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Abstract
AIM: To identify and analyze the clinical presentation,
management and outcome of patients with acute
mechanical bowel obstruction along with the etiology
of obstruction and the incidence and causes of bowel
ischemia, necrosis, and perforation.
METHODS: This is a prospective observational study of
all adult patients admitted with acute mechanical bowel
obstruction between 2001 and 2002.
RESULTS: Of the 150 consecutive patients included
in the study, 114 (76%) presented with small bowel
and 36 (24%) with large bowel obstruction. Absence
of passage of flatus (90%) and/or feces (80.6%) and
abdominal distension (65.3%) were the most common
symptoms and physical finding, respectively. Adhesions
(64.8%), incarcerated hernias (14.8%), and large
bowel cancer (13.4%) were the most frequent causes
of obstruction. Eighty-eight patients (58.7%) were
treated conservatively and 62 (41.3%) were operated
(29 on the first day). Bowel ischemia was found in 21
cases (14%), necrosis in 14 (9.3%), and perforation in
8 (5.3%). Hernias, large bowel cancer, and adhesions
were the most frequent causes of bowel ischemia (57.2%,
19.1%, 14.3%), necrosis (42.8%, 21.4%, 21.4%), and
perforation (50%, 25%, 25%). A significantly higher risk
of strangulation was noticed in incarcerated hernias than
all the other obstruction causes.
CONCLUSION: Absence of passage of flatus and/or
feces and abdominal distension are the most common
symptoms and physical finding of patients with acute
mechanical bowel obstruction, respectively. Adhesions,
hernias, and large bowel cancer are the most common
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INTRODUCTION
Acute mechanical bowel obstruction is a common surgical
emergency and a frequently encountered problem in
abdominal surgery [1,2]. It constitutes a major cause of
morbidity and financial expenditure in hospitals around the
world[3] and a significant cause of admissions to emergency
surgical departments[2,4]. Intestinal obstruction belongs
to highly severe conditions, requiring a quick and correct
diagnosis as well as immediate, rational and effective
therapy[5,6].
Surgeons are concerned about bowel obstruction cases
because strangulation, causing bowel ischemia, necrosis
and perforation might be involved, and it is often difficult
to distinguish simple obstruction from strangulation.
Accurate early recognition of intestinal strangulation in
patients with mechanical bowel obstruction is important to
decide on emergency surgery or to allow safe nonoperative
management of carefully selected patients[1,2,7,8]. Although
close and careful clinical evaluation, in conjunction with
laboratory and radiologic studies, is essential for the
decision of proper management of patients with acute
mechanical bowel obstruction[1], a preoperative diagnosis
of bowel strangulation cannot be made or excluded reliably
by any known parameter, combinations of parameters, or
433
Variable
1
RESULTS
During the two years study period, 150 consecutive adult
patients with acute mechanical bowel obstruction were
admitted and composed our study group. Mean age of
the patients was 63.8 1.3 years while women comprised
60% of the group. The majority of the patients (76%)
presented with small bowel obstruction. Demographic,
clinical, and laboratory data of the study group on arrival
at the Emergency Department are presented in Table 1.
Regarding clinical presentation of the patients, absence
of passage of flatus (90%) and/or feces (80.6%) were
the most common presenting symptoms and abdominal
distension (65.3%) was the most frequent physical finding
on clinical examination.
