Etiologies, Clinical Presentation and Outcome of Adult Patients Presenting with Bowel Obstruction on a Virgin Abdomen ()
1. Introduction
Intestinal obstruction (OI) is defined as an alteration or cessation of the normal flow of intestinal contents from the mouth to the anal canal. This obstruction can be located in the small intestine where it is called upper bowel obstruction or in the large intestine where it is called lower bowel obstruction. Also, some authors have classified bowel obstruction according to the duodenojenal junction, all obstructions above this junction are called upper bowel obstruction, below the junction are called lower bowel obstruction. This obstruction can be mechanical intestinal obstruction which is defined as conditions that arise when there is failure in the spread of intestinal contents due to obstruction or strangulation, associated with intra-abdominal hypertension and abdominal compartment syndrome. It can also be non-mechanical bowel obstruction which refers to the symptoms of bowel obstruction occurring due to dysfunction of the enteric nerve, smooth muscle, or contraction weakness, including dynamic bowel obstruction, acute enteric vascular ischemia [1] . The etiological factors of OI vary by geographic location with dependence on a people’s diets, lifestyles, genetics, and health-seeking behavior as well as access to surgical services [1] [2] . In advanced surgical medical systems such as the United States, the leading cause of obstruction is adhesions (74%), followed by Crohn’s disease, neoplasms and hernias [3] and this is similarly reflected in Greece where adhesions (64.8%), hernias (14.8%) and tumors of the large intestine were common etiologies with 76% of patients having low bowel obstruction while 24% had upper bowel obstruction [4] . In low-resource or developing countries, the tendency is for hernias, malignant tumors, adhesions and the unique presence of tuberculous stenoses with a frequency of 14.7% in India [5] , while in West Africa West, the main etiologic factor noted was obstructed inguinal hernia (45.7%) with an increased proportion of obstruction due to tumors [6] . Some etiologies are unique to Africa, such as in Mulago five decades ago, Ascaris Lumbricoides was found to be a common cause of obstruction [7] . Also in Ethiopia, the most common cause of small bowel obstruction was intussusception (30.9%), followed by small bowel volvulus (30.3%). Large bowel obstruction was caused by sigmoid volvulus (69.0%) followed by colonic tumor (13.8%) [8] . However, although the etiology varies from country to country and there are similar trends, for example, studies in Ghana have shown that hernias (59%) followed by adhesions and intussusceptions were the most common causes of obstruction [9] , while in Nigeria this was similarly reflected with hernias (35%), adhesions (26%) and malignant tumors (9.4%) causing an obstruction [10] [11] , usually in Africa, OI remains the main cause of acute abdomen [12] . We therefore sought to study the current etiological factors of intestinal obstruction on a virgin abdomen or an unscarred abdomen at the Central Hospital of Yaoundé in order to better understand the main causes, to better anticipate, to improve the diagnosis, the management load and evolution of intestinal obstruction in a virgin abdomen.
2. Methodes
We conducted a prospective descriptive study at the Central Hospital of Yaoundé from May 2021 to June 2022 which consisted of researching the etiological, clinical and therapeutic factors of patients with intestinal obstruction on a virgin abdomen respecting the inclusion criteria which were (patients of 16 years and above, patients with no prior abdominal surgery). All pediatric cases were excluded as well as patients with metabolic pathology. A pre-established data collection form was used to collect the relevant data (Appendix 1). We obtained ethical approval from the Ethics Committee of the Faculty of Medicine and Biomedical Sciences of the University of Yaoundé to conduct a prospective observational study with surgical patients admitted to the departments and viceral surgical unit and emergency unit of the Central Hospital from Yaounde, all patients who agreed to participate and who signed the consent form (Appendix 2) were recruited. Data were compiled and analyzed using EPI INFO software version 7 and Microsoft Excel 2007. The Chi-square test was used to test the association between variables
3. Results
3.1. Sociodemographic Profile
- Sex
During our study we recruited 73 patients, we had 44 men and 39 women, i.e. a sex ratio of 1.5:1 M/F as seen in Figure 1.
- Age
Their average age was 42.5 ± 12.9 years with an age varying from 16 to 70 years.
The main group was young adults aged 31 to 40 (28.9%). Figure 2 shows the age distribution of our patients.
3.2. Clinical and Paraclinical Presentation of Patient
Reason for consultation
The patients mainly presented with abdominal pain (98.63%).
