THE PATTERN OF ACUTE INTESTINAL OBSTRUCTION: A HOSPITAL BASED STUDY

BACKGROUND: Intestinal obstruction is a surgical emergency that causes confusion both in the diagnosis and the management. It is related by important disease and mortality. The goal of this study was to classify the etiology, to analyse the methods of performance of acute duodenal obstruction in different age groups, various therapeutic modalities of treatment, to accomplish operative management, anticipate the post-operative complications and outcomes of patients with acute intestinal obstruction. MATERIAL & METHODS: 82 patients of all age groups (except infants) presenting with acute intestinal obstruction were studied between June 2017 and December 2018 in a multispeciality hospital in Eastern India. Patients with history of subacute intestinal obstruction and paralytic ileus were excluded from this study. RESULTS: Males were found to be affected much more than females. Pain abdomen was the most common symptom found in 94% cases followed by distension and vomiting in 86.6% and 68.3% cases respectively. Most common etiology of intestinal obstruction was due to adhesion and bands (40.3%) followed by obstructed hernia (22%) and malignancy (17%). The most common procedure done in intestinal obstruction in present study was release of adhesions and bands (37.8%) followed by resection and anastomosis (26.8%). CONCLUSION: Bowel obstruction continues to be one of the most common abdominal problems faced by general surgeons. Success in the treatment of intestinal obstruction depends largely upon early diagnosis, skilful management and treating the pathological effects of the obstruction just as much as the cause itself.


INTRODUCTION:
Intestinal obstruction is divided into obstruction of the small bowel (including the duodenum) and obstruction of the large bowel. Obstruction may be partial or complete. About 85% of fractional little entrail checks resolve with nonoperative treatment, though about 85% of complete little gut deterrents require surgery.1Overall, the most wellknown reasons for mechanical impediment are grips, hernias, and tumors. Other general causes are diverticulitis, outside bodies (counting gallstones), volvulus (turning of inside on its mesentery), intussusception (extending of one fragment of gut into another), and fecal impaction. Explicit portions of the digestive tract are influenced differently.2 In basic mechanical impediment, blockage happens without vascular trade off. Ingested liquid and nourishment, stomach related discharges, and gas collect over the obstacle. The proximal entrail widens, and the distal portion breakdown. The ordinary secretory and absorptive elements of the mucosa are discouraged, and the inside divider ends up edematous and clogged. Severe intestinal distension is self-sustaining and dynamic, escalating the peristaltic and secretory disturbances and expanding the dangers of lack of hydration and movement to strangulating deterrent. Strangulating check is deterrent with traded off blood stream; it happens in almost 25% of patients with little entrail hindrance. It is typically connected with hernia, volvulus, and intussusceptions.3 Strangulating check can advance to dead tissue and gangrene in as meager as 6 hours. Venous Obstruction happens first, trailed by blood vessel impediment, bringing about fast ischemia of the entrail divider. The ischemic inside winds up edematous and infarcts, prompting gangrene and aperture. In huge gut obstacle, strangulation is uncommon (aside from with volvulus).Perforation may happen in an ischemic fragment (normally little gut) or when stamped expansion happens. The hazard is high if the caecum is widened to a distance across ≥ 13 cm. Perforation of a tumor or a diverticulum may likewise happen at the deterrent site.4,5 Obstruction of the small bowelcauses indications not long after beginning: stomach issues based on the umbilicus or in the e p i g a s t r i u m , h e a v i n g , a n d i n p a t i e n t s w i t h c o m p l e t e impediment-obstipation. Patients with incomplete impediment may create loose bowels. Extreme, enduring agony recommends that strangulation has happened. Without strangulation, the mid-region isn't delicate. Hyperactive, piercing peristalsis with surges agreeing with cramps is typical. Sometimes, dilated loops of bowel are palpable.
With infarction, the abdomen becomes tender and auscultation reveals a silent abdomen or minimal peristalsis. Shock and oliguria are serious 6 signs that indicate either late simple obstruction or strangulation.
Obstruction of the large bowel normally causes milder manifestations that grow more steadily than those brought about by little entrail hindrance. Expanding stoppage prompts obstipation and stomach distension. Retching may happen (generally a few hours after beginning of different indications) yet isn't normal. Lower stomach spasms may happen. Physical assessment regularly demonstrates an enlarged guts with noisy borborygmi. There is no delicacy, and the rectum is typically vacant. A mass relating to the site of a discouraging tumor might be discernable. Fundamental side effects are generally mellow, and liquid and electrolyte deficiencies are uncommon.7,8 Volvulus frequently has a sudden beginning. Torment is persistent, here and there with superimposed floods of colicky torment.
The point of this investigation was to distinguish the etiology, to examine the methods of introduction of intense intestinal hindrance in various age gatherings, different helpful modalities of treatment, to achieve usable administration, envision the post-usable complicationsand results of patients with intense intestinal obstacle.

