A CLINICAL STUDY OF SUB ACUTE INTESTINAL OBSTRUCTION IN ADULTS Archana Shukla, Sudhir Singh Pal 2 HOW TO CITE THIS ARTICLE: Archana Shukla, Sudhir Singh Pal. A clinical study of sub acute intestinal obstruction in adults. Journal of Evolution of Medical and Dental Sciences 203; Vol2, Issue 35, September 2; Page: 6594-6599. ABSTRACT: A study was conducted on 7 patients admitted in Dept of surgery, Hamidia hospital Bhopal. These patients came with complaints of recurrent episodes of vomiting, distension of abdomen, passing flatus and motion but frequency decreased. On examination salient features were increased bowel sounds in most, and palpable abdominal lump in few. This sign and symptom complex is commonly called as sub-acute intestinal obstruction.52 patients got relieved by conservative management where as 9 required operative intervention. Investigations were done which were mainly radiological, X rays of abdomen, ultrasonography of abdomen. CECT was done in selected cases where ultrasonography was not conclusive. It was found that patients of SAIO with history of previous abdominal surgery responded to conservative management. Others had more inclination of having operable lesions and required more investigations and operative intervention. KEYWORDS: sub acute intestinal obstruction, recurrence, previous surgery, conservative treatment INTRODUCTION: Apart from obvious cases of intestinal obstruction an almost equal number of patients were found to have sign and symptoms of partial obstructions but recurrently, 9, 7. They have more than one episode of obstruction hence suffering and hospitalization was for longer period of time. It was puzzling for surgeons to be decisive as few got definite relief by conservative management but had another episode sooner or later. Radiological, hematological, serological and histopathological 7, 8 investigations were done to reach to a conclusion for management of the patient successfully. METHOD: A clinical study was conducted at Dept. of surgery unit iii over a period of one year from March 202 to March 203 on patients who met with the criteria of having recurrent pain in abdomen along with distention, decreased frequency of passage of flatus and motion, x-rays showing multiple air fluid level and conservative management was planned to begin with. Initially most of these patients were relieved by conservative management that is, by keeping them abstained from oral diet, naso-gastric suction and parenteral supplementations. Significant relief was within the period of 6 hr to 48 hr. The patient who had acute symptoms of obstruction with no relief in 6 hrs were put in the category of acute intestinal obstruction and were not included in the study. 9, 0.7 Details of patients were documented as per profile features of age, sex, no. of admissions for similar episodes, and detailed history. All routine investigations were done. Patients having history of tuberculosis, past history of tuberculosis or having family history of this disease were further subjected to mantoux test, Sputum for AFB and TBPCR. Series of X rays of abdomen, ultrasonography was done in all patients and CECT in selected patients. 8, 2 This was done to know the predictors for conservative management, cause of obstruction and pathology underlying. Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 35/ September 2, 203 Page 6594
Those not getting relieved even after trial of conservative management were taken for exploratory laparotomy and procedure as per lesion was performed. 7, 9, 20 All patients were followed up from 6 month to 2 months time RESULT: In one year 7 patients were admitted with the complaints of nausea, vomiting, pain and distension of abdomen, decreased frequency of passage of flatus and motion, increased bowel sounds and palpable abdominal lump. The youngest was 5 year old and the oldest was 80 years of age the mean age being 46.5 yrs. were 38 males 33 females. Number of episodes ranged from 2 to6 times and duration of stay from 7 days to 60 days. History of previous surgery was the commonest followed by history related to tuberculosis. Passage of flatus and motion less frequently associated with generalized pain all over abdomen was the commonest symptom. Increased bowel sound was found in most of the patient and hence is considered as most important sign to diagnose clinically SAIO. Routine hematological tests done in all mostly showed anemia. 8 Mantoux test and sputum for AFB were done in those having positive history or other investigation suggesting tuberculosis was not conclusive. TBPCR was done in all above mentioned patients was conclusive. 