Despite being one of the most common surgical emergencies, intestinal obstruction is often difficult to manage even today and is associated with a significant morbidity and mortality.[1]

The most common complications observed in this series in both adhesiolysis and small bowel resection groups following surgical treatment of SBO were pneumonia, prolonged ileus, failure to wean from the ventilator for >48 hours, unplanned intubation, superficial wound infection, urinary tract infection, systemic sepsis, and wound dehiscence.[2]

Comorbidity (e.g., cardiovascular or pulmonary disease) also contributes to the increased death rate after surgery. However, comorbidity occurs more commonly in old patients.[3] There is limited information on the post operative complications and associated co-morbidities for bowel obstruction. Therefore, present study was done to evaluate the Co-Morbidities and Post operative complications in patients of acute intestinal obstruction at IGMC Shimla.

Aims and Objectives

• To evaluate the Co-Morbidities and Post operative complications in patients of acute intestinal obstruction at IGMC Shimla

• To determine the association between post-operative complications and various co-morbidity factors that may influence patient outcomes               

The study was conducted in the department of General Surgery, Indira Gandhi Medical College, Shimla. The study comprised of 50 patients, selected randomly and presented with clinical features of acute intestinal obstruction between 15 June 2019 to 15 June 2020 in emergency OPD. Written informed consent was taken from all the patients in study group (annexure I). All patients were evaluated in terms of history, clinical examination, biochemical and sonological findings.

Patient Selection Criteria

Inclusion: Patient belonging to age group ranging from 14 years to 85 years of both sexes with clinical and radiological features suggestive of intestinal obstruction.

Exclusion

• Patient less than 14 years of age

• Pregnant females

Data Collection

The history of the patients was taken which included duration of symptoms, the presenting complaints, namely the type of pain, vomiting, passage of faeces and/or flatus, abdominal distension, number of previous attacks in the patients, previous treatment / surgery and presence of any co-morbid condition. Criteria for admission were pain abdomen, vomiting, abdominal distension, and obstipation.

A detailed clinical examination including rectal examination of the patient was done and the findings which were included are fever, tachycardia, abdominal signs like distension, tenderness, rigidity, guarding, bowel sounds, presence of visible/palpable bowel loops, presence of any lumps. Investigations included hemogram, biochemical parameters, plain X-ray of abdomen in erect and supine posture, ultrasonography of abdomen, CT abdomen (if necessary) and the findings were recorded. 

Following a provisional diagnosis of Acute intestinal obstruction, all the patients including those subjected to conservative management were initially managed by withholding oral intake, active aspiration of gastrointestinal secretions by Ryle’s tube, administration of intravenous fluids and correction of electrolyte imbalance. 

The patients were observed for features of relief of obstruction like reduction in vomiting, pain, and passage of faeces / flatus, reduction in tenderness, disappearance of visible/palpable bowel loops; and reduction in nasogastric tube output. Patients were also subjected to daily abdominal x rays erect and supine. If patient improves clinically and serial abdominal x rays shows improvement than patients were managed with conservative management only. 

The patients were monitored regularly for development of signs of strangulation like tachycardia, fever, abdominal tenderness, etc. If the patient developed signs of strangulation, the patient was operated on emergency basis. If the patient did not get relieved conservatively within 24-48 hours of observation, exploratory laparotomy was performed.

The patients who got relieved within few hours of conservative treatment were further investigated if there was a history of recurrent similar attacks or if patient developed recurrent symptoms. Ultrasound of the abdomen and pelvis, CT scan abdomen were undertaken in a sequential order to look for findings suggestive of intestinal obstruction and specific signs which suggest cause of obstruction.

In case the investigation provided sufficient information to confirm the diagnosis of a lesion explaining the symptoms of acute intestinal obstruction in the patient, appropriate operative intervention was undertaken. 

Patients with clear-cut signs and symptoms of acute and progressive bowel obstruction (tachycardia, rebound tenderness, absent bowel sounds) were managed by appropriate surgical procedure after resuscitation.

During the surgery, the findings and procedure adopted were recorded. The patients underwent various operative procedures depending on the intraoperative findings: e.g. release of a bands and adhesions, resection and anastomosis for gangrenous bowel etc. Histopathological examination of the specimen of resection/biopsy was done wherever necessary.

