Clinical Study Of Mechanical Small-Bowel Obstruction In Children In Kashmir

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1 ISPUB.COM The Internet Journal of Surgery Volume 28 Number 2 Clinical Study Of Mechanical Small-Bowel Obstruction In Children In Kashmir M Mir, M Bucch, U Younus, G Sheikh, B Bali Citation M Mir, M Bucch, U Younus, G Sheikh, B Bali. Clinical Study Of Mechanical Small-Bowel Obstruction In Children In Kashmir. The Internet Journal of Surgery Volume 28 Number 2. Abstract Background and Objectives:The study has been conducted with the aim to ascertain etiology and to analyze the presentation, diagnosis and management of mechanical bowel obstruction in children of the Kashmir valley in view of the higher rate of admission of children with small-bowel obstruction due to worm bolus in our hospital and subsequent high economic burden on the state.design and Setting:Prospective study in 980 children with small-bowel obstruction.patients and Methods:The study included 980 consecutive children under the age of 14 years with small-bowel obstruction who reported to the surgical department of this hospital over a period of five years. After a detailed history and clinical examination, laboratory investigations radiological and sonological assessment, the diagnosis was made in each patient. On the basis of clinico-radiological grounds, conservative or operative management was decided. Data collected was tabulated and subjected to appropriate statistical analysis.results: In our study of 980 children with small-bowel obstruction; males and females were almost equally affected with a male-to-female ratio of 1:1.187 and there was a rural preponderance with a rural-to-urban ratio of 1:0.41. The mean age of the children was years. The cause of obstruction included round worm obstruction in 756 patients (77.14%), adhesion obstruction in 105 patients (10.71%), intussusception in 70 patients (7.14%), obstructed hernia in 21 patients (2.14%), congenital bands in 21 patients (2.14%) and enterogenous cyst in 7 patients (0.71%). Operative management was needed in 644 (65.71%) patients and 336 (34.28%) were managed conservatively.conclusion: Small-bowel obstruction due to ascariasis constituted the major cause of intestinal obstruction leading to considerable morbidity in children of the valley of Kashmir. Hence, efforts should be made to eradicate ascariasis in endemic areas through proper sanitation, hygiene and use of antihelminthics. INTRODUCTION Mechanical small-bowel obstruction is a common surgical emergency and is a frequently encountered problem in abdominal surgery1. It constitutes a major cause of morbidity and financial expenditure in hospitals around the world2. Intestinal obstruction belongs to the severe conditions requiring a quick diagnosis as well as an immediate rational 3 and effective therapy. Accurate easy recognition of intestinal strangulation in patients with mechanical smallbowel obstruction is important to decide on emergency surgery or to allow safe non-operative management of carefully selected patients. One should embrace the philosophy of Never Let the Sun Set or Rise towards the treatment for the patients with small-bowel obstruction. Intestinal obstruction is responsible for approximately 20% of surgical admissions for acute abdominal conditions.4,5the small bowel is involved in 60-80% of cases of intestinal obstructions.5in spite of advances in imaging and better understanding of pathophysiology of small bowel, its obstruction is still frequently misdiagnosed5. Despite advances in the treatment of this condition, the attendant mortality is still high and remains in the range of 5-11%6. Small-bowel obstruction is the commonest surgical 7 emergency encountered in childhood. The usual causes being intussusceptions, volvulus, adhesions or bands, obstructed hernias and worm obstruction. Intussusception8ranks high as an acute surgical catastrophe in infancy and early child hood. The pathological leading points are polyps, lymphnodes, Meckel s diverticula and intestinal duplications. Hernias9usually give rise to intestinal obstruction when incarcerated. Among hernias in children, inguinal hernias are common and when obstructed there is a high chance of strangulation or gangrene. Ascaris lumbricoides is the most common intestinal parasite 10 encountered in India. Worm obstruction due to ascariasis is one of the most common causes of intestinal obstruction in children. Ascariasis remains a formidable problem in India, as a study in India has shown that more than 70% of children 1 of 8