2 Plain X ray abdomen was done and all patients revealed multiple air fluid levels. Ultrasonography was done and was conclusive in 5 out of 9 operative patients. It revealed increased peristalsis in most of the cases and ileo -caecal thickness in few. CECT was done in 5 patients and was conclusive in all. 7, 9 Patients were at one point of time required exploration and abdominal laparotomy was done, Rest of 52 patients were treated conservatively. The most common site was small intestine followed by appendix, caecum and sigmoid. Ileal strictures, fibrinous tubercular peritonitis, adhesions due to previous surgery, chronic appendicitis, Carcinoma of ilio-caecal junction, Mal-rotation of small gut and volvulus were the causes respectively. Out of 7 patients 32 had history of previous surgery. 2, 3, 4 In previous surgeries abdominal tubectomies were the biggest culprit followed by abdominal hysterectomy, exploratory laparotomy for perforation peritonitis and appendicectomy. Few patients documents were not available to state exact cause of surgical procedure. Adhesiolysis was done in 2 patients who were not responding to conservative manner and 30 were treated conservatively. 2, 3, 4 25 patients were having abdominal tuberculosis. Most of them where diagnosed for the disease during the stay in hospital and couple of them were already diagnosed but taking irregular treatment of ATT. 3, 8 Adhesiolysis was done in 2 patients who were found to have fibrinous adhesion due to peritonitis. 0, 3 Single passable strictures were found in 4 patients, for which stricturoplasty was done. Passable strictures closely placed were found in 5 patients on which resection and anastomosis was done. 20 Mesentric lymph node and omental biopsy was obtained for confirmation by histopathological examination. 2, 6 Total 4 patients were treated conservatively had TBPCR positive for mycobacterium tuberculi and ATT was continued on this basis. 8 Ten patients were diagnosed as chronic appendicitis with appendicular lump taking inappropriate inadequate treatment. Two of them were operated and adhesiolysis and appendicectomy was done. 8 were treated conservatively. 7 Two patients of adenocarcinoma of ileocaecal junction under went right hemicolectmy., 7 Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 35/ September 2, 203 Page 6595
There was one patient of volvulus of sigmoid colon who was having recurrent episodes. He was treated by performing colocolic resection of redundant part of colon followed by anastomosis. Malrotation of the small intestine was found in one patient in which Ladd procedure of derotation was done. DISCUSSION: The study included 7 patients of SAIO. In sub acute or partial obstruction patient get relieved at intervals giving false impression to patients and their relatives regarding cure of disease. The surgeons on the other hands are puzzled. Due to recurrent episodes suffering was more, and hospitalization was for longer period of time. 9 The patient undergone abdominal-pelvic surgery had more tendency of developing post operative adhesions followed by exploratory laparotomy for perforation peritonitis. Patients who develop post operative adhesion presented as SAIO 2, 3. They outnumbered other causes but thankfully settled well with conservative management. 4 Patients having abdominal tuberculosis develop partial obstruction due to strictures or fibrinous peritonitis 4, 3. The patients already on ATT were irregular in taking treatment. Abdominal tuberculosis was next culprit and maximum surgery was done for this disease. 4, 5 This can occurs at any age. Majority of patients belonged to poor socio- economical class having poor nutrition. 5, 6 Non compliance to anti tubercular therapy is also contributory to present the disease as SAIO. 5, 4 Patients having lump in right iliac fossa on investigations were mostly diagnosed as chronic appendicitis and appendicular lump. After specific conservative management they were advised for interval appendicectomy but only couple of patient came for definitive surgery. 7 Other less common causes were adenocarcinoma of ileo caecal area for which hemi colectomy was performed, followed by volvulus and mal rotation of small gut for which colo colic resection anastomosis and lads procedure was done respectively. 7, 20 Patients who developed SAIO and had history of previous surgery can be treated conservatively where as others should be subjected to radiological and biochemical investigation. In our study, CECT 7, and TBPCR 8 were found to be most diagnostic. In view of health problems of developing countries tuberculosis should be considered as important cause for SIAO. With regular compliance of ATT and using special investigation SAIO due to tuberculosis can be treated successfully. REFERENCES:. Cheong YC, Laird SM, Lil TC, Shelton JB, Ledger WL, Cooke ID. Peritoneal healing and adhesion formation/reformation. Hum Reprod Update 200; 7(6):556 66. 