggressive fluid resuscitation is 
critical in children with intussusception, as 
dehydration is common due to vomiting and third-
spacing of fluids into the edematous bowel. 
• Intravenous fluid resuscitation should be initiated 
immediately. 
• Electrolyte imbalances should be corrected, 
particularly in cases of prolonged illness. 
• Urine output must be adequate before proceeding 
with pneumatic reduction or surgery, as 
hypovolemia increases the risk of cardiovascular 
collapse on induction of anesthesia. 
 
 
In cases where patients present late, with 
sepsis or shock, stabilization should take priority 
over any procedural intervention. 
Children presenting with peritonitis or septic 
shock should undergo immediate resuscitation and 
be taken expeditiously for surgical exploration. 
Both pneumatic and hydrostatic reduction are 
well-documented 
techniques 
with 
comparable 
success rates. However, pneumatic reduction is 
Pneumatic Reduction for Intussusception 
Muse Freneh, Jason Axt 
 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
preferred due to its relative ease of execution and 
lower risk of contamination if perforation should 
occur.  
While some guidelines suggest that a 
symptoms exceeding 48 hours make successful non-
operative reduction less likely, we advocate for an 
attempt at reduction regardless of delay, provided 
there is no septic shock or peritonitis. Even partial 
reduction 
may 
simplify 
subsequent 
surgical 
intervention. 
 
Laparotomy is indicated in cases where: 
• Non-operative reduction fails. 
• The patient is hemodynamically unstable despite 
resuscitation. 
• There are clear signs of bowel gangrene or 
perforation. 
 
The procedure is typically performed in the 
operating room using C-arm fluoroscopy. It is 
possible to follow the progress of reduction with 
ultrasound alone, however this can be a difficult 
technique to master.  
Given the risk of complications, we strongly 
recommend that pneumatic reduction in low-
resource settings be conducted in an environment 
where immediate surgical backup is available.  
Pneumatic reduction is often well-tolerated 
and can be performed with the child awake or under 
light sedation. The stepwise approach to the 
procedure is outlined below. 
 
Materials. 
• Manual sphygmomanometer system with a “Y” 
connector 
• Large size foley catheter (E.g. 20 Fr) 
• 20 mL Syringe 
• Large 
bore 
intravenous 
catheter 
for 
decompression in case of perforation with 
tension pneumoperitoneum 
• Lubricant gel 
• Fluoroscopy machine 
 
 
Sphygmomanometer, inflator cuff, and “Y” connector, shown 
before assembly. A mercury sphygmomanometer, or any other 
manual device that shows pressure, is also acceptable 
 
 
The 
assembled 
foley 
catheter, 
“Y” 
connector 
and 
sphygmomanometer  
 
Pneumatic Reduction for Intussusception 
Muse Freneh, Jason Axt 
 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Steps: 
1. The procedure can be done awake or with light 
sedation. 
 
The patient is positioned at the edge of the operating table in a 
lithotomy position with the hip and knees flexed at 90 degrees. 
 
2. 20 Fr Foley catheter is placed in the anus and 
balloon inflated with 20-30cc of air to create an 
airtight seal. We prefer air over water for 
inflating the balloon, as it is easier to deflate in 
case of respiratory compromise due to abdominal 
distention 
3. The catheter is connected to the “Y” connector of 
the sphygmomanometer system 
 
An assistant will compress the buttocks on either side while 
pulling lightly on the catheter to create an airtight seal.  
 
4. A single shot x-ray is taken with a fluoroscopy 
machine viewing from the pelvis to the 
diaphragm. 
5. Air is instilled using the sphygmomanometer 
device keeping the pressure between 80 and 
100mmHg (no more than 120mmHg) while 
directly observing the meniscus move with 
continuous fluoroscopy. 
 
Meniscus indicated by the arrow moves with instillation of air. 
 
6. Air can be instilled according to the rule of threes: 
three minutes at a time, with 3-minute breaks in 
between and 3 different attempts. 
Pneumatic Reduction for Intussusception 
Muse Freneh, Jason Axt 
 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Between reduction attempts, residual air should be evacuated 
either manually or via the Foley catheter by gently compressing 
the abdomen while maintaining rectal patency with the other 
hand.  
7. A sudden increase in abdominal distention with 
failure to evacuate air strongly suggests bowel 
perforation.  If perforation occurs, air can rapidly 
accumulate in the peritoneal cavity, leading to 
tension 
pneumoperitoneum 
causing 
severe 
respiratory compromise and death if not 
promptly managed. Immediate decompression 
should be performed by inserting a large-bore 
intravenous cannula through the abdominal wall. 
The right upper quadrant is preferred, as it is 
where free air tends to accumulate and has a 
lower risk of bowel injury. A rush of escaping air 
confirms the diagnosis.  Once perforation is 
confirmed, the child should undergo urgent 
exploratory laparotomy. 
8. Reduction is continued until the meniscus moves 
from the left lower quadrant all the way to 
ileocecal valve and complete reduction is 
confirmed with air visibly entering the small 
bowel.  
9.  If reduction is successful, the patient can be 
transferred to the ward and feeding attempted. 
Patients are typically observed overnight due to 
challenges accessing healthcare in case of 
recurrence or incomplete reduction. If the 
attempt was unsuccessful, reduction can be 
attempted up to 3 times at 4–6-hour intervals. 
After three unsuccessful attempts, an exploration 
should be performed.   
 
 
Complete reduction of intussusception is confirmed by sudden 
influx of air into the small bowel in the central portion of the 
abdomen as shown above. 
 
10. After reduction, patients typically have a 
dramatic improvement in condition. A patient 
who continues to vomit, has a distended 
abdomen, or is unable feed should prompt 
concern for incomplete reduction or recurrence. 
Perform a repeat ultrasound. Reduction can be 
performed up to three times.  A fourth 
intussusception event suggests a pathologic lead 
point and warrants an abdominal exploration. 
 
Pitfalls 
• Failure to form an airtight seal will reduce 
chances of reduction. 
• Failure to recognize and address a perforation 
and pneumoperitoneum may cause respiratory 
compromise and even death. As explained above, 
remove the Foley catheter and perform needle 
decompression in the right upper quadrant of the 
abdomen.  
Pneumatic Reduction for Intussusception 
Muse Freneh, Jason Axt 
 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
• Failure to have a large bore intravenous cannula 
nearby at the time of the procedure, leading to 
“frantically searching” for it when it is needed.  
• If a patient does not exhibit rapid reduction of 
symptoms, suspect incomplete reduction or 
recurrence. 
 
Muse Freneh, MD 
AIC Kijabe Hospital 
Kenya 
 
Jason Axt MD FACS FCS(ECSA) 
Indiana University 
Moi University School of Medicine 
Kenya 
 
March 2025 
