|Year : 2017 | Volume
| Issue : 2 | Page : 51-56
The pattern and outcome of surgical acute abdomen at a Nigerian tertiary hospital
Nnamdi Jude Nwashilli, Nkwo Michael Okobia, Odigie Clement Osime, Orumuah Jude Agbugui
Department of Surgery, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
|Date of Web Publication||23-May-2019|
Dr. Nnamdi Jude Nwashilli
Department of Surgery, University of Benin Teaching Hospital, Benin City, Edo State
Source of Support: None, Conflict of Interest: None
Background: Surgical acute abdomen is one of the most common causes of admission into the surgical emergency room. It is a sudden onset of abdominal disease condition which requires immediate surgical evaluation and intervention. Aim: This study aims to determine the pattern and outcome in surgical acute abdomen. Patients and Methods: This was a prospective descriptive study carried out at University of Benin Teaching Hospital, Benin City over 1 year between September 2009 and August 2010. Consecutive patients aged 18 years and above with a diagnosis of surgical acute abdomen formed the study sample. Surgical acute abdomen caused by gynecological and urological problems were excluded from the study. A data form was opened for all patients on admission. Patients who met the inclusion criteria were recruited. Data collated from the patients were analyzed using SPSS version 16. Results: One hundred and eighty-six patients who met the inclusion criteria were recruited. There were 99 males and 87 females with male to female ratio of 1.1:1. The mean age of the patients was 36.60 ± 16.74 years with the age range of 18–92 years. Acute appendicitis confirmed on histopathology in 71 patients was the most common cause of surgical acute abdomen in the study. One hundred and seventy-four patients were treated and discharged while 12 patients died. The overall mortality rate was 6.5%. Conclusion: This study has shown that acute appendicitis is the most common cause of surgical acute abdomen at the University of Benin Teaching hospital, Benin City, and the 21–30 years of age group was most commonly affected.
Keywords: Outcome, pattern, surgical acute abdomen
|How to cite this article:|
Nwashilli NJ, Okobia NM, Osime OC, Agbugui OJ. The pattern and outcome of surgical acute abdomen at a Nigerian tertiary hospital. Niger J Surg Sci 2017;27:51-6
|How to cite this URL:|
Nwashilli NJ, Okobia NM, Osime OC, Agbugui OJ. The pattern and outcome of surgical acute abdomen at a Nigerian tertiary hospital. Niger J Surg Sci [serial online] 2017 [cited 2019 Nov 15];27:51-6. Available from: http://www.njssjournal.org/text.asp?2017/27/2/51/258800
| Introduction|| |
The surgical acute abdomen is one of the most common cases seen at the surgical emergency unit. It is a sudden onset of abdominal disease condition which requires immediate surgical evaluation and intervention. Common causes include inflammatory conditions such as acute appendicitis, perforation of a hollow viscus such as peptic ulcer perforation, typhoid intestinal perforation, and traumatic perforation of a hollow viscus or a solid organ. Other causes include intestinal obstruction from strangulated internal/external hernia, bands and adhesions, volvulus and small/large bowel tumors.
The pattern of surgical acute abdomen varies from one place to another depending on the socioeconomic, dietary, and environmental factors as well as public health setup. Early studies, in Africa revealed intestinal obstruction caused by obstructed/strangulated inguinal hernia as the most common cause of surgical acute abdomen. However, recent studies, revealed that acute appendicitis is now the most common cause.
It is important to distinguish between surgical acute abdomen from other causes of acute abdomen which are amenable to nonoperative treatment such as gastritis and gastroenteritis. This is because any delay in instituting the appropriate treatment can result in increase in morbidity and mortality. Furthermore, the pattern of surgical acute abdomen in any geographical setting will serve as a basis for developing management strategies as well as effective use of resources based on common causes, especially in a resource-limited environment.
This study was aimed at ascertaining the pattern and outcome of surgical acute abdomen at the University of Benin Teaching Hospital, Benin City, Nigeria.
| Patients and Methods|| |
This was a prospective descriptive study carried out over 1-year from September 2009 to August 2010 at the University of Benin Teaching Hospital, Benin City located in the South-South zone of Nigeria with over 600 hospital bed capacity. The study population included all consenting and consecutive adult patients from 18 years and above admitted into the surgical ward with a diagnosis of surgical acute abdomen. Patients with gynecological and urological problems presenting as surgical acute abdomen were excluded from the study. The study was approved by the Research and Ethics committee of the University of Benin Teaching Hospital, Benin City.