All these cases were carefully managed post-operatively by restricting or avoiding oral feeds, RT suctioning and judicious use of intravenous fluids duration, of which depended on the etiology of obstruction and type of surgery performed. Patients were allowed orally only when intestines started functioning by passage of flatus or stools or functioning of stoma if made. Post-operatively, antibiotics were used in all cases. Special emphasis was laid on preventing post-operative respiratory and venous complications by making patient ambulatory early. Follow up after the discharge of patients was done in majority of the patients.

Observations And Results

This prospective study of 50 cases of acute intestinal obstruction was conducted in the Department of General Surgery, Indira Gandhi Medical College, Shimla during period from 15 June 2019 to 15 June 2020. Cases were managed conservatively and surgically. Data regarding socio-demographic characteristics, mode of presentation and physical findings were made out (Figure 1).

Figure 1: Age and Gender distribution of study Participants

Intestinal obstruction occurs in all age groups, the age spectrum in our clinical study was 14 years to 85 years. The study shows the peak incidence in the age group 51-60 (11) and 61-70 (10) years. Mean age in our current study was 53 years. The ratio of male (37) and female (13) patients in our study was 3:1.

Table 1 present study diabetes (18%) was the most common co-morbidity followed by hypertension (10%).

Table 1: Co – Morbidity in Patients with Acute Intestinal Obstruction

Table 2 present Surgical site infection (SSI) was the most common post-operative complication (33%) followed by respiratory tract infection (17%) and septicemia (7%).

Table 2: Postoperative Complications

This study shows that major complications occurred in patients having both hypertension and diabetes. Patients with diabetes are more liable to complications than hypertension (Table 3).

Table 3: Complications Related to Co-morbidity

Acute intestinal obstruction continues to be one of the commonest surgical emergencies. A total of 50 patients admitted with features of acute intestinal obstruction in the general surgery department of Indira Gandhi Medical college Shimla, during the period from 15 June 2019 to 15 June 2020, were randomly selected for the present study.

Intestinal obstruction occurs in all age groups, the age spectrum in our clinical study was 14 years to 85 years. The study shows the peak incidence in the age group 51-60 (11) and 61-70(10) years. The mean age in our current study was 53 years where as B. T Fevang et al. [3] shows a mean age of 59 and Saravanan P.S[4] shows mean age of 52 years and 51.9 year in Patnaik et al. [4]. In the present study male to female ratio was 3:1 Whereas in B.T Fevang et al. [3] study, it was 3:2 and 4:1 in Sarvanan P.S [4].

In present study diabetes (18%) was the most common co-morbidity followed by hypertension (10%). In the present study group out of 50 cases, complications like septicaemia in 2 cases, respiratory tract infection in 5 cases, surgical site infection in 10 cases occurred. Patients with co-morbidities had more complications.Similar findings were reported in the studies done by Suvendu Sekhar Jena et al. [1] and B. T Fevang et al. [3].

Patients having pre-existing co-morbidity like hypertension or diabetes are more prone to develop postoperative complications e.g. wound infection or respiratory infection that may lead to death [5]. 

Acute intestinal obstruction remains a commonly encountered emergency in the surgical field. Our study concluded that diabetes and hypertension were the most common co-morbidities while Surgical site infection, respiratory tract infection and septicemia (SSI) were the most common post-operative complication among patients of Acute Intestinal Obstruction. Patients with diabetes are more liable to complications than hypertension

1. Jena, S.S. et al. “Intestinal obstruction in a tertiary care centre in India: Are the differences with the western experience becoming less?” Annals of Medicine and Surgery, vol. 72, 2021, pp. 103125.

2. Margenthaler, J.A. et al. “Risk factors for adverse outcomes following surgery for small bowel obstruction.” Annals of Surgery, vol. 243, no. 4, 2006, pp. 456.

3. Fevang, B.T. et al. “Complications and death after surgical treatment of small bowel obstruction: A 35-year institutional experience.” Annals of Surgery, vol. 231, no. 4, 2000, pp. 529.

4. Saravanan, P.S. et al. “Clinical study of acute intestinal obstruction in adults.” IOSR Journal of Dental and Medical Sciences, vol. 15, no. 11, 2016, pp. 76–83.

5. Patanaik, S.K. et al. “Clinical profile and outcome of subacute intestinal obstruction: A hospital-based prospective observational study.” Biomedical and Pharmacology Journal, vol. 13, no. 3, 2020, pp. 1563–71.