CLINICAL A STUDY OF SUB ACUTE INTESTINAL OBSTRUCTION IN ADULTS
Authors: Dr. Archana shukla [Assistant professor,, dept of surgery Gandhi medical college Bhopal]
Dr. Sudhir singh pal [ Associate professor dept of surgery Gandhi medical college Bhopal]
Abstract: A study was conducted on 71 patients admitted in Hamidia hospital Bhopal dept. of surgery diagnosed as sub acute intestinal obstruction. That implies recurrent episodes of vomiting, distension of abdomen, increased bowel sounds, passing flatus and motion even after onset of symptoms but frequency reduced and palpable abdominal lump in few cases. 52 patients got relieved by conservative management. Due to this recurrence they were suffering more. Investigations were done which were mainly X rays of abdomen revealing multiple air fluid levels, ultrasonography of abdomen showing increased peristalsis and lesions like ileo- caecal thickness, appendiculer lesion. CECT was done in selected cases where ultrasonography was not conclusive. It was found that patients of SAIO with history of previous abdominal surgery responded to conservative management. Others had more inclination of having operable lesions and required more investigations and operative intervention.
Keywords: sub acute intestinal obstruction, recurrence, previous surgery, conservative treatment
Introduction: Apart from obvious cases of intestinal obstruction an almost equal number of patients were found to have sign and symptoms of obstructions but to lesser degree recurrently. Some of them were getting relieved by conservative management. They have more than one episode of obstruction, it was intermittent and hence suffering and hospitalization was for longer period of time. It was puzzling for surgeons to be decisive. A need was required for Special investigation including ultrasonography CECT to find the etiology and thus helped in management.
Method: a clinical study was conducted at dept of surgery Gandhi medical college Bhopal in unit iii over a period of one and a half year from March 2012 to March 2013. 71 patients were admitted with increased bowel sounds[59n,82%],marked decrease in frequency of passage of flatus and motion[57n,80%],abdominal distension[43n,60%] and vomiting [45n 61%] . Pain all over the abdomen was observed by almost all the patient and nature was varying.
To begin with these patients were relieved by conservative management that is, by keeping them abstained from oral diet, putting nasogasrtic tube and doing active periodical suction, parentral fluid supplementations. Significant relief was within the period of 6 hr to 48 hr. The patient who had acute symptoms of obstruction with no relief in 6 hrs were put in the category of acute intestinal obstruction and were not included in the study.
These patients details were documented as per profile features of age, sex, no. of admissions for similar episodes, and detailed history .All routine investigation were done.
Patients having history of tuberculosis previously or having family history of this disease were further subjected to investigation like mountex test. Sputum for AFB, ELISA and ADA for mycobacterium tuberculi were done. Series of X rays of abdomen, ultrasonography was done in all patients and CECT in selected patients.
This was done to know the predictors for conservative management, cause of obstruction and pathology underlying.
Those not getting relieved even after good trial of conservative mamagement were taken for exploratory laparotomy and procedure as per lesion was performed which are adhesiolysis, resection and anastomosis of bowel, stricturoplasty , ladd procedure for malrotation of gut and appendicetomy.
All patients were followed up from 6 month to 12 months time
Result: In one year 71 patients were admitted with the complaints of nausea, vomiting, pain and distension of abdomen, decreased frequency of passage of flatus and motion, increased bowel sounds and palpable abdominal lump.
The youngest was 15 year old and the oldest was 80 years of age the mean age being 46.5 yrs. were 38 males 33 females. Number of episodes ranged from 2 to6 times and duration of stay from 7 days to 60 days.
Routine hematological tests were done in all. Elisa and ADA were done in those having positive history or other investigation suggesting tuberculosis. Plain X ray abdomen was done and all patients revealed multiple air fluid levels. Ultrasonography was done and was conclusive in 15 out of 36 operative patients. CECT was done in 5 patients and was conclusive in all.
17 Patients were at one point of time required exploration and abdominal laparotomy was done, Rest of 54 patients were treated conservatively.
