Acute Intestinal Obstruction in Children: Experience in a Tertiary Care Hospital

Abstract

Acute Intestinal Obstruction is one of the commonest surgical emergencies in children. These cases are invariably operated upon by general surgeons as pediatric surgeons are very few in Nepal. Outcome to a great extent depends on prompt clinical diagnosis and treatment. This is prospective study of 51 cases of intestinal obstruction admitted, operated and treated at Manipal Teaching Hospital, a tertiary care hospital in the Western Region of Nepal from January 2011 to September 2015. Aim of the study was to observe the pattern of intestinal obstruction in children and the treatment outcome in the hands of general surgeons. Number of cases in the cohort was 51. Out of that 50 cases were operated upon and 1 case was managed conservatively. Age of the patients' ranged from 1 day to15 years (median age 9 months); There were 33 males and 18 females with a ratio of 1.8:1. Causes of intestinal obstruction were Intussusceptions (33), Meckel's diverticulum (6), obstructed /strangulated hernia(4), imperforate anus(2), Hirschprung's disease(2), Meconium ileus (1), Ladd's band with malrotation of mid gut (1),annular pancreas(1) and Adhesions (1) Base line investigations of CBC, BT, CT, PT and serum electrolytes were done in all the cases. Plain x-ray abdomen erect and supine, ultrasonography (USG) and computed tomography (CT) scan were done in most of the cases and. Contrast study using Diatrizoate Meglumine (Gastrografin) was done wherever necessary. There were 3 mortalities and 2 cases had postoperative complications. Average post operative Hospital stay was 6 days. Early diagnosis and surgical intervention gives favorable outcome, delay increases morbidity and mortality. All these cases were taken up by general surgeons and the results were encouraging and good.

Full text

American Journal of Public Health Research, 2015, Vol. 3, No. 5A, 53-56
Available online at http://pubs.sciepub.com/ajphr/3/5A/12
© Science and Education Publishing
DOI:10.12691/ajphr-3-5A-12
Acute Intestinal Obstruction in Children:
Experience in a Tertiary Care Hospital
N K Hazra1,*, Om Bahadur Karki1, Hemant Batajoo2, Niraj Thapa3, Doledra Rijal1, Abhijit De4
1Department of Surgery, Manipal College of Medical Sciences, Pokhara, Nepal
2KUMS, Dhulikhel, Kavre, Nepal
3Urology, BPKH, Dharan, Nepal
4Medical Officer, Kolkata, India
*Corresponding author: niranjan_hazra@yahoo.com
Abstract Acute Intestinal Obstruction is one of the commonest surgical emergencies in children. These cases are
invariably operated upon by general surgeons as pediatric surgeons are very few in Nepal. Outcome to a great extent
depends on prompt clinical diagnosis and treatment. This is prospective study of 51 cases of intestinal obstruction
admitted, operated and treated at Manipal Teaching Hospital, a tertiary care hospital in the Western Region of Nepal
from January 2011 to September 2015. Aim of the study was to observe the pattern of intestinal obstruction in
children and the treatment outcome in the hands of general surgeons. Number of cases in the cohort was 51. Out of
that 50 cases were operated upon and 1 case was managed conservatively. Age of the patients’ ranged from 1 day
to15 years (median age 9 months); There were 33 males and 18 females with a ratio of 1.8:1. Causes of intestinal
obstruction were Intussusceptions (33), Meckel’s diverticulum (6), obstructed /strangulated hernia(4), imperforate
anus(2), Hirschprung’s disease(2), Meconium ileus (1), Ladd’s band with malrotation of mid gut (1),annular
pancreas(1) and Adhesions (1) Base line investigations of CBC, BT, CT, PT and serum electrolytes were done in all
the cases. Plain x-ray abdomen erect and supine, ultrasonography (USG) and computed tomography (CT) scan were
done in most of the cases and. Contrast study using Diatrizoate Meglumine (Gastrografin) was done wherever
necessary. There were 3 mortalities and 2 cases had postoperative complications. Average post operative Hospital
stay was 6 days. Early diagnosis and surgical intervention gives favorable outcome, delay increases morbidity and
mortality. All these cases were taken up by general surgeons and the results were encouraging and good.
Keywords: intestinal obstruction, children, general surgeon
Cite This Article: N K Hazra, Om Bahadur Karki, Hemant Batajoo, Niraj Thapa, Doledra Rijal, and Abhijit
De, “Acute Intestinal Obstruction in Children: Experience in a Tertiary Care Hospital.” American Journal of
Public Health Research, vol. 3, no. 5A (2015): 53-56. doi: 10.12691/ajphr-3-5A-12.
1. Introduction
Vomiting, pain abdomen and non passage of stool
(constipation) or passage of blood mixed mucus are the
symptoms of acute small bowel obstruction (SBO).
Children in general and neonates in particular, have poor
tolerance for dehydration and electrolyte imbalance that
are caused by SBO. Non passage of stool in large bowel
obstruction in neonates distends the gut. Enterocolitis may
ensue causing perforation and peritonitis. The ischemic or
gangrenous gut in strangulated hernia or volvulus leads to
septicemia. Thus an acute intestinal obstruction in children
is a life threatening emergency. It is important for the
pediatrician or the emergency medical officer to diagnose
it early and refer to the surgeons. New born baby who
failed to pass meconium or had an imperforate anus are
readily brought to notice by the attending nurse. Finally,
the many different causes of intestinal obstruction add up
to a sizeable number and load on the general surgeon and
merit an analysis.
2. Material and Methods
The hospital based prospective study was conducted in
the Department of Surgery, Manipal Teaching Hospital,
Pokhara, Nepal, from January 2011 to September 2015.
2.1. Inclusion Criteria
Children below 15 years of age, with intestinal
obstruction, diagnosed by physical examination including
Digital Rectal Examination (DRE) and validated by
investigation like plain x-ray abdomen, USG, CT scan and
Barium/ Gastrografin contrast study.
2.2. Exclusion Criteria
Cases of intestinal obstructions due to non surgical
causes like septicemia, head injury (birth trauma),
hypothyroidism, and post diarrheal ileus.
2.3. Ethical Committee’s Clearance

