Intestinal Obstruction
A 5-year
Retrospective Study in 2nd March Hospital, Sebha
Khalifa.
M. Alayat, Amer T. Irhuma * Mahmoud H. A. Milad ,** Mehrez . M. Ibrahim,* A.
Zain,*
,*
Maher Hamed,*
Summary:
95 cases of intestinal obstruction were
studied retrospectively over a period of 5 years. Obstruction due to hernia
account for 43% of the cases. Adhesions account for 32% of cases secondary to
appcndicectomy, trauma and pelvic surgery. Strangulation account for 7% of
cases. Conservative treatment was successful in 23% of cases, most of them due
to adhesions. Mean hospital stay was 7.4 days. Morbidity was 5.2% Mortality was
5.2%.
Introduction:
Improvement in fluid and electrolyte management had
led to decline in the mortality rate in intestinal obstruction, but still
considerable morbidity and mortality exist which makes early recognition,
prevention, and early treatment of strangulation of critical importance.1,2
However controversy persist in those cases with non-strangulating
intestinal obstruction regarding the indication for surgical versus
conservative management and more specifically in what constitutes the
responsible delay in the timing of operative intervention.3
Some authors4,5,6 advocate early surgery
for small intestinal obstruction, and consider a trial of tube decompression
only to be a source of delay in surgical treatment which result in higher
mortality and morbidity rate along with longer hospital delay. Others7,8
report a high rate of
successful tube decompression.
For
patients with small bowel obstruction we find surgical treatment unnecessary in
many patients who can be treated without it. It is not surprising to note that
those who stress on early surgical approach usually report a high incidence of
strangulation, when compared with authors who advocate conservative approach.7
This suggests that different groups arc dealing with different aspects of the
same disease.
Materials and Methods:
Medical
records of patients treated at 2nd
March Hospital in Sebha from 1995-2000 with intestinal obstruction were
reviewed. Readmission occurred in 2 cases
The
diagnosis of intestinal obstruction was established from the presence of
nausia, vomiting, constipation with characteristic abdominal pain and on the
previous history of episodes of intestinal obstruction, with physical findings
of abdominal distention and abnormal bowel sounds and dilated loops of
intestine and for air fluid levels by X-ray.
Medical
records reviewed for 1- aetiology 2- treatment 3- recurrent episodes 4-
presence of strangulation 5- complications 6- hospital stay.
Results:
Etiology
59 cases 62% occurred in male
36 cases 38% occurred in female
41 cases 43% due to hernia
The types
of hernia were 28 inguinal, right inguinal were 18 and left inguinal hernia
were 10
Umbilical 5
Incisional 1
Paraumbilical 6
Epigastric I
Paraumbilical 6
Epigastric I
Adhesions
accounted for 32 cases 33%
Tumours 8
cases
Intussusception
3 cases
Volvulus
8 cases (4 of them were due to small intestine.
3 cases
in the sigmoid and I case of caecal volvulus.
Hirschsprungs
disease 1 case
Mesenteric
vascular occlusion in 2cases
Large bowel
obstruction occurred in 13 cases l4% (8 cases due to carcinoma, 4 cases of
volvulus and case of hirschsprugs disease.
*
Department of General Surgery, Faculty of Medicine, Sebha University , Libya
** Department of Diagnostic
Radiology, Faculty of Medicine, Sebha
University , Libya
Symptoms
and Physical findings:
The commonest
symptom was vomiting, which was recorded in most cases of obstruction. And
characteristic abdominal pain was a more constant symptom in adhesion than
hernia. Constipation was recorded in only 4 cases of hernia and was a main
symptom in adhesion; also distension was recorded only in 3 cases of hernia and
was also more common in adhesion, volvulus and ca.colon.
Treatment:
Surgical
treatment was done in all but one case of hernia and was umbilical while
operation was done in only 10 cases of adhesion and 22 cases were treated
conservatively. Bowel resection was done in 4 cases of hernia, one of them died
and all were paraumbilcal, while none of the cases of adhesion treated
surgically ended by resection. Surgery performed in all cases of volvulus and
3of them ended by resection. Only half the cases of tumours underwent surgical
treatment; the rest were transferred to other hospitals on request; also the
case of hirschsprung’s was transferred. Three cases of intussusception
underwent surgery without resection, and one case of mesenteric vascular
occlusion was operated and resection performed. The overall number of cases
treated surgically were 66 cases (69.5%).
Hospital stay:
Mean hospital
stay was 7.4 days for cases of adhesional intestinal obstruction; the mean
hospital stay for patients treated by conservative way was 4.5 days and for
cases treated surgically it was 10 days.
Complications:
Complications
accounted for 5.2% and ranged between wound infection 4 cases, intestinal
fistula 2 cases and intestinal obstruction due to technical error l case.
