|Year : 2018 | Volume
| Issue : 1 | Page : 11-14
Changing pattern of intestinal obstruction at Nnewi, South-Eastern Nigeria
Chiemelu D Emegoakor, Ikechukwu C Iloabachie, Henry C Nzeako, Stanley N C Anyanwu
Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
|Date of Submission||23-Dec-2018|
|Date of Decision||29-Apr-2019|
|Date of Acceptance||18-Dec-2019|
|Date of Web Publication||20-Jan-2020|
Dr. Chiemelu D Emegoakor
Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi
Source of Support: None, Conflict of Interest: None
Background: Intestinal obstruction is a common surgical emergency. Its pattern and causes vary between communities. Previous reports, including a study from Nnewi, showed obstructed external hernias to be the most common cause. Objective: The objective of the study is to determine the current pattern of intestinal obstruction at Nnewi. Materials and Methods: All case notes of intestinal obstruction managed at Nnewi between January 1, 2000, and December 31, 2009, were retrieved and analyzed. Results: It was found that adhesions caused 62.1% of cases of intestinal obstruction, while obstructed external hernias caused 21.4%. The rest were from other causes. Furthermore, 62.5% of intestinal obstruction from adhesions were managed nonoperatively. Conclusion: Adhesion has emerged as the most common cause of intestinal obstruction at Nnewi.
Keywords: Adhesions, intestinal obstruction, obstructed external hernias
|How to cite this article:|
Emegoakor CD, Iloabachie IC, Nzeako HC, C Anyanwu SN. Changing pattern of intestinal obstruction at Nnewi, South-Eastern Nigeria. Niger J Surg Sci 2018;28:11-4
|How to cite this URL:|
Emegoakor CD, Iloabachie IC, Nzeako HC, C Anyanwu SN. Changing pattern of intestinal obstruction at Nnewi, South-Eastern Nigeria. Niger J Surg Sci [serial online] 2018 [cited 2021 Jun 22];28:11-4. Available from: https://www.njssjournal.org/text.asp?2018/28/1/11/276109
| Introduction|| |
Intestinal obstruction is a common surgical emergency and a frequently encountered problem in abdominal surgery worldwide., Its pattern and causes vary between communities and in different age groups. Its pattern is also known to change over time.
Previous reports ,,,, indicate that in black Africans, obstructed external hernias, potentially preventable cause of intestinal obstruction, cause the majority of obstruction with the associated high mortality.
There are reports showing increasing incidence of adhesive intestinal obstruction in our environment, in some reports, it is now more common than hernia.
The purpose of this study is to document the pattern of intestinal obstruction in Nnamdi Azikiwe University Teaching Hospital, situated in a semi-urban community, with a view to identifying changing trends in the etiology and also to compare with previous studies and reports in other parts of black African.
| Materials and Methods|| |
The study is a retrospective review of all patients above the age of 15 years with a diagnosis of intestinal obstruction between January 1, 2000, and December 31, 2009. Patients were identified from accident and emergency and surgical wards records. From the admission records, demographic data, the symptoms and duration before presentation, preoperative diagnosis, treatment modality, and outcome were collected. Intraoperative findings were also noted where applicable. Patients who had diagnosis requiring surgery but who died before the operation were also excluded from the study. Data were analyzed using Epi Info.
| Results|| |
From the records, 246 patients were identified as having intestinal obstruction. Of these, only the case notes of 231 patients were found and 13 cases were found not to be intestinal obstruction, while 22 were excluded from the study. The remaining 196 case notes were analyzed.
The age range was 19–90 years, while the mean age was 47.5 years. There was a bimodal peak at 30–39 years and 60–69 years.
The male:female ratio was 1:1.4.
The symptoms and signs at presentation included abdominal pain, bilious vomiting, constipation, abdominal masses, and abdominal distention.
The duration of illness prior to presentation ranged from 1 day to 2 years, with a mode of 4 days and a mean of 34.2 days.
Majority of the patients, 84.6% had visited a peripheral hospital before presentation to the teaching hospital.
