Patients with acute intestinal obstruction consist of a major proportion of emergency room visits and the complication is associated with a significant morbidity and mortality [1].

Due to advances in diagnostic and operative techniques along with postoperative intensive care, the mortality has now decreased from 60% to less than 10% over the last century but there is considerable variation in these with age and different aetiological diagnoses [2].

we opined that with the improvement in living standards and better access to health care facilities, previously reported causes and outcomes of intestinal obstruction from developing countries might be changing, particularly for patients admitted to tertiary care hospitals in larger cities which might now be more similar to the western pattern [3,4]. Although there have been numerous reports on intestinal obstruction from western countries there have been very few publications from the developing world.  Against this background, present study was done to evaluate the Management and outcomes among acute intestinal obstruction patients admitted at IGMC Shimla.

Aims and Objectives

To evaluate the Management and outcomes among acute intestinal obstruction patients admitted at IGMC Shimla

The study was conducted in the department of General Surgery, Indira Gandhi Medical College, Shimla. The study comprised of 50 patients, selected randomly and presented with clinical features of acute intestinal obstruction between 15 June 2019 to 15 June 2020 in emergency OPD. Written informed consent was taken from all the patients in study group (annexure I). All patients were evaluated in terms of history, clinical examination, biochemical and sonological findings.

Patient Selection Criteria

Inclusion

Patient belonging to age group ranging from 14 years to 85 years of both sexes with clinical and radiological features suggestive of intestinal obstruction.

Exclusion

• Patient less than 14 years of age

• Pregnant females

Data Collection

The history of the patients was taken which included duration of symptoms, the presenting complaints, namely the type of pain, vomiting, passage of faeces and/or flatus, abdominal distension, number of previous attacks in the patients, previous treatment / surgery and presence of any co-morbid condition. Criteria for admission were pain abdomen, vomiting, abdominal distension, and obstipation.

A detailed clinical examination including rectal examination of the patient was done and the findings which were included are fever, tachycardia, abdominal signs like distension, tenderness, rigidity, guarding, bowel sounds, presence of visible/palpable bowel loops, presence of any lumps. Investigations included hemogram, biochemical parameters, plain X-ray of abdomen in erect and supine posture, ultrasonography of abdomen, CT abdomen (if necessary) and the findings were recorded. 

Following a provisional diagnosis of Acute intestinal obstruction, all the patients including those subjected to conservative management were initially managed by withholding oral intake, active aspiration of gastrointestinal secretions by Ryle’s tube, administration of intravenous fluids and correction of electrolyte imbalance. 

The patients were observed for features of relief of obstruction like reduction in vomiting, pain, and passage of faeces / flatus, reduction in tenderness, disappearance of visible/palpable bowel loops; and reduction in nasogastric tube output. Patients were also subjected to daily abdominal x rays erect and supine. If patient improves clinically and serial abdominal x rays shows improvement than patients were managed with conservative management only.

The patients were monitored regularly for development of signs of strangulation like tachycardia, fever, abdominal tenderness, etc. If the patient developed signs of strangulation, the patient was operated on emergency basis. If the patient did not get relieved conservatively within 24-48 hours of observation, exploratory laparotomy was performed.

The patients who got relieved within few hours of conservative treatment were further investigated if there was a history of recurrent similar attacks or if patient developed recurrent symptoms. Ultrasound of the abdomen and pelvis, CT scan abdomen was undertaken in a sequential order to look for findings suggestive of intestinal obstruction and specific signs which suggest cause of obstruction.

In case the investigation provided sufficient information to confirm the diagnosis of a lesion explaining the symptoms of acute intestinal obstruction in the patient, appropriate operative intervention was undertaken. 

Patients with clear-cut signs and symptoms of acute and progressive bowel obstruction (tachycardia, rebound tenderness, absent bowel sounds) were managed by appropriate surgical procedure after resuscitation.

