|Year : 2019 | Volume
| Issue : 3 | Page : 49-54
A prospective study to determine the clinical profile of patients suspected to have acute intestinal obstruction in the emergency department
B Kirubagaran1, Kundavaram Paul Prabhakar Abhilash1, Srujan Lam Sharma2
1 Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of General Surgery, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||17-Jul-2019|
|Date of Acceptance||29-Jul-2019|
|Date of Web Publication||26-Sep-2019|
Dr. Kundavaram Paul Prabhakar Abhilash
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Acute intestinal obstruction (AIO) is a surgical emergency, with its varied symptomatology and presentation, and diagnosing it is always a challenge to the emergency physician. This study was done to understand the prevalence, various etiologies, usefulness of computerized tomography (CT) of the abdomen in the diagnosis, rate of surgical management, and outcome of AIO in the emergency department (ED). Materials and Methods: This prospective study included all the patients who presented to the ED with a history of inability to pass stools and flatus and diagnosed to have intestinal obstruction clinically. This study was conducted for a duration of 6 months (December 2017–May 2018). Patient's clinical parameters, radiological imaging, etiology, treatment given, and outcome of the patients were noted. Results: Among 15,857 patients who presented to the ED over a study period, 90 (0.567%) patients had AIO out of 120 suspected cases. The most common age group (22%) was more than 60 years of age with female preponderance (55.6%). Most common etiological factor was adhesion (26.67%), followed by hernia (23.3%). Among 120 suspected patients, those who had undergone CT abdomen (n = 59) showed 95.6% of sensitivity, 100% of specificity, and 96.6% of accuracy in comparison with abdomen X-ray and ultrasonography abdomen. Forty-two (46.7%) patients diagnosed with AIO were operated, while 32 (35.6%) patients were managed conservatively and the remaining 16 (17.8%) patients were discharged against medical advice. The mortality rate among the operated patients was 2.7% (n = 2). Conclusion: In the ED, women in their sixties were the one who most commonly presented with AIO. The most common cause of admission with AIO was adhesions. CT abdomen is an accurate modality for diagnosing AIO.
Keywords: Acute intestinal obstruction, computed tomography, emergency department, intestinal adhesion
|How to cite this article:|
Kirubagaran B, Abhilash KP, Sharma SL. A prospective study to determine the clinical profile of patients suspected to have acute intestinal obstruction in the emergency department. Curr Med Issues 2019;17:49-54
|How to cite this URL:|
Kirubagaran B, Abhilash KP, Sharma SL. A prospective study to determine the clinical profile of patients suspected to have acute intestinal obstruction in the emergency department. Curr Med Issues [serial online] 2019 [cited 2019 Oct 14];17:49-54. Available from: http://www.cmijournal.org/text.asp?2019/17/3/49/267904
| Introduction|| |
Intestinal obstruction occurs due to partial or complete interference with the forward flow of small or large intestinal contents. Acute intestinal obstruction (AIO) has a varied symptomatology; it can be easily missed if the clinical history and examination are inadequate. Hence, the primary objective of the emergency physician in evaluating a patient with abdominal pain, constipation, is to rule in or rule out the possibility of intestinal obstruction. The patients with a history of abdominal distension, obstipation, prior abdominal surgery, and abnormal bowel sounds may fall into the diagnosis of intestinal obstruction. Diagnosing AIO among the suspected patients is crucial as it warrants close observation and surgical intervention if necessary. There is no compelling evidence to identify which patients require operative management or with conservative treatment. Prompt decision regarding appropriate treatment approach might obviate the potential morbidity and mortality. Radiological imaging serves as a useful adjunctive investigation when the diagnosis is less certain. The role of computed tomography (CT) abdomen in the diagnosis of bowel obstruction has recently expanded, in patients with suspected bowel obstruction. CT is recommended for the evaluation, particularly when clinical and initial conventional radiographic findings remain indeterminate or strangulation is suspected. This study describes the prevalence of AIO in the emergency department (ED), various causes, usefulness of CT abdomen in the diagnosis, rate of surgical intervention, and the outcome. To our knowledge, this unique study has been done for the first time in the ED regarding clinical profile of suspected AIO patients globally.
| Materials and Methods|| |
We conducted a prospective, observational study in the ED, Christian Medical College in Vellore, which is a 45-bedded independent clinical unit, one of the largest in South India with an average of 250 patients visiting per day. Patients suspected to have AIO presenting to the ED from November 2017 to May 2018 were included in the study.
The inclusion criteria were:
- All patients who presented to ED with symptoms of inability to pass stools and flatus for more than 48 h.
The exclusion criteria were:
- Pediatric age group, chronic and recurrent intestinal obstruction.