All patients who met the inclusion criteria had their demographic data, symptoms and signs, abdominal findings on physical examination, diagnosis at admission, investigation results, the findings at surgery, postoperative diagnosis and outcome of treatment entered into a structured questionnaire. The outcome of treatment was categorized as uneventful and discharged; the presence of complications managed appropriately and discharged and death (in-hospital or death within 30 days of operative procedure).
Data analysis was carried out using the IBM Statistical Package for Social Sciences (SPSS) Version 16 software (SPSS Inc., Chicago, IL, USA). Results were summarized in texts and tables.
| Results|| |
A total of 186 consecutive patients with surgical acute abdomen were recruited into the study [Table 1]. There were 99 males and 87 females with male to female ratio of 1.1:1. The age range of the patients was 18–92 years with a mean age of 36.6 ± 16.7. The peak age range was in the third decade of life while the least age range was in the ninth decade of life [Table 2].
Acute appendicitis was preoperatively diagnosed in 86 patients. Ten patients had perforated appendix (seven males and three females). Seventy-one patients were confirmed on histology (27 males and 44 females). The remaining 15 patients had negative histology (2 males and 13 females) with overall negative appendectomy rate of 17%. No other pathology was found in the 15 patients with negative appendectomy. The overall age range of the patients with acute appendicitis was 18–65 years with a mean age of 28.4 ± 10.4 years.
Twenty-six patients had perforated peptic ulcer (20 males and 6 females) with a male to female ratio of 3: 1. The mean age of the patients was 53 ± 19 years with the age range of 27–92 years. All the patients presented after 24 h of perforation as suggested by the time of onset of severe abdominal pain. Eight patients were in shock on admission with a recorded systolic blood pressure <100 mmHg. Laparotomy with omental patch closure of the perforation and lavage of the abdominal cavity was carried out in all the patients. Twenty-two patients had duodenal perforation while four had gastric perforation. Additional treatment with triple regimen (proton pump inhibitor and antibiotics) was given to all the patients.
Abdominal trauma occurred in 24 patients. The mean age of the patients was 34 ± 11 years with the age range of 18–60 years. The average time from presentation to the time of surgery was 12.96 ± 20.29 h. Blunt abdominal trauma caused by motor vehicle accident accounted for nine patients while penetrating abdominal trauma caused by gunshot and knife stab accounted for 15 patients. The spleen and the small intestine were the most common organ injured in blunt and penetrating abdominal injury, respectively. All the patients had laparotomy. Six patients with Grade IV spleen injury had total splenectomy; three patients with Grade I gastric perforation had simple closure of the perforations; a patient with duodenal laceration had it repaired; a Grade I liver injury was repaired with absorbable suture and Surgicel applied over the repair; six patients with multiple intestinal perforations had resection of the affected segments with end-to-end anastomosis carried out; a patient with Grade III rectal injury had closure of the perforation with a defunctioning colostomy and two patients with urinary bladder injury had it repaired with absorbable suture and catheter drainage of the bladder for 10 days.
Forty-one patients presented with acute intestinal obstruction. Their mean age was 43.4 ± 18.3 years with age range of 18–80 years. The male to female ratio was 2:1. Bands and adhesions from previous abdominal surgery were the most common cause of acute intestinal obstruction and occurred in 17 patients. The predisposing surgeries are appendicectomy in six patients, laparotomy for abdominal trauma in three patients, laparotomy for volvulus in one patient, and one patient each for hysterectomy, myomectomy, cholecystectomy, and herniorrhaphy. Three male patients had no previous abdominal surgery and were found to have markedly inflamed appendix with adhesions causing intestinal obstruction. All the 17 patients were initially managed conservatively (nonoperatively) but later had laparotomy when there was no clinical improvement except one patient with previous abdominal stab injury that was successfully managed nonoperatively. Adhesiolysis and release of bands were carried out in the patients that had surgery.
Obstructed/strangulated hernia occurred in 13 patients. The mean age of the patients was 43.9 ± 16.0 years with the age range of 23–72 years. All the patients had inguinoscrotal hernia except the only female among them who had incarcerated supraumbilical hernia. Eight patients had herniorrhaphy (two out of the eight had gangrenous segments of small bowel which were resected via the groin incision with end-to-end anastomosis carried out). The remaining five patients had laparotomy. Two patients out of the five had viable gut in the hernia sac while the remaining three had gangrenous segments of small bowel which were resected and end-to-end anastomosis carried out. The patient with incarcerated hernia had its sac excised and simple repair was carried out with nylon 2.
