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Study on Surgical Management of Acute Intestinal Obstruction in

Adults
P. Vanathi1, B. Aquinas2, V. Meenakshi Sundaram3

The death due to acute intestinal obstruction is decreasing

ABSTRACT with better understanding of pathophysiology. Improvement
Introduction: Bowel obstruction is the most common in diagnostic techniques, fluid and electrolytes correction,
intra-abdominal problem faced by general surgeons in their much potent anti-microbials and knowledge of intensive
practice. It accounts for 12-16% of surgical admissions care.3,7 Most of the mortalities occur in elderly individuals
for acute abdomen.1 The clinical presentation varies from who seek late treatment and who are having associated pre-
slight discomfort, abdominal distension to the state of sepsis existing diseases like, diabetes mellitus, cardiac diseases or
or hypovolemic shock or both requiring an emergency
respiratory disease.
intervention which all depends on the age of the patient,
Early diagnosis of obstruction, skilful operative management,
comorbidities, nutritional and hydration status, level of
obstruction, the presence of contamination in the peritoneal
proper technique during surgery and intensive postoperative
cavity. Hence timely diagnosis, prompt resuscitation and treatment carries a good result.
proper intervention with skilful technique in surgery are Study aimed to study the various ways of presentation,
needed for an optimal outcome and to reduce the mortality variousetiologies, importance of early recognition, Diagnosis
rate.16 Aim: To study the various ways of presentation, and management, to study the various influencing factors like
variousetiologies, importance of early recognition, Diagnosis age, sex, diet and socio-economic status in the pathogenesis
and management. To study the various influencing factors like of acute intestinal obstruction and to study the morbidity and
age, sex, diet and socio-economic status in the pathogenesis mortality rates in acute intestinal obstruction.
of acute intestinal obstruction. To study the morbidity and
mortality rates in acute intestinal obstruction. MATERIAL AND METHODS
Material and Methods: The incidence of acute bowel The materials for this clinical study on intestinal obstruction
obstruction in adult age group was studied from the cases were collected from cases admitted to various surgical
admitted in Department of Surgery of Thanjavur Medical wards in Thanjavur medical college Hospital attached to
College Hospital attached to the thanjavur Medical College,
Thanjavur Medical College, Thanjavur, during the period
Thanjavur during the period 1st March 2015 to 31st December
from 1st March 2015 to 31st December 2016. fifty cases of
2016.
Results: The study showed maximum incidence is in the age
intestinal obstruction have been studied. Patients belonged to
group of 31 to 40 years. Males are commonly affected. Post the age group ranging from 12 years to 85 years, paediatric
Operative adhesions are the most common cause of Intestinal age group being excluded from this study. The criteria for
obstruction. selection of cases were based on the clinical history, physical
Conclusion: Acute intestinal obstruction remains to be an examination findings, radiological and haematological
important surgical emergency in the surgical field. Success investigations. Informed consent was obtained from the
in the management of acute intestinal obstruction depends patient.
largely upon the early diagnosis, skilful management and Patients who had sub acute Intestinal obstruction, who
treating the pathological effects of the obstruction as much as were treated conservatively were excluded from the study,
the cause itself.  and only those patients of acute intestinal obstruction who
Keywords: Surgical Management, Acute Intestinal were managed surgically have been studied to establish the
Obstruction pathology of intestinal obstruction with an aim to identify
the mode of presentation, physical findings, radiological and
haematological findings, operative findings and outcome
INTRODUCTION 1
Assistant Professor, Department of General Surgery, Thanjavur
Bowel obstruction remains one of the most common intra- Medical College, Thanjavur, TN MGR University, Tamilnadu,
abdominal problemsfaced by general surgeons in their 2
Post graduate, Department of Urology, Madras Medical College,
practice whether caused by hernia, neoplasm, adhesions or Chennai, 3Post graduate, Department of General Surgery, Thanjavur
related to biochemical disturbances. Intestinal obstruction Medical College, Thanjavur, India
of either thesmall or large bowel continues to be a major
Corresponding author: Dr. P. Vanathi, M.S., No. 8, Vennila Street,
cause of morbidity and mortality.1,2 They account for 12% to
Thangam Nagar, Thanjavur – 613 007, Tamilnadu, India
16% of surgical admissions for acute abdominal complaints.
Manifestations of acute intestinal obstruction can range How to cite this article: P. Vanathi, B. Aquinas, V. Meenakshi
from a fairly good appearance with only slight abdominal Sundaram. Study on surgical management of acute intestinal
discomfort and distension to a state of hypovolemic or septic obstruction in adults. International Journal of Contemporary
shock (or both) requiring an emergency operation.3-10 Medical Research 2017;4(9):1851-1855.