MATERIALS AND METHODS:
A total number of 82 cases of acute intestinal obstruction were studied between June 2017 to December 2018 in a multispeciality hospital in Eastern India..
Patients of all age groups (except infants)who attended the OPD and Emergency Departmentof the hospital, with history and clinical picture suggestive of acute intestinal obstruction, also the patients who had hernia with recent onset of irreducibility, pain, vomiting and constipation were included in this study.
All patients with provisional diagnosis of acute intestinal obstruction were assessed clinically in detail after admission. Patients with history of subacute intestinal obstruction and paralytic ileus were excluded from this study.
On admission, relevant pathological and biochemical investigations were carried out in all cases. Plain X-ray erect abdomen was carried out in almost all patients. Ultrasonography and CT abdomen was done in 10,11 some cases whose diagnosis by X-ray was inconclusive. Prior to surgery, stabilization of patients with shock, correction of electrolyte imbalance and nasogastric decompression was done. Appropriate surgical procedure was carried out. Postoperative follow up period ranged between 2-6 months from time of discharge. Some patients were not regular in their follow up visits. The results were tabulated according to age, sex, symptoms, signs, probable causative factors, operative findings, operative procedure adopted and post- 12 operative complications .

RESULTS:
A clinical study of 82 cases of acute intestinal obstruction was done for a period of 18 months. It was done in all groups (except infants) with a mean age of 46.5 years. Age distribution was as shown in Table 1.
Occurrence of acute intestinal obstruction was common in males(66%) as compared to females (34%) Patients of intestinal obstruction were mainly from age group 50-59 years (25.6%) ( Table 1).Most of the patients (62%) presented with symptoms between 48-96 hours as shown in Figure 1.

Figure 1: Duration of symptoms
The present study of acute intestinal obstruction showed that abdominal pain was seen in 77 patients (94%), followed by distension of abdomen seen in 71 patients (86.6%), and vomiting seen in 56 patients (68.3%). The most common sign encountered was tenderness, seen in 61 patients (74.4%) as shown in Table 2.

Table 2: Symptoms and signs
Small intestinal obstruction (58 cases) was seen more commonly than large intestinal obstruction (24 cases) Most common etiology of intestinal obstruction was due to adhesion and bands (40.3%) followed by obstructed hernia (22%) and malignancy (17%) ( Table 3 and Figure 2).

Figure 2: Aetiologies of intestinal obstruction
The most common procedure done in intestinal obstruction in present study was release of adhesions and bands (37.8%) followed by resection and anastomosis (26.8%). Hernioplasty was performed in 18 % of cases (Table 4 and Figure 3).

Figure 3: Management of cases in the study
Post operative complications were seen in 27 (33%) cases, out of which surgical site infection was most common complication encountered (16%) followed by septicemia seen in 8 % of cases. Respiratory infection was seen in 4 % of cases. Anastomotic leak and wound dehiscence were seen in 2.5% of cases individually (Table 5). Rate of complications was more when patient presented late to the hospital. Morbidity was seen in 3 patients who presented less than 48 hours, while it was seen in 25 patients who presented after 48 hours ( Table 6).