2. Hills BA. Lubrication of visceral movement and gastric motility by peritoneal surfactant. J Gastroenterol Hepatol 996; :797 803. 3. Jacqueline NG, Diamond MP. Principles of Laparoscopic Microsurgery and Adhesion Prevention. In: Azziz R, Murphy A, editors. Practical manual of operative laparoscopy and hysteroscopy. Second Edition, New York Inc: Springer-Verlag; 997. p. 94 07. 4. Mutsaers SE, Whitaker D, Papadimitriou JM. Mesothelium regeneration is not dependant on subserosal cells. J Pathol 2000;90:86 92 5. Tan K-K, Chen K, Sim R: The spectrum of abdominal tuberculosis in a developed country: a single institution s experience over 7 years. J Gastrointest Surg 2009, 3:42 47. Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 35/ September 2, 203 Page 6596
6. Sharp JF, Goldman M: Abdominal Tuberculosis in East Birmingham, a 6years study. Postgrad Med J 2002, 63:539 542. 7. Hills B A, Lubrication of visceral movement and gastric motility by peritoneal surfactant. J Gastroenterol Hepatol 996; :797 803. 8. Jacqueline NG, Diamond MP. Principles of Laparoscopic Microsurgery and Adhesion Prevention. In: Azziz R, Murphy A, editors. Practical manual of operative laparoscopy and hysteroscopy. Second Edition, New York Inc: Springer-Verlag; 997. p. 94 07. 9. Mutsaers SE, Whitaker D, Papadimitriou JM. Mesothelium regeneration is not dependant on subserosal cells. J Pathol 2000;90:86 92 0. Tan K-K, Chen K, Sim R: The spectrum of abdominal tuberculosis in a developed country: a single institution s experience over 7 years. J Gastrointest Surg 2009, 3:42 47.. Sharp JF, Goldman M: Abdominal Tuberculosis in East Birmingham, a 6years study. Postgrad Med J 2002, 63:539 542. 2. Suri S, Gupta S, Suri R: Computed tomography in abdominal tuberculosis.br J Radiol 999, 92:92 98. 3. Khan MR, Khan IR, Pal KNM: Diagnostic issues in Abdominal Tuberculosis. J Pak Med Assoc 200, 5:38 40. 4. Wang HS, Chen WS, Su WJ, Lin JK, Lin TC, Jiang JK: The changing pattern of intestinal tuberculosis: 30 years experience. Int J Tuberc Lung Dis 998, 2:569 574. 5. Shaikh MS, Dholia KR, Jalbani MA: Prevalence of intestinal tuberculosis in cases of acute abdomen. Pakistan J Surg 2007, 23:52 56. 6. Engin G, Balk E: Imaging findings of Intestinal Tuberculosis. J Comput Assist Tomogr 2005, 29:37 4. 7. Rajpoot MJ, Memon AS, Rani S, Memon AH: Clinicopathological profile and surgical management outcomes in patients suffering from intestinal tuberculosis. J Liaqaut Uni Med Health Sci 2005, 4:3 8. 8. Gondal KM, Khan AFA: Changing pattern of Abdominal Tuberculosis. Pak J Surg 995, :09 3. 9. Skopin MS, Batyrov FA, Kornilova Z: The prevalence of abdominal tuberculosis and the specific features of its detection. Probl Tuberk BoleznLegk 2007, :22 26. 20. Khan IA, Khattak IU, Asif S, Nasir M, Ziaur R: Abdominal tuberculosis an experience at Ayub Teaching Hospital Abbottabad. J Ayub Med Col Abbottabad 2008, 20:5 8. 2. Khan SM, Khan KM, Khan AS, Jehanzeb M, Jan WA, Khan M, Ali U:Presentation of abdominal tuberculosis in NWFP and its correlation with operative findings. J Postgrad Med Inst 2005, 9:286 29. 22. Gondal SH, Gulshan S, Naseeb U: Intestinal Tuberculosis as an abdominal emergency. Pak Postgrad Med J 2000, :03 05. 23. Gomez JE, McKinney JD: Tuberculosis persistence, latency and drug tolerance. Tuberculosis 2004, 84:29 44. 24. Niaz K, Ashraf M: Intestinal tuberculosis; Diagnostic dilemma. Professional Med J 200, 7:532 537. 25. Iqbal T, Khan A, Iqbal A, Tahir F: Obstruction due to intestinal tuberculosis strictureplasty versus resection anastomosis. Pak J. Surg. Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 35/ September 2, 203 Page 6597
Table no. : s.no cause No. of patients. 2. 3. 4. 5. 6. Post op. adhesions Intestinal tuberculosis Appendicular lump Ileocaecal adenocarcinoma Volvulus Malrotation of gut 32 25 0 2 Table no.2: s.no surgery No. of patients. 2. 3. 4. 5. 6. 7. Resection anastomosis Stricturoplasty Adhesiolysis Appendectomy Rt. Hemicolectomy Colocolic resection anastomosis Ladd s procedure 5 4 4 2 2 Fig. Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 35/ September 2, 203 Page 6598
Fig. 2 AUTHORS:. Archana Shukla 2. Sudhir Singh Pal PARTICULARS OF CONTRIBUTORS:. Assistant Professor, Department of Surgery, Gandhi Medical College, Bhopal. 2. Associate Professor, Department of Surgery, Gandhi Medical College, Bhopal. NAME ADRRESS EMAIL ID OF THE CORRESPONDING AUTHOR: Dr. Archana Shukla, 48/2, Doctors Quarter, Hamidia Hospital, Bhopal, M.P. Email archie220@gmail.com Date of Submission: 0/08/203. Date of Peer Review: 03/08/203. Date of Acceptance: 23/08/203. Date of Publishing: 27/08/203 Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 35/ September 2, 203 Page 6599