The diagnosis of adhesive intestinal obstruction was made in 122 patients (62.1%), 42 patients (21.4%) had intestinal obstruction from hernias of various types and 19 (9.7%) patients were diagnosed with malignancy. The rest of the causes are listed in [Table 1]. Malignancy accounted for 13 of the patients presented as chronic intestinal obstructions with symptoms lasting more than 30 days before presentation, while adhesions accounted for 20. The rest presented as acute obstruction.
Of those that had adhesions, 76 (62.5%) were managed nonoperatively, 29 (23.4%) required surgery, while the treatment was primarily operative in 17 patients because they presented late and already qualified for surgery at presentation.
A history of previous surgery was present in 89 of the 122 patients with adhesions, 11 patients had no history of surgeries, and there was no documentation for the remaining 22 patients. Ninety-four different types of surgeries were documented for the 89 patients, some having undergone more than one surgery. The types of surgery and their frequency are outlined in [Table 2]. The rest were probably caused by primary inflammatory conditions.
All the patients, apart from those with adhesions, were managed surgically. The recorded postoperative complications were bleeding, deep venous thrombosis that was complicated by pulmonary embolism, postoperative fever, ileus, electrolyte in balance, and wound infection.
The average duration of hospital stay was 14 days with a range of 1–78 days.
There were five deaths, one from deep venous thrombosis and others from aspiration pneumonitis. One patient died on table while the causes of death for the remaining two were not recorded. Of these five deaths, two occurred before surgery, one from aspiration pneumonitis, and the others from one of those in which the cause of intestinal obstruction was not recorded.
| Discussion|| |
The mean age of presentation, 47.5 years, is similar to that obtained by Oladele et al. They also noted a bimodal peak in age presentation, but in their case, it was in the 15–29 and 45–59 years of age groups as opposed to the 30–39 years and 60–69 years found in this study. Ojukwu and Aghaji  found that intestinal obstruction is the most common between 21 and 50 years old. No explanation is documented in literature for these, but this is the active age group and hernias are more common in this age group, this can probably explain these.
The Male:female ratio of 1:1.4 is a reversal of what obtained in other studies with a greater male preponderance ranging from 1.7:1 to 4:1., It is possible that the high number of gynecological conditions in our series may contribute to this. In addition, females suffer more from primary inflammatory conditions that may lead to adhesive intestinal obstructions. These inflammatory conditions include pelvic inflammatory disease and primary peritonitis.
Some recent studies , have reported an increasing incidence of adhesive intestinal obstruction. This study was not different with 62.1% being diagnosed with adhesive intestinal obstruction; the figures from other studies are similar. Ojukwu and Aghaji  reported 61% of cases of intestinal obstruction over a 5-year period due to adhesive intestinal obstruction.
Osuigwe and Anyanwu  in a previous review in the same center as this study noted a slightly greater number of cases of intestinal obstruction due to hernias than adhesions.
The rising incidence of adhesive intestinal obstruction can be attributed to the increasing number of abdominal surgeries and also an increase in elective hernia surgeries.,, Other causes of adhesion noted include abdominal inflammatory conditions, including sepsis and abdominal trauma. Oladele et al. noted that 75% of patients with adhesive intestinal obstruction have had previous surgeries. It is important to note that studies from Europe report adhesions as the commonest cause of intestinal obstruction like the study by McEntee et al. It also important to note that in Caucasians, malignancy is the second most common cause of obstruction.
Most cases of adhesive intestinal obstruction were diagnosed clinically following typical history and examination findings. However, the certainty of the diagnoses in cases managed nonoperatively may be called into question. Osuigwe and Anyanwu  eliminated this uncertainty in their study using only cases with an operative diagnosis. Oladele et al. in addition, assumed improvement with conservative treatment as confirmation of the diagnosis. In this study, the diagnosis of adhesive intestinal obstruction was confirmed either by successful nonoperative management or by findings at surgery.
In this study, of the 19 patients diagnosed with an adhesive intestinal obstruction that underwent surgery, 17 had correct diagnosis giving an accuracy rate of 89.4%, similar to the 84.4% recorded by Oladele et al. The others 2 were caused by tumors.