The physical examination of the patients revealed ill-appearing patients with an absence of stools (98.63%), a distended abdomen (97.26%). Table 1 shows the most frequent complains of our patients during consultation.
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Figure 1. Distribution of patients by gender.
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Table 1. Presentation of patient complaints.
- Duration of symptoms
Most of our patients consulteds 72 hrs after the onset of symptoms giving us 42.9%. Table 2 shows us the duration of the syptoms.
- Imaging
Most of the patients did not perform any imaging work-up, i.e. 54.9%. Table 3 shows us the percentages of patients who carried out imaging works, which ones they did and those who did none.
Nevertheless, as seen in Table 4 there was a good concordance between imaging results and intraoperative results in 84.8% of cases.
3.3. Etiologies of Intestinal Occlusions on Virgin Abdomen Found
- Etiologies found
Intraoperative findings of bowel obstruction on a virgin abdomen were dominated by non-tumor etiologies at 74%, the first was obstructed hernias at 38.4%. Table 5 shows us the divisions between tumoural and non tumoral etiologies and the more detail the specific etiologies found.
Tumor etiologies were dominated by digestive tumors at 23.3%.
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Table 2. Duration of symptoms in patients.
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Table 3. Medical imaging performed for diagnostic confirmation of bowel obstruction.
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Table 4. Consistency of imaging and intraoperative findings.
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Table 5. Distribution of patients according to the etiologies found.
3.4. Etiologies Found According to Sex
In men, the most found etiology was strangulated hernias, i.e. 43.2%, while in women, the most found etiology was adhesions. Table 6 shows us the frequencies of etiology per gender.
3.5. Etiologies Found According to Age
The mst represented age group were the young adults of 31 - 40 years with a percentage of (42.8%) having stragulated hernias. Table 7 shows the age distribution per etiology.
3.6. Patient Care
- Directions
All the patients we received had an acute surgical abdomen for which a diagnosis of bowel obstruction was made. Therefore, surgery was indicated for bowel obstruction syndrome.
3.7. Anesthesia
All our patients, after clinical confirmation and/or imaging of their intestinal obstruction, were evaluated by the anesthetist team.
3.8. ASA Score
The most found ASA score of our patients was ASA 3, i.e. 50.7%. Table 8 shows the variation in the ASA score of our patiets.
3.9. Type of Anesthesia
The majority of our patients received general anesthesia. Table 9 breaks down the different type of anesthesia received by our patients.
3.10. Surgical Procedure
The surgical procedures performed on our patients depended on the intestinal viability and the level of damage to the intestines. The main procedure performed
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Table 6. Distribution of etiologies found according to sex.
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Table 7. Distribution of etiologies according to age.
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Table 8. Distribution of patients according to ASA score.
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Table 9. Breakdown by type of anesthesia.
was bowel resection and anastomosis. Table 10 demonstrates the different procedures carried out.
3.11. Outcome of Operated Patients
Complications
Poor results were mainly associated with bowel obstruction, delay in consultation and poor preoperative score.
A total of 25 patients developed complications, i.e. 31.5%. Table 11 shows us the frequency of the different complications that our patients presented. Table 12 shows us the complications per etiology. In Table 13 we see the onset of the different complications per etiology. Finally Table 14 shows us frequency of complication in relation to the duration of syptoms.
3.12. Mortality
We had 5 cases of death among our patients, amortality rate of 6.8%. Table 15 shows us the complications with highest mortality found in our patients. Table 16 shows us that tumoral etiologies presented with highest mortality and in Table 17 we see the specific etiology with the highest mortality. Finaly in Table 18 shows us the mortality risk which is elevated with late consultation.
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Table 10. Distribution according to surgical procedures.
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Table 11. Distribution according to the various complications found.
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Table 12. Distribution of complications according to etiology.
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Table 13. Breakdown by onset of complications.
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Table 14. Frequency of complications according to duration of symptoms.
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Table 16. Distribution of mortality according to etiology.
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Table 17. Distribution of mortality according to etiology.
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Table 18. Mortality according to duration of symptoms.
4. Discussion
4.1. Socio-Demographic Profile
4.1.1. Sex
In our study, a total of 73 patients were identified with a male predominance. Our result joins the other results of other authors in Africa like that of Nakanwagi et al. in Uganda also with the results obtained by MC Adam et al. in Mulango where the male sex was the most dominant [1] [4] . The male predominance can be explained by the fact that men are more involved in heavy work.
