Intestinal obstruction in a tertiary care centre in India: Are the differences with the western experience becoming less?

Background

Patients with intestinal obstruction consist of a major proportion of emergency room visits and the complication is associated with a significant morbidity and mortality. It has a diverse aetiology which varies from country to country. In developed countries it is mainly due to adhesions and in developing countries due to obstructed hernias. Although there are numerous studies from the western world on this subject there have been few recent publications from the developing world.

Patients and methods

We retrospectively analyzed all the patients admitted with intestinal obstruction to our department from January 1996 to December 2019. Their demographic data, duration of symptoms before presenting to the hospital and interval between admission and surgery were noted along with the cause and level of obstruction. The type of procedure, post-operative complications, mortality or whether re-exploration was done were also noted. Post-operative complications were graded according to the Clavien Dindo classification.

Results

A total of 986 patients presented with intestinal obstruction during this period out of which 743 patients underwent surgery. The commonest cause of obstruction was adhesions in 273 (36.7%) – the proportion increased significantly from 23% in 1996–2004 to 51.6% in 2013–2019. This was followed by carcinoma [130(17.5%)], tuberculosis [111(14.9%)], strictures [94(12.7%)] and hernia (5.4%). Colorectal surgery was the most common previous procedure in the adhesions group [85(31.1%)].The overall operative mortality was 41 (5.5%).

Conclusion

The aetiology of intestinal obstruction in our hospital is now mainly due to adhesions and is thus shifting towards the western pattern. But tuberculosis and obstructed inguinal hernias still constitute of a sizable proportion of our patients.

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Post-operative adhesions have now become a common cause of intestinal obstruction our tertiary care centre situated in a developing country.

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These were most commonly preceded by operations on the colon and rectum.

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Our overall mortality rate was comparable with those reported from the west. Old age, malignancy and strangulation were associated with a higher risk of mortality as has been the experience from other centres.

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Compared to Western reports our patient population was younger, males predominated.

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Although the proportion of patients with adhesions is rising tuberculosis continues to be an important cause for intestinal obstruction.

Intestinal obstruction caused by encircling fallopian tube

A 50-year-old woman was admitted to our emergency surgery department with 1-week history of abdominal pain, distension, vomiting and constipation. On examination, she has a distended abdomen with sluggish bowel sounds, but no clinical signs of peritonitis. Blood tests were normal except for the increased white cell count and erythrocyte sedimentation rate (ESR). CT scan with oral as well as intravenous contrast demonstrated the small bowel obstruction without any insight into the aetiology of the disease. Intraoperatively, the right fallopian tube was found to encircle the terminal ileum. A right salpingo-oophorectomy was performed to release the bowel. This case report describes a rare cause of the small bowel obstruction in female patients.

Cannabis Use Is Associated With an Increased Risk of Intestinal Obstruction in Patients Hospitalized With Diverticulitis

Objectives Diverticulitis is a common cause of hospitalization. The use of substances such as tobacco and alcohol can predispose patients to diverticulitis, and smoking is also associated with an increased risk of diverticulitis complications. Cannabis availability is growing in the United States, but there is a lack of data on the effects of cannabis use on the outcomes of diverticulitis. Thus, we investigated the effects of cannabis use on diverticulitis outcomes. Methods A retrospective analysis was conducted using 2014 data from the National Inpatient Sample. Patient demographics and outcomes of diverticulitis were compared between the groups with and without a history of cannabis use. The outcomes of interest were inpatient mortality, length of stay, total hospital charge, intestinal obstruction, shock/hypotension, colectomy, intestinal abscess, intestinal fistula, and intestinal perforation. Results Among 48,214 patients with diverticulitis, 447 patients had a history of cannabis use. Patients with a history of cannabis use were younger, more likely to be male, less likely to be White, had a lower Charlson Comorbidity Index, and had shorter hospital stays. There were no significant differences in inpatient mortality and total hospital charge. After adjusting for age, sex, race, and the Charlson Comorbidity Index, cannabis use was an independent risk factor for intestinal obstruction in patients hospitalized with diverticulitis. There were no statistically significant differences in other outcomes. Conclusions This study indicates that patients hospitalized with diverticulitis with a history of cannabis use are more likely to have an intestinal obstruction. Inhibition of gastrointestinal motility by cannabis in the setting of diverticular inflammation may explain this finding.

The Safety of Expectant Management for Adhesive Small Bowel Obstruction: A Systematic Review

BACKGROUND

Surgical training has long been to "never let the sun set on a bowel obstruction" without an operation to rule out and/or treat compromised bowel. However, advances in diagnostics have called into question the appropriate timing of non-emergent operations and expectant management is increasingly used. We performed a systematic review to evaluate the safety and effectiveness of expectant management for adhesive small bowel obstruction (aSBO) compared to early, non-emergent operation.