International Journal of Contemporary Medical Research 1851

ISSN (Online): 2393-915X; (Print): 2454-7379 | ICV: 77.83 | Volume 4 | Issue 9 | September 2017
Vanathi, et al. Surgical Management of Acute Intestinal Obstruction

of acute bowel obstruction.4 After admission of the patient, Patients who showed a reduction in the abdominal distension
clinical data were recorded according to the proforma. and improvement in the general condition especially in those
The diagnosis was mainly based on clinical examination with postoperative adhesions,8,9 conservative treatment was
and often supported by haematological and radiological confined (by extending the supportive treatment) for next 24
examinations.11-17 hours, those who showed improvement by moving bowels
Methods or reduction in pain/tenderness were considered for further
Study has been divided into conservative treatment and such individuals were excluded
a. Clinical study from this study. Patients with clear-cut signs and symptoms of
b. Investigations acute obstruction had been managed by appropriate surgical
c. Treatment procedure after initial resuscitation. Surgery adopted and the
Study has been conducted under the following headings: criteria for deciding the procedure were noted, e.g. release
a. History taking of a band or an adhesion,20 reduction and caecopexy for
b. Physical examination intussusception, resection and anastomosis for gangrenous
c. Laboratory examination intestine and release and repair for strangulated obstruction.
d. Radiological examination – Plain X-ray abdomen – Histopathological examination of the specimen of resection/
erect view. biopsy was undertaken whenever necessary.
e. Ultrasound examination in selected cases The postoperative period had been monitored carefully and
f. Surgical treatment and results all the parameters were recorded hourly or fourth hourly basis
g. Follow-up depending on the patient’s general condition and toxemia.
i. History taking Postoperatively Nasogastric tube aspiration, intravenous
fluids and antibiotics were administered. Any complications
History taking were noted and treated accordingly.
complete detailed history was obtained from the patient and Postoperative follow-up after the discharge of patients was
the complaints were entered in the proforma in a chronological done in majority of the patients till 6 months. Most of the
order. Each complaint in the history of presenting illness has patients did not turn up for follow up after one or two visits.
been documented in detailed enquiry. The results are tabulated stressing on the following points like
Physical examination age, sex, symptoms, examination findings, investigations,
(i) General physical examination – evidence of dehydration abnormalities, possible causative factors, operative findings
and its severity were looked into and vital parameters and operative procedure that is adopted and complications
were recorded. if any.18-23
(ii) Local examination – Abdominal examination was done Statistical Methods
under the standard headings inspection, palpation, Chi-square and Fisher Exact test has been used to find the
percussion and auscultation. Per rectal examination was significance of proportion of postoperative complications in
done and findings were noted. association with etiology of acute Intestinal Obstruction. The
(iii) Systemic examination – All other systems were Statistical software namely SPSS 11.0 and Systat 8.0 had
examined carefully to rule out any associated anomalies been used for the analysis of the data and Microsoft word
and to assess the fitness for surgery. and Excel have been used to generate graphs, tables, etc.
Laboratory examination RESULTS
(i) Haemoglobin
(ii) TC and DC The incidence of acute bowel obstruction in adult age group
(iii) Bleeding and clotting time was studied from the cases admitted in Department of
(iv) Blood grouping and Rh typing Surgery of Thanjavur Medical College Hospital attached to
(v) Urine for albumin estimation and microscopy the thanjavur Medical College, Thanjavur during the period
1st March 2015 to 31st December 2016. The data on the
Radiological examination symptoms and the signs and laboratory investigations has
Erect abdomen X-ray is done in all cases, barium enema and been adopted in 50 cases during this study period. During
ultrasound examination is done in selected cases. the period of 20 months, the total number of admissions
Surgical management in surgery were 12, 233 patients. Of which 228 cases with
Immediately after the admission along with above procedure, acute intestinal obstruction were treated during this period
resuscitation with IV fluids especially ringer lactate and which comprise 1.9% of the total admissions. Among
normal saline infusion were started till the hydration and these surgically managed cases, 50 cases were randomly
urine output become normal. Nasogastric decompression selected for the present study. Table 1 and 2 shows the age
with rylestube insertion was carried out and antibiotic distribution of the patient and gender percentage of the
prophylaxis initiated. A close observation of all bedside sample. Socioeconomic status, Diet and Symptoms and
parameters (like pulse rate, BP, RR, urine output, abdominal Signs are represented in table 3, 4 and 5 respectively. Causes
girth, bowel sounds and tenderness and guarding) were done. of Intestinal Obstruction in Adults are depicted in table 5.
Emergency Blood transfusion was given in required cases. Post operative Complications including mortality is shown