During the surgery, the findings and procedure adopted were recorded. The patients underwent various operative procedures depending on the intraoperative findings: e.g. release of a bands and adhesions, resection and anastomosis for gangrenous bowel etc. Histopathological examination of the specimen of resection/biopsy was done wherever necessary.

All these cases were carefully managed post-operatively by restricting or avoiding oral feeds, RT suctioning and judicious use of intravenous fluids duration, of which depended on the etiology of obstruction and type of surgery performed. Patients were allowed orally only when intestines started functioning by passage of flatus or stools or functioning of stoma if made. Post-operatively, antibiotics were used in all cases. Special emphasis was laid on preventing post-operative respiratory and venous complications by making patient ambulatory early. Follow up after the discharge of patients was done in majority of the patients.

Observations And Results

This prospective study of 50 cases of acute intestinal obstruction was conducted in the Department of General Surgery, Indira Gandhi Medical College, Shimla during period from 15 June 2019 to 15 June 2020. Cases were managed conservatively and surgically. Data regarding socio-demographic characteristics, mode of presentation and physical findings were made out.

Table 1: Age and Gender distribution of study Participants

Table 1 shows Intestinal obstruction occurs in all age groups, the age spectrum in our clinical study was 14 years to 85 years.  The study shows the peak incidence in the age group 51-60 (11) and 61-70(10) years. Mean age in our current study was 53 years.  The ratio of male (37) and female (13) patients in our study was 3:1 (Table 2).

Table 2: Management of Study Participants

In our study patients of intestinal obstruction were managed more commonly surgically (60%) than conservative (40%).

History and detailed examination of every patient done. Patients with short duration of symptoms and normal pulse rate with normal bowel sounds were subjected to conservative management. Total of 29 cases were subjected to conservative management initially with daily monitoring of vitals, per abdomen examination and daily abdominal x rays erect and supine. The patients were observed for features of relief of obstruction like reduction in vomiting, pain, and passage of faeces / flatus, reduction in tenderness, disappearance of visible/palpable bowel loops; and reduction in nasogastric tube output. If patient improves clinically and serial abdominal x rays shows improvement than patients were managed with conservative management only. Out of 29 cases subjected to conservative management 9 cases showed no improvement in symptoms after 24-48 hr and exploratory laparotomy was performed in these cases (Table 3).

Table 3: Outcome among study Participants

In the present study of 50 patients, 2 patients died. All death were due to Septicaemia.

In surgical management adhesiolysis was done in 8 cases of postoperative adhesions (8). Resection and end to end primary ileo-ileal anastomosis was done in 5 cases of strictures, obstructed umbilical hernia with pre-gangrenous changes in ileum and in midgut volvulus. Resection and primary end to end jejunoileal anastomosis was done in 1 case of obstructed epigastric hernia. Appendicectomy was done in 2 cases of perforated appendix which presented clinically as acute intestinal obstruction.

Hemicolectomy was done in 6 cases of colonic malignancies and resection anastomosis and colostomy was done in 1 case of carcinoma rectosigmoid and transverse loop colostomy was done in 1 case of unresectable carcinoma rectosigmoid.

Resection anastomosis was done in 1 case of sigmoid volvulus with pre-gangrenous changes in sigmoid colon and de-rotation with sigmoidopexy was done in 1 case of sigmoid volvulus.

Resection anastomosis and ileostomy was done in 4 cases of Koch’s abdomen with perforated and gangrenous ileum.

Table 4: Factor associated with Mortality

Acute intestinal obstruction continues to be one of the commonest surgical emergencies.A total of 50 patients admitted with features of acute intestinal obstruction in the general surgery department of Indira Gandhi Medical college Shimla, during the period from 15 June 2019 to 15 June 2020, were randomly selected for the present study.