4.1.2. Age
The age of the patients varied from 16 to 70 years old, with a mean age of 42.5 ± 12.9 years old, the most represented age group was young adults from 30 to 40 years old leading to all the different etiologies. This was very similar to that of Archampong et al. in Ghana [13] who had young adults aged 30 - 45 as the main age group, but contrasted sharply with that of Van Steensel et al. in America who found that the main patient age group was >60 [7] .
4.1.3. Clinical Presentation
The most common symptoms that presented were colicky abdominal pain, vomiting, abdominal distension and relative constipation. Physical examination of our patients revealed ill-appearing patients with tender abdomens. We had 42.9% who presented after 72 hours of symptoms, only 27.1% of participants presented within 24 hours, this was similar to the results of Nakawangi et al. in Uganda and also that of MC Adam in Mulango [1] [4] where most patients presented after 72 hours after onset of symptoms, but was very different from the results of Van Steensel et al. America [7] and that of Souvika et al. in India where most of patients consulted within 24 hours. This can be explained by the fact that most of our patients were unemployed, and in our healthcare systems we have direct patient payment, this tends to delay consultation as most patients are struggling financially by compared to those working in the United States with an insurance payment method.
4.1.4. Etiologies
This study showed that hernias were the most common etiology across all areas, contrasting sharply with the findings of Collom ML et al. in Europe showing peritoneal adhesions as the most common cause of bowel obstruction [14] and also with that of Pavlidis et al. in America who described hernia as a rare etiology of intestinal obstruction [15] . However, our results were very similar to those of Nakanwagi et al. in Uganda, where hernias were the main etiology [1] . This finding also reflects the African continent where hernias are the leading cause of bowel obstruction, which may be due to the fact that most young adults are involved in heavy labor such as agriculture, masonry and many more others.
Digestive tumors (23.3%) were the second most predominant etiology in our community more common in young adults 31 - 40 years old, this finding was similar to that of Shittu OB et al. in Ibadan where digestive tumors were the second etiology after hernia [3] . This result is also very similar to all the studies carried out in our country by Eloumou AF et al. in 2020 which show that patients < 40 years old are more exposed to digestive tumours, in particular colorectal cancer [16] . Nevertheless, it was different from the studies carried out in Europe which rather portray patients > 60 years as being more exposed to digestive tumors [17] .
Third, we had peritoneal adhesions (17.8) which were more common in women. This finding was similar to a study in Accra by Archampong et al. who had peritoneal adhesions as the third most common cause in women [6] . This could be explained by the high incidence of sexually transmitted infections in our community.
Exceptionally, we had cases of intestinal obstruction by ASCARIS lumbricoides which were similar to the results of Mc Adam et al. in Mulango where ascaris obstruction was always a cause. This could be explained by the low knowledge and practice of the population in terms of deworming. Our result was extremely different from that of Van Steensel et al. in the United States where roundworm was not found among the etiologies of bowel obstruction (Table 5).
4.2. Imaging
Most of our patients did not perform imaging work up (54.9%), the main reason being financial constraints. However, the CT-scan was performed the most (19.2%) in the emergency room of our hospital, because it gave clearer and more detailed information on the pathology. These results are similar to the results of Souvika in India who present CT as a good imaging workup that gives details on the type, location and nature of the obstruction [18] .
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4.3. Surgical Procedure
Most patients underwent bowel resection with anastomosis or stoma. This can be explained by late consultations accelerated by intestinal necrosis.
4.4. Outcome of Operated Patients
An overall complication rate of 31.5% was described in our patients. The main complications being bleeding and hematoma (36%) followed by local complications (24%). Complications occurred mainly in young adults aged 31 to 40 who consulted 72 hours after the onset of symptoms. Consultation time was statistically significant with a p-value of 0.018. This result was similar to studies conducted in Ethiopia by Yousef amara et al. and in Uganda by Nakawanji et al., in both studies patients who consulted after 72 h after the onset of symptoms were more prone to develop complications [1] [18] , this could be explained by the delay of patients seeking care in our community. But our results were very contrasted with those of collom Ml et al. in London who had very few complications, however the complications were not due to the time of the consultation because most of their patients consulted within 24 hours of the consultation onset of symptoms [14]
In addition, a large majority of patients who developed complications were diagnosed with digestive tumors (30.4%), this result is similar to a study conducted in university teaching hospitals in our community which shows that patients diagnosed with a digestive tumor are at high risk of complications.
