The Spectrum of Paediatric Intestinal Obstruction in Kenya

Introduction Intestinal obstruction (IO) occurs when there is impedance to the flow of intestinal contents due to a congenital or acquired pathology, and is a common paediatric surgical emergency. This study aimed to assess the pattern and outcome of paediatric IO in western Kenya. Methods A retrospective review of all recorded cases of mechanical IO in patients aged 15 years or below admitted at Tenwek Hospital between January 2009 and December 2013. Results The cohort included a total of 217 children (130 boys and 87 girls). The mean age was 6.7 years (range: newborn-15 years), with most (65, 30%) cases aged 1-3 years. Vomiting (161, 74.2%), abdominal pain (152, 70%), abdominal tenderness (113, 52.1%), constipation (111, 51.2%), and abdominal distension (104, 47.9%) were the predominant signs and symptoms. The most common causes of IO were ascariasis (96, 44.2%), adhesions (34, 15.7%), and intussusception (30, 13.8%). Intussusception was the leading cause of IO in children aged ≤ 1 year, ascariasis in children aged 1-5 and 6-10 years, and adhesions in children aged 11-15 years. Operative management was undertaken in 120 (55.3%) cases with 39 (32.5%) of these having gangrenous bowel. The overall mortality rate was 5%. Conclusion The most common causes of mechanical bowel obstruction in this series were ascariasis, adhesions, and intussusception. Ascariasis remains a significant cause of paediatric IO in this region, thus public education, improved sanitation and deworming campaigns may be helpful in reducing the worm burden.


Introduction
Intestinal obstruction (IO) occurs when there is impedance to the flow of intestinal contents due to a congenital or acquired pathology. It is a common paediatric surgical emergency and can be associated with significant mortality, especially when associated with bowel gangrene [1][2][3]. The pattern of IO in children in the tropics, Kenya included, is buried within the wider spectrum of IO people of all ages [2]. Age, environmental and social factors may play a role in the spectrum of IO aetiology [4,5]. This study was conducted to ascertain the etiology, presentation, management, and outcomes of IO in children in the region and to compare these findings with those of other studies.

Methods
This was a retrospective review of all children aged 15 years and below managed for mechanical IO at Tenwek Hospital, in Bomet Kenya between January 2009 and December 2013.Tenwek is a 320 bed hospital that acts as a referral centre for the south-western region of rural Kenya, which supports a population of over 800,000 people. Data were extracted and analysed including patient age, sex, presenting signs and symptoms, plain X-ray findings, management, complications and duration of hospitalisation. Cases involving functional IO, or with unclear diagnosis were excluded.

Results
A total of 217 children (130 boys and 87 girls) were admitted with acute mechanical IO during the study period. The mean age was 6.7 years (range: newborn-15 years), with peak incidence in noted in children aged 1-3 years (65, 30%) (

Discussion
Intestinal obstruction is a common pediatric surgical emergency whose etiologies vary mainly with patient age [5]. Anorectal malformation is the most common cause of IO in neonates at 35-39%, followed by hirschprung's disease at 11-23% [6,7]. Similar findings were noted in this series, with the slightly higher proportions due to the lower number of cases. Intussusception has been reported to be not only the most common cause of IO in infants [8,9], but also the most common cause of IO in children overall, responsible for 22-46% of all cases of IO [1,2,4,5]. In this study, intussusception was the most common cause of IO in infants.
Similar to other studies from developing countries, most of the cases of intussusception in this series were managed surgically [1,2,5,[8][9][10][11][12]. The predominant operative management is due to delayed patient presentation with concern for gangrenous bowel, predominant clinical diagnosis, with a significant proportion of cases being confirmed at laparotomy and lack of around-the-clock radiologic facilities and personnel to perform nonsurgical reduction [2,11,12]. This argument is underscored in this series where the median durationof presentation was 3 days, with gangrenous bowel noted in 62.1% of the cases. The mortality rate of cases with intussusception in this series at 10%, is similar to the reported mortality rate of 5-28% in series form developing countries [8,[10][11][12].
Ascariasis was the leading overall cause of IO in this series, accounting for 44.2% of all cases of IO; 64.1% of IO cases in children aged 1-5 years, and 51.8% of all cases in children aged 6-10 years. Similarly, two studies from Kashmir reported ascariasis to be the cause of IO in 63-77% of the study cohort [13,14]. Ascariasis is a common infection in the tropics, and is associated with poor hygiene and low socioeconomic conditions that are more prevalent in rural areas such as western Kenya [14]. The incidence of IO estimated to be 1 in 500 infected children [15], with peak age between 2 and 10 years [16][17][18]. While most cases can be managed non-operatively, the proportion of patients undergoing operative intervention has been reported to be between 8% and 26% [15][16][17][18]. Main procedures performed include the milking of worms into the colon (48-71%), enterotomy for worm extraction (13-49%), and resection and anastomosis in the face of bowel gangrene or perforation (14-26%) [16][17][18]. The reported overall mortality is 0-1%, and 0-6% in those undergoing operative management [15][16][17][18].
Adhesions have been reported to be the second most common cause of IO, accounting for 10-16% of all cases of IO in series from developing countries [1,4,13]. Most are post-operative, while operative intervention is required in 53-66% of cases [4,14,19].
Similar findings were noted in this series. The clinical presentation of the patients in this study is similar to studies performed in developing countries, with abdominal pain at 60-89%, vomiting at 63-85%, abdominal distension at 43-82 and constipation at 35-70%, being the most commonly reported signs and symptoms [1,5,14]. The overall mortality rate in this series at 3.2%, is comparable to the reported mortality rate of 2%-11% from similar series conducted in developing countries [1,2,4,5].

Conclusion
The most common causes of mechanical IO in this series varied by age and included ascariasis, adhesions, and intussusception. Most   Intussusception was the most common cause of IO in infants, with most cases managed surgically.
 The highest rates of morbidities were noted in patients with bowel gangrene due to intussusception and malrotation.