Pattern, management and outcome of intestinal obstruction at the Moi Teaching and Referral Hospital

Abstract

Background: Intestinal obstruction is severe impairment or complete failure in propagation of intestinal contents in the normal cranio-caudal direction. It is a common surgical emergency with an incidence of 8.8/100,000/year in Uasin Gishu County. The outcomes vary in different centers. Despite MTRH providing care for patients with intestinal obstruction for years, no data exists on the outcome among these patients. This study aimed at bridging this gap. Objective: To determine the pattern, management and outcome in patients with intestinal obstruction at the MTRH. Methodology: Study site: The surgical wards and accident/ emergency department at the MTRH. Subjects: Patients diagnosed with intestinal obstruction and met the selection criteria presenting at the MTRH between 15th Sept. 2013 and 15th Dec. 2014. Study design: Hospital-based prospective study. Sampling method: Purposive consecutive sampling. Sample size: A total of 199 patients were eligible during the study period and all were included. Data management: Data was collected using interviewer administered structured questionnaires through interviews, clinical examination and review of medical records. The data was entered in MS Access, coded and SPSS version 21 used for analysis. Statistical tests used in analysis were Chi square, student-t test and Fisher’s exact tests while logistic regression was used to control for confounders. Main results: A total of 199 patients were studied. Among them 80 (40.2%) were children (≤12 years). The male/female ratio was 1.4:1. The median age was 22 years (mean and SD of 25.8 ±24.7years and range of 1 day to 86 years). Majority (84.3%) of the patients had a late presentation to hospital (>24 hours). Many (93 patients, 46.7%) of the patients studied had an acute presentation (less than 4 days) with a mean duration of illness of 2.03±0.9 days. The main presentation was abdominal distension (58.6%) and vomiting (55.1%). Among children, anorectal malformation (35cases, 43.8%) and intussusception (22cases, 27.5%) were the commonest causes of obstruction. Adhesion (39cases, 32.8%) and bowel volvulus (31cases, 26.1%) were the commonest causes among subjects aged >12 years. Surgery was done in 164 patients (82.4%) and gangrene was found in 23% of these. Intussusception was the commonest diagnosis among patients with gangrene. Among the patients treated surgically, only 38.8% and 57.3% received adequate fluids in the pre- and post-operative periods respectively. None of the patient studied had adequate nasogastric tube management. Complications occurred in 47 (23.6%) patients and the mean length of stay was 8.5±6.7days (range 1-46 days). The overall mortality rate was 15% (18.8% in children and 12.6% in patients > 12 years). The main cause of death was septicaemia. Bowel gangrene was the only factor among those evaluated that significantly influenced outcome after control for confounders (p-0.015). Conclusion: Adhesions, ARM, volvulus and intussusception are the common causes of intestinal obstruction at MTRH. Bowel gangrene is the single independent determinant of outcome in patients with intestinal obstruction. Recommendation: Timely diagnosis and management of intestinal obstruction should be encouraged to reduce the rate of bowel gangrene. Improvement in supportive treatment, including fluid therapy and bowel decompression, among patients with intestinal obstruction at MTRH may help improve the outcome.