2 have round worm ova in their stool samples10. In Kashmir valley, the incidence of ascariasis was observed as 85.1% of the total helminthic and protozoal infested cases. It affects mainly children from rural areas, low-income groups whose 10 standard of public health and personal hygiene is low. It is the big mass of worms which causes mechanical bowel 11 obstruction in the small intestine. Patients with partial small-bowel obstruction may be treated conservatively with resuscitation and tube decompression alone12,13. The most important complication which has been constantly bothering the surgeons in intestinal obstruction is strangulation, where surgical intervention becomes mandatory. Certain criteria have been proposed for the surgical intervention in patients with intestinal obstruction, especially ascaridial obstruction. The two important ones being Dayalan s and Louw s criteria. Figure 2 Table 2: Sex distribution of patients with mechanical smallbowel obstruction Figure 3 Table 3: Demographic distribution of patients with mechanical small-bowel obstruction PATIENTS AND METHODS This prospective study included 980 consecutive children under the age of 14 years with small-bowel obstruction who reported to the Department of General Surgery, Government Medical College, Srinagar, over a period of five years from 1stJune 2006 to 31stMay Patients with adynamic obstruction, age >14 years and large-bowel obstruction were excluded from the study. After a detailed history and clinical examination, laboratory investigations, radiological and sonological assessment, the diagnosis was made in each patient. On the basis of clinico-radiological grounds, conservative or operative management was decided. Data collected was tabulated and subjected to appropriate statistical analysis. Figure 4 Table 4: Presenting symptoms of mechanical small-bowel obstruction in patients Figure 1 Table 1: Age distribution of patients with mechanical smallbowel obstruction More than one symptom was present in most of the patients. Mean age of patients was years. 2 of 8

3 Figure 5 Figure 8 Table 5: Signs of mechanical small-bowel obstruction in patients Table 8: Type of mechanical small-bowel obstruction in patients Figure 9 Most of the patients revealed more than one sign. Figure 6 Table 6: Etiology of small-bowel obstruction in patients Figure 7 Table 7: Management strategies used in patients with small bowel obstruction 3 of 8 Figure 1: Small-gut gangrene secondary to worm obstruct ion

4 Figure 10 Figure 12 Figure 2: Ileocaecal intussusception Figure 4: Abdominal X-ray with multiple air-fluid levels Figure 11 Figure 3: Band causing obstruction RESULTS In our study of 980 children with small-bowel obstruction, males and females were almost equally affected with a maleto-female ratio of 1:1.187 and there was a rural preponderance with a rural-to-urban ratio of 1:0.41. The mean age of the children was years. The causes of obstruction included round worm obstruction (figure 1) in 108 patients (77.14%), adhesion obstruction in 105 patients (10.71%), intussusception (figure 2) in 70 patients (7.14%), obstructed hernia in 21 patients (2.14%), congenital bands (figure 3) in 21 patients (2.14%) and enterogenous cyst in 7 patient (0.71%). Abdominal pain was the predominant symptom in 82.14% of the patients followed by vomiting in 74.28% and constipation in 62.14%. Abdominal tenderness was the most frequent physical sign in 74.28% followed by tachycardia in 68.57% and abdominal distension in 59.28%. Plain abdominal radiography (figure 4) suggested the diagnosis in 80% of cases. Most of the patients (59.78%) had strangulation obstruction and 40.22% had simple obstruction. Among those with strangulation obstruction, 61.82% had viable gut and 38.18% had non-viable gut. Operative management was needed in 92 (65.71%) patients and 48 (34.28%) were managed conservatively. DISCUSSION In our series of 980 patients, 315 (32.14%) presented in the 4 of 8