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434
ISSN 1007-9327
CN 14-1219/R
World J Gastroenterol
Adhesions
Hernia
Large bowel cancer
Small bowel tumor
Retroperitoneal tumor
Crohns disease
Small bowel volvulus
Ovarian
cystadenocarcinoma
Acute diverticulitis
Sigmoid volvulus
84 (73.8%)
21 (18.5%)
3 (2.6%)
3 (2.6%)
0 (0%)
2 (1.7%)
1 (0.8%)
0 (0%)
0 (0%)
0 (0%)
13 (36.3%)
1 (2.7%)
17 (47.4%)
0 (0%)
2 (5.5%)
0 (0%)
0 (0%)
1 (2.7%)
97 (64.8%)
22 (14.8%)
20 (13.4%)
3 (2.0%)
2 (1.3%)
2 (1.3%)
1 (0.6%)
1 (0.6%)
1 (2.7%)
1 (2.7%)
1 (0.6%)
1 (0.6%)
n (%)
Value
Ischemia
Necrosis
Perforation
Small bowel
obstruction
group (n = 114)
15 (13.2%)
8 (7%)
4 (3.5%)
Large bowel
obstruction
group (n = 36)
6 (16.6%)
6 (16.6%)
4 (11.1%)
Total study
group
(n = 150)
21 (14%)
14 (9.3%)
8 (5.3%)
Volume 13
Number 3
Small bowel
Large bowel
Total study
obstruction
obstruction
group
group (n = 114) group (n = 36) (n = 150)
Cause
Value
Small bowel
obstruction
group (n = 114)
Large bowel
obstruction
group (n = 36)
Total study
group
(n = 150)
Operative
treatment1
Nonoperative
treatment1
Time between
arrival and
operation (h)2
Operation on the
1st day1
Operation on the
2nd day1
Operation on the
3rd day1
Complication1
Intensive Care
Unit (ICU)
admission1
ICU length of
stay (d)2
Hospital length
of stay (d)2
Mortality1
35 (30.7%)
27 (75%)
62 (41.3%)
79 (69.3%)
9 (25%)
88 (58.7%)
22 (19.3%)
7 (19.4%)
29 (19.3%)
4 (3.5%)
2 (5.5%)
6 (4%)
5 (4.3%)
3 (8.3%)
8 (5.3%)
4 (3.5%)
6 (5.2%)
2 (5.5%)
3 (8.3%)
6 (4%)
9 (6%)
435
Cause
Ischemia
(n = 15)
Necrosis
(n = 8)
Cause
Ischemia
(n = 6)
Necrosis
(n = 6)
Perforation
(n = 4)
Hernia
Adhesions
Small bowel volvulus
Large bowel cancer
Small bowel tumor
11 (73.3%)
2 (13.3%)
1 (6.7%)
1 (6.7%)
0 (0%)
5 (62.5%)
2 (25%)
1 (12.5%)
0 (0%)
0 (0%)
3 (50%)
1 (16.6%)
1 (16.6%)
1 (16.6%)
0 (0%)
0 (0%)
3 (50%)
1 (16.6%)
1 (16.6%)
1 (16.6%)
0 (0%)
0 (0%)
2 (50%)
1 (25%)
1 (25%)
0 (0%)
0 (0%)
0 (0%)
Perforation
(n = 4)
3 (75%)
1 (25%)
0 (0%)
0 (0%)
0 (0%)
DISCUSSION
Acute mechanical bowel obstruction remains a frequently
encountered problem in abdominal surgery and a common
surgical emergency [1,2] , which is a frequent cause of
admissions to hospital emergency surgical departments[2,4].
The majority of our study group presented with acute
mechanical small bowel obstruction. This has also been
found in other studies with small bowel obstruction
accounting for about 80% of total obstruction cases[9,20,21].
Regarding clinical presentation of our patients, absence
of passage of flatus and/or feces were the most frequent
presenting symptoms and abdominal distension was the
most common physical finding on clinical examination.
Additionally, vomiting, nausea, colicky abdominal pain, and
abdominal discomfort were frequent symptoms on arrival.
Our results, even though some differences are noticed,
are in accordance with the literature[6,12,13,22,23]. Particularly,
Ischemia
(n = 21)
Necrosis
(n = 14)
Perforation
(n = 8)
Hernia
Large bowel cancer
Adhesions
Small bowel volvulus
Sigmoid volvulus
Small bowel tumor
Retroperitoneal tumor
Ovarian cystadenocarcinoma
12 (57.2%)
4 (19.1%)
3 (14.3%)
1 (4.7%)
1 (4.7%)
0 (0%)
0 (0%)
0 (0%)
6 (42.8%)
3 (21.4%)
3 (21.4%)
1 (7.2%)
1 (7.2%)
0 (0%)
0 (0%)
0 (0%)
4 (50%)
2 (25%)
2 (25%)
0 (0%)
0 (0%)
0 (0%)
0 (0%)
0 (0%)
436
ISSN 1007-9327
CN 14-1219/R
World J Gastroenterol
Volume 13
Number 3
437
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REFERENCES
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11
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25
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27
28
29
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E- Editor Lu W
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