Nine patients had colonic cancer. The mean age of the patients was 48.7 ± 17.2 years with the age range of 24–77 years. Four patients had tumor in the right side of the colon while five had it in the left side. A right and left hemicolectomy with ileotransverse and colocolic anastomosis respectively was carried out. All the tumors were confirmed on histology to be adenocarcinoma.
Two patients, a 56-year-old male and an 80-year-old female, were diagnosed with cecal and sigmoid volvulus, respectively. The cecal volvulus with vascular compromise had right hemicolectomy with ileotransverse anastomosis while the sigmoid volvulus which was gangrenous had left hemicolectomy with colocolic anastomosis.
Acute cholecystitis occurred in seven females and they subsequently all had interval cholecystectomy after antibiotics treatment. The patient with typhoid perforation had a resection of the segment of the affected bowel with end-to-end anastomosis while the patient with gastric volvulus had gastropexy after de-rotation of the volvulus and confirmation of viability of the stomach. Other results of symptoms and abdominal signs are shown in [Table 3] and [Table 4].
|Table 4: Abdominal signs with respect to etiology of surgical acute abdomen|
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| Discussion|| |
Out of the 186 consecutive patients recruited into this study with surgical acute abdomen, 99 were males while 87 were females with a male to female ratio of 1.1:1. These findings were in keeping with the observations of other studies, that have reported male preponderance in surgical acute abdomen. The mean age of the patients was 36.60 ± 16.74 years with a range of 18–92 years. Marjan and Armita in a study of 139 patients with a diagnosis of acute abdomen over 11 months reported almost a similar mean age of 35.3 ± 18.6 years. However, a similar study by Kotiso and Abduraham in a 1-year retrospective study conducted on adult patients with surgical acute abdomen in Addis Ababa, Ethiopia, reported a lower mean age of 30.7 ± 14.9 years.
Surgical acute abdomen was most common in this study in the third decade of life and uncommon after the eighth decade which was similar to what Agboola et al. reported in their study on pattern and presentation of acute abdomen in a Nigerian Teaching Hospital.
The most common cause of surgical acute abdomen in this study was appendicitis which was confirmed on histology in 71 out of the 86 patients preoperatively diagnosed with female preponderance. Agboola et al. also reported appendicitis as the most common cause of surgical acute abdomen in their study but with male predominance. However, Mbah et al. reported intestinal obstruction as the most common cause of acute abdomen in their study in Sokoto, Nigeria.
Acute intestinal obstruction (22%) was the second common cause of acute abdomen observed in this study with bands and adhesions from appendicectomy being the most common cause. Other surgeries that predisposed to bands and adhesions in this study included laparotomy for abdominal trauma and acute intestinal obstruction from volvulus, hysterectomy, myomectomy, cholecystectomy, and herniorrhaphy. Ohanaka and Adobamen reported a similar finding of postoperative adhesions being the most common cause of intestinal obstruction in their study on emergency abdominal surgery in Benin City. A similar report by Macutkiewiez and Carison in Britain also corroborated this finding. These differ from the work of Agboola et al. that reported anterior abdominal wall hernia as the most common cause of acute intestinal obstruction in their study in Ilorin, Nigeria. Obstructed/strangulated hernias were observed to be the second-most common cause of acute intestinal obstruction in this study and were mainly due to inguinoscrotal hernia while colon cancer accounted for the third. Earlier study carried out at the University of Benin Teaching Hospital, Benin City by Chiedozi et al. reported that obstructed/strangulated groin hernias were the most common cause of acute intestinal obstruction. However, the finding in this study suggests a changing trend with bands and adhesions as the most common cause of acute intestinal obstruction. This can be explained by the increasing number of abdominal surgeries performed these days and repair of some hernias on elective basis.