Our study also revealed that patients with a high ASA score had a greater tendency to develop complications. This was statistically significant with a p-value of 0.032.
4.5. Mortality
We observed a total mortality rate of 6.8%. Most of our deceased cases had tumor etiologies (60%) with a mortality rate of 15.8%. This result is similar to recent studies conducted in our country by Eloumou et al. which show a high risk of morbidity and mortality in late diagnosis of digestive tumors [16] . This result was very far from the mortality rate of 2.8% in the study by Pavilidis et al. in America [15] . This is mainly because most of their patients consulted and were taken care of early.
We also noticed that cases of death were more frequent in patients who consulted after 72 hours (13.3%). this was very similar to the results of Nakawangi et al. in Uganda [1] . This can be explained by the fact that most of these patients had severe intestinal lesions and progressive sepsis. This result was statistically significant with a p-value of 0.280
All of our deceased patients had an ASA score of 4 (100%). Which was statistically significant with a p-value of 0.032.
The main complication associated with the death of our patient was attributed to an embolism. This was closely followed by bleeding leading to anemia.
But some causes of death could not be assessed or purely attributed to postoperative complications due to the immunocompromised state of our patients.
5. Conclusion
Bowel obstruction remains a cause of acute abdomen in our community; it seemed appropriate to us to know the causes and to determine the outcome in patients who have never been operated on. Thus it is found mainly in men aged 31 to 40 years. Most patients presented with abdominal pain, constipation, distension and tenderness, presenting after 72 hours. We experienced a low rate of imaging workups performed by our patients, which was attributed to lack of finance and knowledge. Strangulated hernia first, closely followed by digestive tumors and peritoneal adhesions were the most frequent etiologies. Complications and mortality depend on time of consultation, etiology and ASA score.
Recommendations
● To ministry of public health
- To organise campaigns for the distribution of albendazole in our rural areas.
● To the FMBS
- Futher studies should be carried on BO-VA in our community.
● To the physicians
- Faster actions should be posed on patients presenting with BO-VA.
- Pre operatory reanimation such as blood transfusion and post operatory reanimation to avoid complications should be done in patients with especially with etiologies of digestive tumours to ameliorate outcome.
- Close follow up of patients with tumoral in post operatory as they are at high risk of developing complications.
- Patients with ASA score of 4 should be systematically sent to intensive care unit after surgery.
● To hospital administration.
- To encourage the insurance paying method especially at the emergency unit. As this will accelerate the management of patients.
Appendix 1: Questionnaire
DATA COLLECTION SHEET
Number of file:
Date:
Phone Number:
Appendix 2: Participant Consent Form
(English version)
Mr./Mrs./Ms....................................................................................................
Title: “AETIOLOGIES OF BOWEL OBSTRUCTION ON A VIRGIN ABDO- MEN IN THE CENTRAL HOSPITAL OF YAOUNDE”.
The final year Medical Student, EL ALAOUI MOUNJID Khadija Emmanuella, proposed to me to participate in a study they are carrying out at the Yaounde Central Hospital (HCY) in view of her M.D. Thesis. This study has as main aim to
She précised to me that I was free to accept or refuse the proposal. I have received and understood the following information:
● The aim of this study
● The procedure
● Possible constraints and risks
I accept that my medical records be consulted by the research personnel and used for research purposes only. My medical record will be discussed with me at the end of the study. My participation can be interrupted at any time if the principal investigator deems it necessary or if I wish. All data concerning me will be strictly confidential. Only the research personnel, and eventually a health authority representative will be given access to my data. The research protocol for this study has been reviewed and validated by the institutional committee of research and ethics of the Faculty of Medicine and Biomedical Sciences. At any time, I can ask for supplementary information from the student investigator EL ALAOUI MOUNJID Khadija Emmanuella, using the phone number: 651744547.
I hereby accept to participate in the study under the aforementioned conditions. A signed copy of this consent form will be given to me and will serve its purpose in time of need.
Date: ......../........../..............
Investigator’s signature Volunteer’s signature