Intestinal obstruction occurs in all age groups, the age spectrum in our clinical study was 14 years to 85 years.  The study shows the peak incidence in the age group 51-60 (11) and 61-70(10) years. The mean age in our current study was 53 years where as B. T Fevang et al. [2] shows a mean age of 59 and Saravanan P.S [5] shows mean age of 52 years and 51.9 year in Patnaik et al. [6]. In the present study male to female ratio was 3:1 Whereas in B.T Fevang et al. [2] study, it was 3 :2 and 4:1 in Sarvanan P.S [7]. In the present study, out of 50 cases, 30 were operated and rest were managed conservatively (Table 5). 

Table 5: Comparison of Management with other Studies

The surgical management for the present study group includes release of adhesions 27% which is comparable with Naveen N et al. [8]with 30% , resection and anastomosis 23% which is comparable with Saravanan P.S [5] with 22%, resection anastomosis with stoma(ileostomy and colostomy) 17% which is comparable with Yuktansh Pandey et al. [9] with 14.4%, transverse loop colostomy in 3% which is comparable with Saravanan P.S⁵ with 6%, de-rotation with sigmoidopexy of sigmoid volvulus in 3% which is comparable with Yuktansh Pandey et al. [9] with 3.3%.

Although it is commonly accepted that early operation for intestinal obstruction (<24 h) decreases immediate morbidity¹⁰ however no difference in the long-term outcomes between patients operated within or after 24 h of admission were found in our study. Based on this observation, it seems reasonable to attempt conservative management for patients without any signs of severity (Table 6). In our study out of 30 operated patients 21 were operated within 12hr of admission and 5 patients were operated between 12- 24hr of admission and 4 were operated between 24-48hr after admission.

Table 6: Comparison of Mortality with other studies

Frequency of mortality in our study is 4%. These deaths were due to post- operative complications like septicaemia with other comorbidities.  Also, these cases presented to hospital lately. Table 6 represent deaths were due to delay in presentation which led to septicaemia with associated co-morbidities which played significant role in the outcome of the disease.

Acute intestinal obstruction remains a commonly encountered emergency in the surgical field. Our study concluded that most of cases of Acute Intestinal Obstruction were managed surgically. Adhesiolysis, Resection and anastomosis, Resection anastomosis & stoma creation and Hemicolectomy were the common mode of surgical management. 

Outcome of the patients is much better when time period between patient's presentation to hospital and treatment is short. Mortality is still significantly high in acute small intestinal obstruction mostly in patients with pre-existing co-morbidities like hypertension, diabetes& in patients who present late with decompensated septicaemia. 

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2. Fevang, B.T. et al. “complications and death after surgical treatment of small bowel obstruction: A 35-year institutional experience.” Annals of Surgery, vol. 231, no. 4, 2000, pp. 529–36.

3. Popoola, D. et al. “Small bowel obstruction: review of nine years of experience.” Journal of the National Medical Association, vol. 76, no. 11, 1984, pp. 1089–93.

4. Fevang, B.T. et al. “Long-term prognosis after operation for adhesive small bowel obstruction.” Annals of Surgery, vol. 240, no. 2, 2004, pp. 193–201.

5. Saravanan, P.S. et al. “Clinical study of acute intestinal obstruction in adults.” IOSR Journal of Dental and Medical Sciences, vol. 15, no. 11, 2016, pp. 76–83.

6. Patanaik, S.K. et al. “Clinical profile and outcome of subacute intestinal obstruction: A hospital-based prospective observational study.” Biomedical and Pharmacology Journal, vol. 13, no. 3, 2020, pp. 1563–71.

7. Patil, A.M. et al. “A study on clinical profile & management of acute intestinal obstruction.” WIM Journal, vol. 4, no. 1, 2017, pp. 49–56.

8. Naveen, N. et al. “A clinical study of intestinal obstruction and its surgical management in rural population.” Journal of Evolution of Medical and Dental Sciences, vol. 2, no. 21, 2013, pp. 3636–50.

9. Pandey, Y. “A prospective study of cases of intestinal obstruction and role of conservative expectant management.” International Surgery Journal, vol. 5, no. 6, 2018, pp. 2191–94.