MATERIALS & METHODS

We queried PubMed, EMBASE, and Cochrane databases for studies (1990-present) comparing early, non-emergent operations and expectant management for aSBO (PROSPERO #CRD42017057676).

RESULTS

Of 4873 studies, 29 cohort studies were included for full-text review. Four studies directly compared early surgery with expectant management, but none excluded patients who underwent emergent operations from those having early non-emergent surgery, precluding a direct comparison of the two treatment types of interest. When aggregated, the rate of bowel resection was 29% in patients undergoing early operation vs. 10% in those undergoing expectant management. The rate of successful, non-operative management in the expectant group was 58%. There was a 1.3-day difference in LOS favoring expectant management (LOS 9.7 vs. 8.4 days), and the rate of death was 2% in both groups.

CONCLUSION

Despite the shift towards expectant management of aSBO, no published studies have yet compared early, non-emergent operation and expectant management. A major limitation in evaluating the outcomes of these approaches using existing studies is confounding by indication related to including patients with emergent indications for surgery on admission in the early operative group. A future study, randomizing patients to early non-emergent surgery or expectant management, should inform the comparative safety and value of these approaches.

Adhesive Small Bowel Obstruction due to Pelvic Inflammatory Disease: A Case Report

We report a rare case of a 32-year-old woman with adhesive small bowel obstruction due to pelvic inflammatory disease. She had no history of abdominal surgery, gynecological complaints or constitutional symptoms of chronic illness. The diagnosis was based on the laparoscopic findings of small bowel adhesions, free peritoneal fluid, “violin string” adhesions of Fitz-Hugh–Curtis syndrome and left hydrosalpinx. Laparoscopic adhesiolysis was performed successfully, and the patient had an uneventful postoperative course. The authors conclude that pelvic inflammatory disease should be included as a cause of adhesive small bowel obstruction in sexually active young women with no history of abdominal surgery or constitutional symptoms of chronic disease. When performed by experienced surgeons, laparoscopy in such patients is feasible and safe.

Gallstone ileus with jejunum perforation managed with laparoscopic-assisted surgery: rare case report and minimal invasive management

Gallstone ileus is an uncommon complication of cholelithiasis. Most patients affected by gallstone ileus are elderly and have multiple comorbidities. Symptoms are vague and insidious, which may delay the correct diagnosis for days. Here we are reporting an uncommon complication of gallstone ileus. We report on a 70-year-old man with small bowel obstruction at the jejunum due to an impacted stone, which led to necrosis and perforation of the proximal bowel wall. Laparoscope-assisted small bowel resection with enterolithotomy was used to successfully treat the patient's perforation and obstruction. His recovery was uneventful. Gallstone ileus commonly presents with bowel obstruction, but intestinal perforation occurs very rarely. A laparoscopic approach can provide both diagnostic and therapeutic roles in management.

The Combination of D-Dimer and Peritoneal Irritation Signs as a Potential Indicator to Exclude the Diagnosis of Intestinal Necrosis

Intestinal necrosis is a life-threatening disease, and its prompt and accurate diagnosis is very important. This study aimed to evaluate the value of D-dimer as a marker for early diagnosis of bowel necrosis. From 2009 to 2013, patients undergoing operation due to acute intestinal obstruction were retrospectively analyzed. Clinicopathologic characteristics were compared among no ischemia group, reversible ischemia group, and bowel necrosis group. There were totally 274 patients being included for analyses. Patients with bowel necrosis had a significant highest level of D-dimer compared with other 2 groups (P =  .007) when FEU unit was applied. The optimal cutoff value of D-dimer levels as an indicator in diagnosing bowel necrosis was projected to be 1.965 mg/L, which yielded a sensitivity of 84.0%, a specificity of 45.6%, a positive predictive value of 60.7%, and a negative predictive value of 74.0%. And the sensitivity of 84.0% and specificity of 70.0% were detected, when 1.65 mg/L of D-dimer was set as the cutoff value to distinguish the reversible ischemia and bowel necrosis. The corresponding results in patients with no or slight peritoneal irritation signs were 85.2%, 44.7%, 35.4% and 89.5% respectively. The sensitivity and negative predictive value were 96.0% and 91.7%, respectively, when D-dimer and peritoneal irritation signs were combined to perform the parallel analysis. The combination of D-dimer and peritoneal irritation signs could generate a reliable negative predictive value, which is helpful to exclude the diagnosis of intestinal necrosis. However, it should also be proved in well-designed large-scale prospective study.