Nonoperative treatment was successful in 62.5% of patients with adhesions. It has been documented that up to 50% of cases can be managed conservatively. The formation of adhesions after transperitoneal operation can be both beneficial and deleterious.,,, On the one hand, adhesions can isolate suture line leakage or localize an inflammatory process, thus preventing more widespread disease. On the other hand, it may contribute to morbidity, with obstruction being the major serious contribution. Small bowel obstruction due to postoperative adhesions develops in 6%–11% of all patients undergoing laparotomy.,,
Obstructed external hernias still remain an important cause of intestinal obstruction. In this study, inguinal hernias were the most common; others recorded include femoral, paraumbilical, epigastric, and lumbar hernias.
Colonic cancers accounted for 9.2% of cases in this study. The age of the patients ranged from 54 to 85 years, indicating that malignancy occurs in the older patients.
The overall mortality rate is 4.2%, which is much lower than the 20% mortality quoted for intestinal obstruction. Remarkably, Ojukwu and Aghaji recorded no mortality while others recorded figures ranging from 14% to 19.7%.
A notable limitation of this study was the unavailability of a lot of records and also incomplete documentation in the case folders. A number of patients had intestinal obstruction diagnosed without a provisional or definitive diagnosis regarding the cause.
| Conclusion|| |
Adhesive intestinal obstruction is presently the leading cause of intestinal obstruction in our environment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
MuchaPJr. Small intestinal obstruction. Surg Clin North Am 1987;67:597-620.
Miller G, Boman J, Shrier I, Gordon PH. Natural history of patients with adhesive small bowel obstruction. Br J Surg 2000;87:1240-7.
Oladele AO, Akinkuolie AA, Agbakwuru EA. Pattern of intestinal obstruction in a semiurban Nigerian hospital. Niger J Clin Pract 2008;11:347-50.
] [Full text]
Adesunkanmi AR, Agbakwuru EA. Changing pattern of acute intestinal obstruction in a tropical African population. East Afr Med J 1996;73:727-31.
Osuigwe AN, Anyanwu SN. Acute intestinal obstruction in Nnewi Nigeria: A five year review. Niger J Clin Res 2002;4:107-11.
Naader SB, Archampong EQ. Changing pattern of acute intestinal obstruction in Accra. West Afri J Med 1993;12:82-8.
Archampong EQ, Naaeder SB, Darko R. Changing pattern of intestinal obstruction in Accra, Ghana. Hepatogastroenterology 2000;47:185-93.
Badoe EA. Acute Intestinal Obstruction in Kurle Bu Teaching Hospital, Accra: 1965-1969. Ghana Med J 1970:283-7.
Lawal OO, Olayinka OS, Bankole JO. Spectrum of causes of intestinal obstruction in adult Nigerian patients. S Afr J Surg 2005;43:34, 36.
Ojukwu JO, Aghaji AE. Causes and management of intestinal obstruction at the University of Nigeria Teaching Hospital Enugu. J Coll Med 2002;7:57-8.
McEntee G, Pender P, Mulvins D. Current Spectrum of intestinal obstruction. BJS 1987;74:976-80.
Scott-Coombes DM, Whawell SA, Thompson JN. The operative peritoneal fibrinolytic response to abdominal operation. Eur J Surg 1995;161:395-9.
Holmdahl L, Eriksson E, Eriksson BI, Risberg B. Depression of peritoneal fibrinolysis during operation is a local response to trauma. Surgery 1998;123:539-44.
Holmadahl L, Risberg B. Adhesions: Preventions and complications in general surgery. Eur J Surg 1997;163:169-14.
Dijkstra FR, Nieuwenhuijzen M, Reijnen MM, van Goor H. Recent clinical developments in pathophysiology, epidemiology, diagnosis and treatment of intra-abdominal adhesions. Scand J Gastroenterol Suppl 2000:52-9.
Bass KN, Jones B, BulkleyGB BB. Current management of small bowel n
obstruction. Adv Surg 1997;161:395-9.
Jastaniah S, Abu-Eshy S, Batouk AN, al-Shehri M. Intestinal obstruction in a Saudi Arabian population. East Afr Med J 1996;73:764-6.
Sourkati EO, Fahal AH, Suliman SH, el Razig SA, Arabi YE. Intestinal obstruction in Khartoum. East Afr Med J 1996;73:316-9.
[Table 1], [Table 2]