1852
International Journal of Contemporary Medical Research
Volume 4 | Issue 9 | September 2017 | ICV: 77.83 | ISSN (Online): 2393-915X; (Print): 2454-7379
Vanathi, et al. Surgical Management of Acute Intestinal Obstruction

in the tables 6 and 7. Frequency of mortality in this study is DISCUSSION

14% i.e. 7 cases out of 50 cases. Among these, 6 cases were Disease Incidence
because of malignancy and one due to mesenteric ischaemia. In our clinical study, the incidence of acute intestinal
Mortality that occurred during various studies have been obstruction is 1.9% of the total surgical cases. In other studies
tabulated as follows (Table 8). Cause of death are outlined the incidence was 9.87% of total surgical cases. In one series
in table-9. incidence was 3% of total number of surgical cases. The most
common cause was found to be the postoperative adhesions
Age (years) Male female Total followed by obstructed/ strangulated10,11,15 inguinal hernia,
11 -20 5 1 6 carcinoma, intussusception, volvulus, tuberculosis and
21-30 5 3 8 mesenteric ischaemia. Although in the developing countries
31-40 7 3 10 like India, the commonest cause used to be obstructed /
41-50 3 1 4 strangulated hernia,8 in our study, commonest cause was
51-60 8 2 10 adhesions8 followed by obstructed/strangulated hernia as the
61-70 5 3 8 second cause. The decrease in the incidence of obstructed
71-80 2 1 3 hernia indicate the changing trend towards early surgery
81-90 1 0 1
before hernia gets complicated.
Total 36 14 50
Table-1: Age distribution of the patient Age Incidence
Acute Intestinal obstruction although occurs in all age
groups, the age spectrum in our study is 15 years to 85
Sex No. of Patients Percentage
Male 36 72
years.10 The study showed the maximum incidence is in the
Female 14 28 age group 31-40 of 20% and 51-60 years of 20% which is
Table-2: Sex incidence comparable to the previous study groups SouvikAdhikari et
al.,10 Cole GJ et al. group, which are nearly similar to our
clinical study of acute intestinal obstruction. The mean age
Socio economic status No. of. Patients Percentage
is our current study is 45 years where as Souvik Adhikari et
al. shows mean age of 44 years, Jahangir Sarwar Khan series
Poor 38 76
shows a mean age of 33 years. These studies are almost
Middle 12 24
comparable with our current clinical study.10-12
Upper 0 0
Total 50 100 Etiology
Table-3: Socioeconomic status The cause of acute intestinal obstruction differs from
different geographical locations. In the present clinical study,
Diet No. of Patients Percentage about 76% of the patients were of poor socio-economic class
Vegetarian 18 36 and the remaining 24% were of middle class which does not
Non Vegetarian 32 64 yield much statistical significance. But our hospital being
Total 50 100 a government set-up, which is serving mostly the poor
Table-4: Diet socio-economic status. Hence the percentage of poor socio-
economic status is high. The diet pattern in this study showed
Symptoms Signs 64% to be non-vegetarians and 36% to be vegetarians which
Abdominal pain Tachycardia did not show any significance in relation to the disease (Table
Vomiting Previous surgical scar 4). In the present clinical study of 50 cases of acute intestinal
Abdominal distension Tenderness obstruction, 40% of the cases occurred due to post operative
Constipation Rigidity adhesions who has undergone previous surgeries.
Mass In the present study, postoperative adhesions are the most
Visible peristalsis
Table-5: Symptoms and Signs Post Operative Complication Number of cases
Wound infection 2
Respiratory Tract Infection 2
Clinical Condition No. of. cases
Wound Dehiscence -
Postoperative adhesions 20
Faecal fistula -
Obstructed Hernia 15
Septicaemia 5
Volvulus 2
Table-7: Post operative complications
TB Abdomen 2
Malignancy 7
Intussusception 3 Mortality No.of Patients Percentage
Mesentric ischemia 1 Cured 43 86
Total 50 Dead 7 14
Table-6: Causes of intestinal obstruction in adults Table-8: Mortality