Marine natural products with P-glycoprotein inhibitor properties

P-glycoprotein (P-gp) is a protein belonging to the ATP-binding cassette (ABC) transporters superfamily that has clinical relevance due to its role in drug metabolism and multi-drug resistance (MDR) in several human pathogens and diseases. P-gp is a major cause of drug resistance in cancer, parasitic diseases, epilepsy and other disorders. This review article aims to summarize the research findings on the marine natural products with P-glycoprotein inhibitor properties. Natural compounds that modulate P-gp offer great possibilities for semi-synthetic modification to create new drugs and are valuable research tools to understand the function of complex ABC transporters.

Impact of persistent constipation on health-related quality of life and mortality in older community-dwelling women

OBJECTIVES

Very little is known about whether the reported health-related impact of constipation is worse in people who experience constipation over a long period of time vs. those with more transient symptoms. We aimed to determine the impact of persistent vs. transient constipation on health-related quality of life (QOL), depression, and mortality.

METHODS

We analyzed data from 5,107 women (aged 70-75 years in 1996) who answered "Have you had constipation in the past 12 months?" in all five surveys sent out every 3 years of the Australian Longitudinal Study on Women's Health.

RESULTS

Of the 5,107 women, 20.9, 54.1, and 24.7% reported having persistent constipation on at least 4 out of 5 surveys, transient constipation reported on 1-3 surveys, or none reported over the 15-year time frame, respectively. Women who reported persistent constipation had significantly lower scores for all domains of QOL on the SF-36 except role-emotional, and had higher levels of self-reported depression, even after adjusting for number of chronic illnesses and fluid intake. Mortality rates were increased when comparing women with no reported constipation with persistently reported constipation (8.2% vs. 11%, odds ratio = 1.32, 95% confidence interval 1.0, 1.74, P = 0.05) controlling for specific chronic illnesses.

CONCLUSIONS

Persistent constipation among older women is associated with poor health outcomes.

Tetrandrine enhances cytotoxicity of cisplatin in human drug-resistant esophageal squamous carcinoma cells by inhibition of multidrug resistance-associated protein 1

Multidrug resistance is one of the major causes limiting the efficacy of chemotherapeutic agents to control esophageal cancer. Herein, we investigated that the effect and mechanism of tetrandrine (TET) in the human esophageal squamous carcinoma cisplatin-resistant cell line YES-2/DDP. The human esophageal squamous carcinoma cisplatin-resistant cell line YES-2/DDP was isolated by stepwise selection in increasing concentrations of cisplatin. The CCK-8 method was carried out to measure the cell viability when cells were exposed to TET with or without cisplatin, and the IC50 and resistance index (RI) of cisplatin was then calculated. Real-time RT-PCR and western blotting were used to detect the mRNA and protein expression of multidrug resistance 1 (MDR1), multidrug resistance-associated protein 1 (MRP1) and breast cancer resistance protein (BCRP), respectively. Flow cytometry was adopted to determine CMFDA efflux and cell apoptosis, respectively. The resulting cell line YES-2/DDP was 16.4-fold resistant to cisplatin, the cytotoxicity of cisplatin to YES-2/DDP cells was enhanced by TET in a dose-dependent manner. Further, it was found that the expression of MDR1 and BCRP was similar in different treated cells. In contrast, the expression of MRP1 was markedly increased in YES-2/DDP cells, which was dose-dependently decreased by TET. In agreement with the results, MRP1 activity was also reversed by TET. In conclusion, TET possesses a reversal effect on drug resistance in YES-2/DDP cells through downregulation of MRP1, and has the potential to be an adjunct to chemotherapy for esophageal cancer.

Ileus and intestinal obstruction--comparison between children and adults

Bowel obstruction is the interference with movement of bowel content. Large and small in testing from duodenum to anal region can be obstructed mechanical or non-mechanical and complete or partial. Mechanical obstruction can presented because of obstructive causes in intestinal lumen, intestinal wall or pressure from other tissue on intestine. The aim of the study was to evaluate etiology, laboratory findings of intestinal obstruction and ileus among children and adults who discharged with good condition.

MATERIAL AND METHODS

This retrospective study was carried out from 2001 to 2006 in Imam Khomeini Hospital (Ahvaz-Iran). Cases of bowel obstruction were included in this study. For each case, a questionnaire was filled. There are 752 cases with suspected bowel obstruction. From 752 cases, 403 patients that agreed and treated and discharged with good condition were studied. Cases were divided into two groups: children (age < 15 yrs) and adults (age> 15 yrs). Data were analyzed by SPSS Ver 16.0 (Chicago, IL, USA) and Epi-info Ver 6.00.