5 age group of 0-2 years and the incidence decreased with increase in age (Tables 1 & 2). A similar decreasing trend was observed in the study by Rao et al.7and the maximum of cases in his study belonged to the age group of 0-2 years. The mean age in our study was years, which is 16 almost the same as reported by Villamizar et al. who recorded a mean age of 4.6 years. In our series of 980 patients (Tables 1 & 2), 448 (45.71%) were males and 532 (54.29%) were females. These results correlate well with 16 those noted by Villamizar et al. who reported figures of 44.8% males and 55.2% females. In our study (Table 3), 693 (70.71%) patients belonged to rural and 287 (29.28%) to urban areas. Thus forms a rural-to-urban ratio of 1:0.41. This difference seems to be due to rampant ascariasis in the rural population, the reason being lack of health education, poor hygiene and sanitation, poverty and low standard of living. In our study (Tables 4 & 5), the predominant symptom was abdominal pain (82.14%) followed by vomiting (74.28%), constipation (62.14%) and other symptoms with less frequencies. Our findings are at par with those reported by Brolin et al.12, Budhraja et al.17and Mucha1. Abdominal pain was predominantly colicky in nature to start with and in the umbilical region, radiating to the whole abdomen (602 of 805, i.e %). While continuous type of pain was present in 203 of 805 patients, i.e %, vomiting was one of the commonest symptoms in our study present in 74.28%, particularly with reference to ascaridial obstruction, as this form of obstruction topped the list of etiology of smallbowel obstruction in our study. Of the patients with ascaridial obstruction, 469 of 728 patients (64.24%) had history of vomiting of worms. Our findings are at par with Villamizar et al.16who also reported history of vomiting of worms in 49% of patients of ascaridial obstruction. Bleeding per rectum or its presence on the examining finger was seen in 91 of 980 patients (9.28%), out of which 77 had gangrenous small bowel and 14 had acute intussusceptions. Thus it is important to perform digital rectal examination of every patient of small-bowel obstruction to rule out or to support the diagnosis of the above mentioned etiological factors. Pyrexia (>100F) was present in 147 of 980 (15.0%) patients in our study. It was present in 98 of 385 (25.45%) patients with strangulation of 49 of 259 (18.91%) with simple obstruction. Our findings were almost the same as 18 those observed by Shatila et al. who reported figures of 24% and 19%, respectively. In our study, the physical sign most frequently present was abdominal tenderness (74.28%) followed by tachycardia (68.57%). These were at par with those observed by Lefall et al.19who reported abdominal 5 of 8 tenderness in 82% and tachycardia in 71%. As in their study, nothing was gained from these clinical findings in differentiating simple from strangulation obstruction of small bowel in our study. Various clinical criteria have been described to establish that19,20. In our study, most of these criteria were present in simple obstruction as well. In our study, direct tenderness was present in 74.28%, rebound tenderness in 9.28%, tachycardia in 68.57%, fever in 15.0% and bowel sounds were absent in 19.28%. Strangulation obstruction of the small bowel was established in 59.78% in our study. It is quite evident that the majority of these clinical criteria like rebound tenderness, tachycardia, fever, and absent bowel sounds were not seen in all patients of strangulation obstruction nor were they absent in all cases of simple obstruction. Therefore, in the majority of cases in our study, differentiation between simple and strangulation obstruction on clinical grounds was not possible and was confirmed only after surgery. Similar conclusions were drawn by Shatila et al., Sarr et al. and Silen et al.. In our study, plain abdominal radiography remained the first step in diagnostic evaluation of the patients with suspected smallbowel obstruction. Both standing and lying-down films were taken in all the patients and diagnosis was suggested in 80% (784 of 980). Our observations are almost at par with those 22 of Suri et al. where plain radiography of the abdomen was able to diagnose 77% of patients. In our study (Table 6), ascaridial obstruction (round worms) was the most common etiology occurring in 756 of 980 patients (77.14%). These observations are at variance with those recorded in the Western literature where adhesion obstruction is the most common etiology1,18,19,23,24. Also these are at variance with some of the reported Indian services by Rao et al.7and 14 Dayalan et al. who reported intussusception as the commonest cause of small-bowel obstruction in children. Dayalan et al.14reported ascariasis as the second most common cause of intestinal obstruction in children. The reason for our observation could be that since most of these children reside in rural areas with poor sanitation and personal hygiene, they get commonly infested with this parasite in this part of the country, resulting in worm obstruction. Also because of favorable climatic conditions for the parasite in this part of the country, ascariasis infestation is very common here. Most of the cases in our study were due to mechanical factors caused by a bunch of adult worm remaining stationary in the lumen of the bowel. This observation was at par with that of Dayalan et al.14in their published series. Adhesion obstruction was the second commonest etiology occurring in 105 of 980 patients