The third common cause of surgical acute abdomen was perforated peptic ulcer (14%) with a male to female ratio of 3:1. This finding is in agreement with other studies, that reported a high preponderance of perforated peptic ulcer in males more than in females. The overall mean age of patients with perforated peptic ulcer was 53.20 ± 19.1 years with age range of 27–92 years. Ohene-Yeboah and Togbe in Ghana reported a mean age of 52.2 ± 17.50; a finding almost similar to our observation. However, Nuhu et al. in a study on perforated duodenal ulcer in Maiduguri, Nigeria, reported lower mean age of 39.9 ± 13.6 years with a range of 18–65 years. Thirty-four out of the 55 patients reported in Nuhu's study were below 40 years while in this study only four patients were below 40 years. Twenty-two patients had duodenal perforation while the remaining four had gastric perforation, which is in agreement with a study that reported duodenal ulcer perforation as much more common than gastric ulcer perforation but differs from the study of Ohene-Yeboah and Togbe in Ghana that reported a higher incidence of gastric perforations than duodenal. The reasons adduced for the higher incidence of gastric ulcer perforation were abuse of nonsteroidal anti-inflammatory drugs, ingestion of herbal concoctions, and fasting for religious reasons.
Abdominal trauma (12.9%) was the fourth common cause of surgical acute abdomen. This differed from the work of Agboola et al. that reported perforated peptic ulcer as their fourth common cause of acute abdomen. There were 20 males and 4 females with a ratio of 5:1 which is similar to other studies, that reported male predominance. The males are the breadwinners of most households and are probably more involved in activities that predispose them to injury in the process of trying to earn a living. The mean age of the patients was 34 ± 11 years with age range of 18–60 years. Adamu et al. in a 2-year study on waiting time for emergency abdominal surgery on 488 patients with abdominal trauma in Zaria, Nigeria, reported a mean age of 32 ± 1.7 years; a finding almost similar to the observation in this study but differs from the study by Musau et al. over a 4 months' period in Nairobi, Kenya, on 80 consecutive patients with abdominal trauma with a lower mean age of 28.2 years. Most patients in this study were in the 21–30 and 31–40 years of age group with male predominance. Dogo et al. reported an age range of 21–30 and 31–40 years with male predominance in their study on pattern of abdominal trauma in North-East Nigeria. Osime and Oludiran in a 10-year study on penetrating abdominal injury in Benin City also reported that the age group of 21–30 years was the most vulnerable with male predominance. The reasons adduced were that the males generally demonstrate resistance to perceived threat and are endowed with a lot of natural strength when compared with females, the very young and the elderly. Penetrating abdominal trauma mainly caused by gunshot injury was noted to have a higher incidence than blunt abdominal trauma in this study. This is in agreement with the study by Alagoa and Jebbin but differs from the study by Okobia and Osime earlier at University of Benin Teaching Hospital, Benin City, Nigeria, that reported a preponderance of blunt abdominal trauma - a changing pattern of abdominal trauma. The higher prevalence of penetrating abdominal trauma in this study may be related to the crisis in Niger Delta region, rising wave of kidnapping for ransom and cases of armed robbery attack, since virtually, all the cases of penetrating abdominal trauma were due to gunshot injury.
Out of the 186 patients with surgical acute abdomen in this study, 174 were discharged while 12 died giving a mortality rate of 6.5%. Five patients each died from perforated peptic ulcer and abdominal trauma while two died from complications of acute intestinal obstruction [Table 5]. All the patients with perforated peptic ulcer presented 24 h after perforation as suggested by the time of onset of severe abdominal pain with eight of them in shock. Preoperative shock, delayed presentation, old age, and delayed treatment are factors known to predict mortality in perforated peptic ulcer. In abdominal trauma, the average time from presentation to the time of surgery was 12.96 ± 20.29 h. The delays were as a result of time spent in resuscitation and carrying out some basic investigations before surgery. Late presentation accounted for the poor outcome in the patient with strangulated inguinoscrotal hernia and the patient with gangrenous sigmoid volvulus. The overall mortality rate in this study was 6.5% which was lower than the mortality rate of 13.3% and 15.3% reported by Datubo-Brown and Adotey and Kotiso and Abduraham, respectively which they attributable to late presentation. Although some of the patients in this study presented late, most of them were in the young age group with adequate functional reserve which could have contributed to their survival.
| Conclusion|| |
In this study, the most common cause of surgical acute abdomen was acute appendicitis with age range of 21–30 years mainly affected. Bands and adhesions were noted as the most common cause of acute intestinal obstruction which differs from the previous report of obstructed/strangulated hernias. Early presentation and intervention will go a long way in improving the overall outcome of the patients.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]