Table 7: Outcomes
Mortality rate in present study was 6 % (Table 7). Among them, one patient had mesenteric ischemia; two patients were suffering from malignancy with metastasis and other two patients died due to septicaemia and itssequele. It constitutes a major cause of morbidity and financial expenditure in hospitals around the world and a significant cause of admissions to 8,9 emergency surgical departments.
Intestinal obstruction occurs in all age groups. In present clinical study, it includes all the age groups except infants. The study showed the peak incidence in the age groups of 50-59 years (25.6%) followed by 40-49 years (22%), 60-69 years (19.5%) which is comparable with the Most of the cases presented with abdominal pain (94%), followed by abdominal distension (86.6%), vomiting (68.3%) constipation (63%), 15 which was comparable to the study conducted by Khan et al. and 12 Adhikari et al.
Causes of bowel obstruction include adhesions, hernias, volvulus, endometriosis, inflammatory bowel disease, appendicitis, tumors, diverticulitis, ischemic bowel, tuberculosis, and intussusception. Small bowel obstructions are most often due to adhesions and hernias while large bowel obstructions are most often due to tumors and 1,2 volvulus. The diagnosis may be made on plain X-rays; however, CT scan is more accurate. Ultrasound or MRI may help in the diagnosis of 2 children or pregnant women.
The condition may be treated conservatively or with surgery.In small bowel obstruction about 25% require surgery. Complications may include sepsis, bowel ischemia, and bowel perforation.
The prognosis for non-ischemic cases of small bowel obstruction is good with mortality rates of 3-5%, while prognosis for small bowel obstruction with ischemia is with mortality rates as high as 30%. . Cases of large bowel obstruction related to cancer are more complicated and require additional intervention to address the malignancy, recurrence, and metastasis, and thus are associated with 16 poorer prognosis.
Out of the 82 cases, the site of obstruction was small bowel in 58 cases and large bowel in 24 cases. Hence, small bowel obstruction was found to be the most common cause. In the study conducted by Malik et al.,in 17 71.1% of the cases, the obstruction was located on the small bowel.
Among the 82 cases, most common cause of acute intestinal obstruction was found to be post operative adhesions and bands which accounted for 40% of cases. Second most common cause was found to be obstructed/strangulated inguinal hernia which accounted for 22% of cases.This is different from the study conducted by Adhikari et al. 12 where inguinal hernias account for most of the cases.
The most common surgical procedure was adhesiolysis followed by resection and anastomosis/colostomy. Next common procedure was hernia reduction and repair which included inguinal, femoral, incisional, and paraumbilical hernia repairs. Most of the cases recovered without any complications (67%). Infection was the major case of morbidity and was seen in 16% of patients. Mortality was 6% and was commonly seen in patients with strangulation and increased age. Two deaths were due to sepsis. This observation is comparable to a 12 18 similar study conducted by Adhikariet al. and Ramachandran.
The mortality rate in the present study is comparable to Ramachandran 18 CS et al. Study but it is more when compared to Adhikari S et al 12 study. The mortality in intestinal obstruction is more in patients who develop strangulation and gangrene of the bowel, also who reached the hospital late. With all these, the age of the patient, general condition of the patient, duration of symptoms and operative procedures carries a 19 prominent role in progress as well as the mortality .

CONCLUSION:
Present study concluded that intestinal obstruction is seen more commonly in middle age group although no age is immune. Males were affected twice as common as females. Abdominal pain was the most common symptom, while tenderness was the most common sign. Average time of presentation of patient of obstruction was 2-4 days. Small bowel obstruction is more common than large bowel obstruction.
Bowel obstruction continues to be one of the most common abdominal problems faced by general surgeons. Irrespective of the cause, it remains a major cause of morbidity and mortality.
Success in the treatment of intestinal obstruction depends largely upon early diagnosis, skilful management and treating the pathological effects of the obstruction just as much as the cause it self.
Early recognition and aggressive treatment are crucial in preventing irreversible ischemia and transmural necrosis and thereby in decreasing mortality and long-term morbidity. Post-operative adhesion caused most cases of small bowel obstruction while large bowel obstruction was caused most commonly by malignancy. Plain X-ray erect abdomen is the single important diagnostic tool for diagnosing intestinal obstruction and its level of obstruction.
In present study it had been observed that early diagnosis, adequate preoperative hydration, prompt investigations and early operative intervention improves survival in patients of intestinal obstruction.