International Journal of Contemporary Medical Research 1853

ISSN (Online): 2393-915X; (Print): 2454-7379 | ICV: 77.83 | Volume 4 | Issue 9 | September 2017
Vanathi, et al. Surgical Management of Acute Intestinal Obstruction

common cause of intestinal obstruction, which can be resection and anastomosis for many of the cases of obstructed/
comparable with the other study groups Playforth et al. with strangulated hernia where the viability of the intestine was
54%. Although the incidence of obstructed/ strangulated doubtful and also for ischaemic bowel 22%, release of the
hernia is more in developing countries, in this study group, constricting agents and herniorrhaphy was done in 18% of
it is the second most common aetiology for the intestinal the obstructed/strangulated hernia cases. Derotation of the
obstruction. It may be because of the awareness of public, the volvulus and sigmoidopexy was done in around 4% of the
availability of good surgical facilities in the periphery for the cases.5,2 Resection and anastomosis and herniorrhaphy was
hernia repair, the hernias are managed early (table-10).10-15 done in 8% of the cases. Reduction of intussusception was
Clinical features done in one case. Two cases were managed with Hartman’s
The clinical feature of intestinal obstruction like abdominal procedure and one patient with a transverse loop colostomy.
pain, vomiting, abdominal distension and constipation were Complications
not present in all cases.2 Pain abdomen was present in 88% In the present group out of the 50 cases, complications like
of the patients in the present study, where as vomiting was septicemia occurred in 5 cases, respiratory tract infection
present in 78% of the patients. Abdominal distension was in 2 cases, wound infection occurred in two cases. The
present in 66% and constipation was present in 54% of the complication of septicemia was more in the patients with
cases. malignancy and one case with mesenteric ischaemia wherein
In the present study, the clinical features of abdominal pain there was already sepsis at the time of admission. Bowel
was 88%, vomiting was 78%, which comparable with the surgeries were done in unprepared bowel in such cases. In
other study groups (SouvikAdhikari et al. and Jahangir Two cases – one with obstructed inguinal hernia and one with
Sarwar Khan et al). Only about 66% of the patients in the carcinoma rectum, the patients already had prior co-morbid
present study group had Abdominal distension. It may be conditions of COPD, and they suffered from respiratory tract
due to an early approach to the hospital by patients in the infection.
present study. The abdominal mass on palpation is present
in 24% of the total study, more in Malignancy and ileocaecal CONCLUSION
tuberculosis. Visible peristalsis is present in only 60% of Acute intestinal obstruction remains to be an important
the intestinal obstruction patients. The rectal examination surgical emergency in the surgical field. Success in the
did not reveal any abnormality except in four patients of management of acute intestinal obstruction depends largely
intussusception (8%) and 2 cases of malignancy (4%) upon the early Diagnosis, killful management and treating
where in red currant Jelly and rectal growth were the rectal the pathological effects of the obstruction as much as the
examination findings respectively.10-12 cause itself. Erect abdomen X-ray is a valuable investigation
Surgical Management in the diagnosis of acute intestinal obstruction.
The surgical management in the present study group includes Post-operative adhesions are the common cause to produce
release of adhesions for postoperative adhesions 22%, intestinal obstruction. Clinical, radiological and operative

Age and Sex Symptoms Operative Findings Operative Procedure Cause of Death
prior to
admission
75/F (Cases no. 8) 3 days Carcinoma sigmoid colon Resection and anastomosis Septicemic shock
72/M (Cases no. 11) 8 days Carcinoma rectum Hartman’s procedure Respiratory Tract Infection
(RTI)
65/M (Cases no. 21) 5 days Mesenteric ischemia Resection anastomosis Septicemic shock
45/M (Case no. 36) 3 days Carcinoma caecum Resection and anastomosis RTI
38/F (Case no. 37) 5 days Carcinoma ovary with sigmoid Transverseloop colostomy Septicemic shock
colon infiltration
63/M (Case no. 39) 3 days Carcinoma rectum Hartman’s procedure Septicaemia
55/M (Case no. 43) 4 days Carcinoma colon Resection and anastomosis septicaemia
Table-9: Cause of death

Causes Souvik Adhikari Jahangir Brooks Arshad Playfroth Cole and m. Present study
Adhesions 16% 34% 54% 5% 40%
Hernia 36% 5% 4% 9% 18% 30%
Volvulus 6% 1% 24% 12% - 4%
Tuberculosis 14% 3% 2% - 54% 4%
Malignancy 17% 6% - 23% 23% 14%
Intussusception 2% 2% 10% 25% 3% 6%
Mes.ischaemia 9% 41% 10% 1% - 2%
Table-10: Comparison of etiology with other studies

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Volume 4 | Issue 9 | September 2017 | ICV: 77.83 | ISSN (Online): 2393-915X; (Print): 2454-7379
Vanathi, et al. Surgical Management of Acute Intestinal Obstruction

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ISSN (Online): 2393-915X; (Print): 2454-7379 | ICV: 77.83 | Volume 4 | Issue 9 | September 2017