Data of the patients were obtained from the electronic hospital records; details of history and physical examination findings of all patients were recorded on a standard data collection sheet. The following were extracted: demographics, symptoms, signs, laboratory tests, radiological findings, the proportion of patients undergoing operative intervention, and surgical complications. Triage priority level was described as follows:
- Triage priority 1: Airway, breathing, or circulation compromise or hemodynamically unstable and altered sensorium
- Triage priority 2: Stable airway, breathing, and circulation. Severe abdominal pain which requires immediate attention or analgesic
- Triage priority 3: Hemodynamically stable with mild abdominal pain.
All patients had routine blood investigations and relevant radiological tests based on the initial presentation. After initial stabilization by the ED team, patients were handed over to the surgeons for further management.
Statistical analysis was performed using SPSS Inc., Released 2007. SPSS for Windows, version 16.0, (Chicago, Ilinois, USA), and frequencies of each variable were entered. This was a descriptive analysis, and no test of significance was used. This study was approved by the institutional review board, and patient confidentiality was maintained using unique identifiers and by password-protected data entry software with restricted users.
| Results|| |
Among 15,857 patients who presented to ED over the study period of 6 months, the prevalence of AIO was 0.6%. There were 90 patients with AIO out of 120 suspected intestinal obstructions in our prospective study. The remaining 30 patients were diagnosed as nonobstruction. The baseline characteristics of patients who diagnosed as intestinal obstruction are summarized in [Table 1]. Of ninety patients, fifty patients were female and forty were male. The mean age was 54.21 with standard deviation of 17.47. Forty-six patients had undergone previous abdominal operation.
[Table 2] and [Table 3] depict the examination and laboratory findings (sign and symptoms, vital signs, and blood work). The most common presenting symptom was abdominal pain (96.6%), followed by constipation (86.6%). Tender abdomen (62.2%) was observed as a common sign, followed by per-rectum empty (40%), exaggerated bowel sounds (36.7%), and guarding (34.4%). In laboratory investigation, leukocytosis in 42 (46.7%) patients and hypokalemia in 17 (18.9%) patients were observed. Radiological findings are shown in [Table 4].
[Table 5] describes etiology of AIO and nonobstruction cases. The most common causes for intestinal obstruction were adhesions (26.7%), hernia (23.3%), and carcinoma (12.2%).
We calculated relative efficacy based on specificity, sensitivity, and accuracy of the three imaging modalities. Among 120 suspected patients, 59 patients underwent CT abdomen. It showed 95.6% of sensitivity, 100% of specificity, and 96.6% of accuracy in comparison with X-ray showing 27.6% of specificity, 88.76% of sensitivity, and 73.7% of accuracy and ultrasonography (USG) abdomen showing 88% of accuracy, 81.3% sensitivity, and 100% of specificity.
[Table 6] outlines the management and outcome of the AIO. Out of 90 cases with AIO, 42 (46.7%) patients were operated, 32 (35.6%) patients were managed conservatively, and the remaining 16 (17.8%) patients were discharged against medical advice. Ten (13.5%) patients of those who were operated had surgical complications. The most common complication encountered was fever and wound dehiscence of about 2.7%. The mortality rate among the operated patients was 2.7% (n = 2).
[Table 7] describes the comparison of various factors between obstruction and nonobstruction cases. This comparison depicts that two findings such as previous history and signs were valid in diagnosing intestinal obstruction. Patients with intestinal obstruction had a significant history of previous abdominal surgery (51.1%) as compared to those without obstruction (23.3%). The signs observed more in intestinal obstruction than nonobstruction patients were tender abdomen and empty rectum, which is statistically significant (P= 0.01).
| Discussion|| |
Intestinal obstruction is one of the most common life-threatening surgical emergencies in ED. It occurs due to obstruction of intestinal contents. Hence, this study was done to determine the prevalence, etiology, usefulness of CT in diagnosis, rate of surgical intervention, and outcome of patients diagnosed with AIO. Our study shows a prevalence of 6 among 1000 ED patients, which is much less compared to a study done in Eastern India where it was 13 among 1000 patients.
It shows majority (55.6%) of the patients were women and male-to-female ratio was 1:1.25. It is consistent with the study done in Poland showing a ratio of 1:1.3. The study shows that more than 60 years of age group was the most commonly affected. This result was similar to another study done in India (Tamil Nadu) where maximum was in the fifth decade, followed by sixth decade. The incidence of previous abdominal surgery in this study was 46 (51.1%). This result was consistent with the study done in Andhra Pradesh, South India (48%).
Abdomen pain was the most common (96.6%) complaint followed by constipation (86.6%), which is consistent with the study done in Pakistan. The most common sign was abdominal tenderness (62.2%) followed by prerectum empty (40%), which is consistent with the study done in Maharashtra. The most common etiological factor was adhesion (26.67%) as seen in various other studies with similarly high rates 28.75% in Saudi  and 41% in Pakistan.