The most common site was small intestine followed by appendix, caecum and sigmoid.
Adhesions due to previous surgery, ileal strictures, fibrinous tubercular peritonitis , chronic appendicitis. Carcinoma of ilio-caecal junction, Mal-rotation of gut and volvulus were the causes respectively.
Out of 71 patients 32 had history of previous surgery [45.1%]. In previous surgeries again laparoscopic and abdominal tubecetomies were the biggest culprit followed by abdominal hystectomy, exploratory laparotomy for perforation peritonitis and appendicectomy. In few patients documents were not available to state exact cause of surgical procedure. Adhesiolysis was done in 2 patients who were not responding to conservative manner and 30 were treated conservatively.
25 patients were having abdominal tuberculosis. 23 out of this where diagnosed for the disease during the stay in hospital and 2 were already diagnosed but taking irregular treatment of ATT. Adhesiolysis was done in 2 patients who were found to have fibrinous adhesion. Passable strictures were found in 9 patients for which stricturoplasty and resesection anastomosis was done. Mesentric lymph node and omental biopsy was obtained for confirmation by histopathological examination. 14 patients were treated conservatively had ELISA, ADA positive for myco bacterium tuberculi and ATT was continued on this basis.
Ten patients were diagnosed as chronic appendicitis with appendiculer lump taking inappropriate inadequate treatment. Two of them were operated and adhesiolysis and appendicectomy was done . 8 were treated conservatively.
Two patients of adenocarcinoma of ileoceacal junction under went right hemicolectmy.
There was one patient of volvulus of sigmoid colon who was having recurrent episodes. He was treated by performing colocolic resection anastomosis of redundant part of colon.
Malrotation of the small intestine was found in one patient in which ladd procedure of derotation was done.
Discussion:
The study included 71 patients of SAIO. Mean age was 45.5. there were 33 males and 38 females.
In sub acute or partial obstruction patient get relieved at intervals giving false impression to patients and their relatives regarding cure of disease. The surgeons on the other hands are puzzled. Duration of symptoms ranged from 2 days to 120 days, episodes were from 2 to 6 hence suffering was more.
The most common history elicited was undergone abdominal-pelvic surgery followed by patient on ATT or a family history of tuberculosis. The patients on ATT were irregular in taking treatments.
The most common sign was that of increased bowel sounds [82%] next was decreased passage of flatus and motion.
17 patients under went exploratory laparotomy. Most common procedure was stricturoplasty and resection and anastomosis for ileal strictures [9n] followed by adhesiolysis [4] , right hemi colectomy, appendectomy, colo-colic resection and anastomosis and ladd procedure for mal rotation.
Patients who develop post operative adhesion presented as SAIO. They outnumbered other causes but thankfully settled well with conservative management.
Abdominal tuberculosis was next culprit and maximum surgery was done for this disease. This can occurs at any age. Majority of patients belonged to poor soco- economical class having poor nutrition. Non compliance to anti tubercular therapy is also contributory to present the disease as SAIO.
Patients who developed SAIO and had history of previous surgery can be treated conservatively where as others should be subjected to special radiological and biochemical investigation. In our study CECT and special ELISA for myco bacterium tuberculi were found to be most diagnostic .
In view of health problems of developing countries tuberculosis should be considered as important cause for SIAO. With regular compliance of ATT and using special investigation SAIO due to tuberculosis can be treated successfully.
Table no. 1:
s.no / cause / No. of patients1.
2.
3.
4.
5.
6. / Post op. adhesions
Intestinal tuberculosis
Appendicular lump
Illeoceacal adenocarcinoma
Volvolus
Malrotation of gut / 51
25
10
2
1
1
s.no / surgery / No. of patients
1.
2.
3.
4.
5.
6.
7. / Ressection anastomosis
Stricturoplasty
Adhesiolysis
Appendectomy
Rt.hemicolectomy
Colocolic resection anastomosis
Ladd s procedure / 5
5
4
2
2
1
1
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