RESULTS

In our study, 221 adults and 192 children were included. Mortality rate was 12.2%. Forty-eight percent of 403 cases were children (m - 61%, f - 38%, ambigus genitalia - 1%) and 52% were adults (m - 67%, f - 33%). Etiology of bowel obstruction in children were as follows: ileus (26%); adhesion band (17.7%), partial obstruction (16.1%), and Hirschsprung's disease (12%). Causes of bowel obstruction in adults are: partial obstruction (29.9%); ileus (19%); adhesion band (18.5%); colonic pseudo obstruction(8.5%); GI cancer (5.2%); hernia (4.7%); Crohn (2.8%); fecal impaction (3.3%); bezoar (2.4%), and 4.7% for other causes. Fifty-one percent of children and 36% of adults were operated. Of all children, 91.7% had upright abdominal X-ray, 51.6% had supine X-ray, and 80.7% had sonography. Hundred percents of adults had upright & supine plain abdominal X-ray and 75.4% had sonography. Most change in children's CBC was 10000<WBC<15000 and in adult for WBC<10000.

CONCLUSIONS

Partial obstruction, pseudo-obstruction, and cancer were more common in adults than children. Ileus was the commonest cause of obstruction in children and it was partial obstruction for adult. Children were more operated than adult. Sonography was more use for children but plain abdominal X-ray for adult. In 45% of children 10000<WBC<15000 while most adult had WBC<10000. Hypokalemia was the most common biochemical finding in both group.

Pattern of acute intestinal obstruction: is there a change in the underlying etiology?

BACKGROUND/AIM

To study the changing pattern of acute intestinal obstruction at a teaching institute.

PATIENTS AND METHODS

It is a prospective descriptive study conducted at a teaching hospital during the period from June 2004 to June 2009. All patients with clinical or radiological evidence of acute intestinal obstruction were included in this study regardless of the gender of the patient. Patients below the age of 10 years were excluded from the study. The treatment strategy was planned ranging from conservative treatment to emergency laparotomy after resuscitation and rehydration of the patient. Details of individual patients were recorded on a pro forma sheet and data analyzed statistically on SPSS version 14.

RESULTS

A total of 229 patients with acute intestinal obstruction were admitted and treated. The mean age of the study population was 43.08 ± 13.07 years. Postoperative adhesions accounted for 41% (n = 95) of the total cases, followed by abdominal tuberculosis (25%, n = 58), obstructed/ strangulated hernias of different types (18%, n = 42). There was an obvious change in the pattern of etiology of acute intestinal obstruction as the common causes were postoperative adhesions and abdominal tuberculosis instead of obstructed inguinal hernias.

CONCLUSION

An increase in the adhesive obstruction and a concomitant decrease in the incidence of obstructed hernias indicate a changing trend towards early operation before it gets complicated. Abdominal tuberculosis is emerging as another common cause of acute bowel obstruction.

Etiology and outcome of acute intestinal obstruction: a review of 367 patients in Eastern India

BACKGROUND/AIM

The etiology of acute intestinal obstruction, which is one of the commonest surgical emergencies, varies between countries and has also changed over the decades. We aimed to provide a complete epidemiological description of acute intestinal obstruction in a tertiary care hospital in Eastern India.

MATERIALS AND METHODS

This was a retrospective study of patients admitted in our unit with a diagnosis of acute intestinal obstruction between the years 2005 and 2008 at Medical College, Calcutta. The study comprised of 367 patients.

RESULTS

Acute intestinal obstruction was the diagnosis in 9.87% of all patients admitted with males (75.20%) grossly outnumbering females. The commonest age group affected was 20-60 years. In our patients, the main cause of obstruction was obstructed hernia followed by malignancy with adhesions coming third. Intestinal tuberculosis was an important cause for obstruction in our patients comprising 14.17% of patients. Conservative management was advocated in 79 patients while the rest underwent surgery. Postoperative complications occurred in 95 patients and of these, 38 patients had a single complication and the rest, more than 1. The main complications were wound infection, basal atelectasis, burst abdomen and prolonged ileus. The mortality rate was 7.35% (27 patients). The highest mortality occurred in those with intestinal tuberculosis.

CONCLUSION

This study demonstrates that the pattern of intestinal obstruction differs from the Western world with obstructed hernias being the most important cause and also emphasizes the fact that intestinal tuberculosis assumes a prominent role. It also highlights the necessity of using universal precautions because of the ever increasing number of HIV patients in those with intestinal obstruction.