In comparison with contrast-enhanced computed tomography, plain radiography and USG abdomen are relatively less sensitive methods in diagnosis. CT shows highly sensitivity (95.6%), specificity (100%), and accuracy (96.6%) in the diagnosis of intestinal obstruction in our study, which is similar to the study done in Chandigarh, India. CT accuracy was overwhelmingly high (96.6%) in comparison to a study done in the USA in 1993. This could well be explained by the significant advances achieved in imaging technology in the recent years such as multidetector CT scanner which enables a better spatial resolution through thinner collimation.
In this study, 42 (46.7%) patients were managed surgically, which is similar to the result (57%) obtained in the study done in Washington. After surgical intervention, only 10 (13.5%) cases had postoperative complications. The most common complications encountered were postoperative fever and wound dehiscence was 2.7%. The mortality rate in this study was 2.7%, which is relatively low as compared to the study done in Eastern India where the mortality rate was 7.3%. It might be because our study was done in a tertiary care center.
History of previous abdominal surgery and clinical findings such as tender abdomen and empty rectum were statistically significant in diagnosing AIO.
| Conclusion|| |
Previous abdominal surgery proves to be a clinical entity with high incidence and specific risk factors of intestinal obstruction. It is mandatory to take preventive measures to reduce adhesion formation subsequent to any abdominal surgery. CT shows accurate modality for diagnosis. Therefore, patients presenting with common symptoms of AIO should be encouraged to undergo CT scan immediately after inconclusive result of other radiological findings. It is essential for an emergency physician to make early diagnosis and if necessary surgical intervention at the earliest, even in suspected intestinal obstruction cases.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Research Quality and Ethics Statement
The authors of this manuscript declare that this scientific work complies with reporting quality, formatting and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Review Board / Ethics Committee review, and the corresponding protocol / approval number is IRB Min. No. 11023 dated August 11, 2017. We also certify that we have not plagiarized the contents in this submission and have done a Plagiarism Check.
| References|| |
Prasad M, Pathak AK, Gupta RK. Incidence of acute intestinal obstruction in adults in Eastern India. Int J Med Health Res 2017;3:25-9.
Frasure SE, Hildreth A, Takhar S, Stone MB. Emergency department patients with small bowel obstruction: What is the anticipated clinical course? World J Emerg Med 2016;7:35-9.
Suri S, Gupta S, Sudhakar PJ, Venkataramu NK, Sood B, Wig JD. Comparative evaluation of plain films, ultrasound and CT in the diagnosis of intestinal obstruction. Acta Radiol 1999;40:422-8.
Springer JE, Bailey JG, Davis PJ, Johnson PM. Management and outcomes of small bowel obstruction in older adult patients: A prospective cohort study. Can J Surg 2014;57:379-84.
Pandey Y. A prospective study of cases of intestinal obstruction and role of conservative expectant management. Int Surg J 2018;5:2191-4.
Matrawy KA, El-Shazly M. Intestinal obstruction: Role of multi-slice CT in emergency department. Alex J Med 2014;50:171-8.
Wysocki A, Krzywoń J. Causes of intestinal obstruction. Przegl Lek 2001;58:507-8.
Priscilla SB, Edwin IA, Kumar K, Gobinath M, Arvindraj VM, Anandan H. A clinical study on acute intestinal obstruction. Int J Sci Stud 2017;5:4.
Bhaskar BG, Naresh Y, Sivakrishna G. A prospective study on adhesive intestinal obstruction in a tertiary care centre, South India. Int J Integr Med Sci 2015;2:178-81.
Khayat M, Aldaqal S. Incidence and causes of intestinal obstruction in Saudi adults: tertiary care hospital study. Int. Res. J. Medical Sci 2014;2:2320-7353.
Malik AM, Shah M, Pathan R, Sufi K. Pattern of acute intestinal obstruction: Is there a change in the underlying etiology? Saudi J Gastroenterol 2010;16:272-4.
] [Full text]
Maglinte DD, Gage SN, Harmon BH, Kelvin FM, Hage JP, Chua GT, et al.
Obstruction of the small intestine: Accuracy and role of CT in diagnosis. Radiology 1993;188:61-4.
Williams SB, Greenspon J, Young HA, Orkin BA. Small bowel obstruction: Conservative vs. surgical management. Dis Colon Rectum 2005;48:1140-6.
Adhikari S, Hossein MZ, Das A, Mitra N, Ray U. Etiology and outcome of acute intestinal obstruction: A review of 367 patients in Eastern India. Saudi J Gastroenterol 2010;16:285-7.
] [Full text]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]