Discussion:
Still hernia
is the most common cause of intestinal obstruction as mentioned in many reports
from developing countries.9,10 On the other hand in the developed
countries obstructed hernia is declining in the list of the causes of
intestinal obstruction and adhesions becoming the 1st of
obstruction.11
Carcinoma is
the major cause of large bowl obstruction followed by volvulus which is the
same percentage in other series.11
Appendecectomy,
colorectal carcinoma and other pelvic procedures are the most important causes
of intestinal adhesions
Some authors
suggest that suture size rather than tissue reactivity is the paramount factor
in the induction of adhesions.12 Others suggest that suture tention
is more important than suture material and suggest avoiding peritonial closure
altogether.13
Considering clinical features our series is in general
agreement with other reports3
and vomiting is the most constant clinical feature.
Several
reports have pointed out that early recognition of obstruction with
strangulation plays a crucial role in determining morbidity and mortality.
Surgery should be performed in the presence of the slightest suspicion of
strangulation. Stewardson14 said that in the absence of all clinical
findings in strangulation (leukocytosis, fever, tachycardia, signs of
peritoneal irritation) a period of observation is safe.
Morbidity and Mortality:
Morbidity
occurred in 5.2% of cases the most frequent complication being wound infection.
Mortality was
52% and occurred in 5 cases which is low compared with other series. Bizer8
et al, reported a mortality of 6.7% and Shannon15 (1968) showed a
mortality rate of 10%.
In our study
no case of intestinal obstruction due to adhesion died whether treated by
surgically or conservatively, and since 22 cases were treated by conservative
treatment compared with 10 cases by surgical treatment, enough time may be
allowed to patients of intestinal obstruction due to adhesions to correct their
fluid and electrolyte imbalance and to decompress the bowel and observe the
response of the patient. This time may be prolonged to 48 hours safely and to
extend this period if there are no signs of peritoneal irritation, no fever,
and no raised WBC. In the series of Wolfson et al, long tube decompression was
successful in the avoidance of surgical procedures in 2/3 of patients with
intestinal obstruction due to adhesions.
Bizer in a
report of 405 patients recommends an observation period of 48-72 hours using
conservative management for mechanical obstruction thought to be secondary to
adhesions, when there are no signs of strangulation.
Brolin3
in a series of a partial small intestinal obstruction reported 88% successful
management with tube decompression. In our series successful management by
conservative way occurred in 22 cases of the 32 cases of intestinal obstruction
thought to be secondary to adhesions and this forms 68% of cases which is not
much different from other series.
On the other
hand surgical treatment as early as the general condition of the patient
permits and certainly within the first 6 hours of admission is advocated for
patients with irreducible external hernia causing obstruction and for patients
with signs of peritoneal inflammation and suspected strangulated bowel.
Conclusion:
1. Conservative management was successful in 68% of
patients with intestinal obstruction secondary to adhesions.
2. Conservative measures are strongly
recommended for recurrent episodes of bowel obstruction due to adhesions.
3. Mortality was nil in all cases of
intestinal obstruction secondary to adhesions whether treated by conservatively
or by operation.
4. In cases of hernia all the cases ended by
resection were secondary to paraumbilical hernia.
5. Only
one case of intestinal obstruction was secondary to incisional hernia.
References:
1. Silen W, Hein
M F, Goldman L. Strangulation obstruction of the small intestine. Arch Surg
1962. 85: 137145
2. Sarr MG, Bulkely GB, Zuidema GD. Preoperative
recognition of intestinal strangulation obstruction Am J Surg 1983; 145(1
):176-182.
3. Brolin ER.
Partial small bowel obstruction. Surgery 1984; 95(2):145-149.
4. Becker WF,
Intestinal obstruction. An analysis of 1OO7 cases. South med J, 1955; 48:
41-46.
5. Hofstetter SR. Acute adhesive obstruction of small
intestine. Surg Gynaecol Obstet. 1981; 152: 141-144.
6. Turner DM, Groom RD. Acute adhesive obstruction of
the small intestine. Am Surg. 1983; 49(3):126-130.
7. Wolfson PG, Bower GG, Gerlent IM, Kreel l, A
8. Bizer LS, Liebling RW, Delang HM, Gliedman ML.
Small bowel obstruction Surgery, 1981;89 (4): 408-413.
9. Mc Adam I W J. A three year review of intestinal
obstruction Malago hospital, Kampala ,
Uganda E Afr Med J, 1961;38:538.
10. Brooks VEH, Butler A. Acute intestinal obstruction
in Jamaica
11. Wagensteen OH. Intestinal obstruction.
12. Holtz G. Adhesion induction by suture of tissue
reactivity and caliber.
13. Ellis H. The cause and prevention of post
operative intraperitoncal adhesions. Surg Gynecol obstet, 1971; 133 :497-511.
14. Stewardson
RH, Bombcck TC, Nyhus ML. Critical operative management of small bowel. Ann
Surgery, 1978;1 87(2):89-193.
15. Shannon R. Strangulation intestinal obstruction, a
review of 115 cases. Astr. N. Z. J Surg, 1968 ;38:21.
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