6 (10.71%). The cause of adhesions were post-operative in 63 patients (60%), post-inflammatory in 35 patients (33.33%) and post-traumatic in 7 patient (6.66%). Intussusception was third in the list of etiology of mechanical small-bowel obstruction in children occurring in 70 of 980 patients (7.14%). The causes of intussusception were idiopathic in 56 patients (80%) and enlarged lymphnode in 14 patients (20%). Thus, leading points initiating intussusceptions were seen in 20% of cases. Obstructed hernia was next in list occurring in 21 of 980 patients (2.14%). Obstructed inguinal hernias were present in 14 patients (1.42%) and obstructed umbilical hernias in 7 (0.71%). Other infrequent causes were congenital bands in 21 patients (2.14%) and enterogenous cyst in 7 (0.71%). At our institution, we have continued to pursue the philosophy of never let the sun set or rise in the treatment of the patients with mechanical small-bowel obstruction, but not to the extent that it implies automatic surgery in every case. Based on this philosophy (Table 7), 644 of 980 patients (65.71%) were managed operatively and 336 of 980 patients (34.28%) were managed conservatively, the reason being that our institution is a tertiary health care centre and most of the cases were referred from first and second referral units when the conservative management failed there. The most common etiological group which successfully responded to conservative treatment was worm obstruction, i.e. 294 of 756 (38.88%). The patients with worm obstruction were operated as per Dayalan s14and 15 Louw s criteria. In our series of 980 patients (Tables 8 & 9), 644 patients (65.71%) were operated, 259 (40.22%) had simple and 385 (59.78%) had strangulated obstruction. At operation, viable strangulation was noted in 238 of 385 patients (61.82%) and non-viable strangulation (42 with gut gangrene) in 147 of 385 patients (38.18%). These observations were different from those reported by Sarr et 20 al. in their series of 51 patients, where 30 patients (38.62%) had simple and 21 (41.17%) had strangulation obstruction. The reason for this difference is that in our study the cases with strangulation obstruction were referred from first and second referral units of rural areas and they reached our tertiary care centre after the failure of conservative management attempted at first and second referral units. CONCLUSION Hence we concluded in our study that small-bowel obstruction due to ascariasis constituted the major cause of intestinal obstruction leading to considerable morbidity in children of the valley of Kashmir. Hence, efforts should be made to eradicate ascariasis in endemic areas through proper sanitation, proper health education regarding personal 6 of 8 hygiene and route of entry of the parasite, and periodic deworming of children with antihelminthics, so as to reduce the incidence of the problem in our society. It is important to start the health education regarding prevention of this infestation right from the admission of such patients, as this is the best time when they and their relatives are very receptive to health advice. We should follow the saying that prevention is better than cure. References 1. Mucha P Jr.: Small intestinal obstruction. Surg Clin North Am; 1987; 67: Miller G, Boman J, Shrier I et al.: Etiology of small bowel obstruction. Am J Surg; 2000; 180: Dite P, Lata J, Novotny I: Intestinal obstruction and perforation - the role of gastroenterologist. 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8 Author Information Mohd Altaf Mir, MS Registrar, Department of Surgery, Govt. Medical College Mudasir Hameed Bucch, MBBS Postgraduate, Department of Surgery, Govt. Medical College Umar Younus, MBBS Postgraduate, Department of Surgery, Govt. Medical College G.M. Sheikh, MS Professor, Department of Surgery, Govt. Medical College Biant Singh Bali, MS Professor, Department of Surgery, Govt. Medical College 8 of 8