54 American Journal of Public Health Research
Permission from the institutional ethical committee was
taken prior to the study. All operations were performed
after written informed consent from the parents.
2.4. Clinical Presentation
Pain abdomen is present in all the cases of
intussusceptions with vomiting ,constipation (or bloody
mucus discharge per rectum) and a palpable abdominal
lump sometimes. Vomiting, pain abdomen, constipation
and distension were present in obstructed hernias and
Meckel’s diverticulum. Meckel’s’ diverticulum could only
be diagnosed after laparotomy.
Diagnosis of Ladd’s band with malrotation of mid gut
could only be made with the aid of USG, CT scan and
Gastrografin study [1,2].
A case of annular pancreas presents persistent bilious
vomiting. Abdominal radiograph shows double bubble
sign. A case of meconium ileus in new born presents with
distended abdomen, fails to pass meconium and DRE
realized very sticky meconium. Plain x-ray abdomen has
ground glass appearance. Gastrografin eases the sticky
meconium out which is the standard practice being
followed in uncomplicated cases [3,4].
2.5. Procedures
General measures
Resuscitation with IV fluid, naso/orogastric intubation,
IV antibiotic were instituted in all the cases.
Operative measures
Figure 1. Pre Operative Abdominal Xray of Malrotated Gut
All cases were operated under endotracheal general
anesthesia. A transverse right upper quadrant supraumbilical
incision was made for laparotomy. To add to safety, the
abdominal wall can be lifted at the time of incision by the
assistant between thumb and forefinger of both hands.
Intussusceptions were reduced whenever possible and
appendectomy and ileo-cecopexy done. Resection
anastomosis was done in all the cases of strangulated
hernias, in all cases of Meckel’s diverticulum, and in cases
of intussusceptions where the gut was gangrenous and in
cases the lead point were Meckel’s diverticulum. Gut
anastomosis was performed by one layer interrupted
suture technique. Colostomy was done for imperforate
anus and Hirschprung’s disease. Ladd’s procedure was
performed for the malrotation of gut (untwisting of the
twisted gut, excision of the band and appendectomy).
(Figure 1 & Figure 2). Duodenodudenostomy was done
for annular pancreas and adhesionolysis for intraperitoneal
adhesion.
Figure 2. Post Operative Abdominal Xray of Malrotated Gut
Preoperative Xray shows cecal gas shadow on left in
Figure 1 which is confirmed in postoperative contrast
Xray in Figure 2.
3. Results
The total number of cases in the cohort were 51. Out of
that 50 cases were operated and one case was managed
conservatively.
Age of the patients ranged from 1 day to 15 years
(median age 9 months); Males were 33 and Females 18
with a ratio of 1.8:1. Causes of intestinal obstruction were
Intussusceptions 33(64.70%), Meckel’s diverticulum
6(11.76%), Obstructed /Strangulated Hernia 4 (7.84%),
Imperforate Anus 2 (3.92%), Hirschprung’s disease
2(3.92%), Meconium ileus, Ladd’s band with malrotation
of mid gut, annular pancreas and Adhesions one each
(1.96%) respectively (Figure 3)
Figure 3. Causes of Intestinal Obstruction
Pain abdomen was present in all the cases of
Intussusceptions (33cases), Meckel’s diverticulum (6),
obstructed/strangulated hernia, malrotation of gut, and
adhesion.

American Journal of Public Health Research 55
Vomiting was present in 46 cases (except in imperforate
anus, Hirschprung’s disease and meconium ileus).
Constipation was seen in 50 cases. The intussusceptions
cases only passed blood mixed mucus (red currant jelly)
and in malrotated gut constipation was episodic.
Distension was noticed in Hirschprung’s disease,
imperforate anus, meconium ileus and all the obstructed
hernia cases.
Lumps were seen in all the cases of obstructed hernia
and felt in 16 cases of intussusceptions.
Meckel’s diverticulum had pain right lower quadrant,
vomiting, tenderness and leucocytosis; laparotomy
clinched the diagnosis
Obstructed /strangulated hernias – (three inguinal
hernia and one umbilical hernia) presented with pain
abdomen, vomiting and irreducible swelling.
Imperforate anus (2 cases) were easy to diagnose.
Invertogram showed both to be of high variety.
Hirschprung’s disease (2 cases) presented with non
passage of meconium, distension of abdomen. DRE
revealed gripping of the finger with passage of stool.
Contrast enema with Gastrografin revealed dilatation of
descending colon with abrupt termination.
A 2 year female child presented with pain abdomen off
and on. Diagnosis of Ladd’s band with malrotation of mid
gut was made with the aid of USG, CT scan and
Gastrografin study.
Single case of annular pancreas, a 14 day old female
had persistent bilious vomiting. Abdominal radiograph
showed double bubble sign.
In our single case of meconium ileus the new born had
distended abdomen, failed to pass meconium and DRE
realized very sticky meconium. Plain x-ray abdomen
showed ground glass appearance. Gastrografin eased the
sticky meconium out which has been the standard practice
in uncomplicated cases. Clinical presentations are
summarized in Table 1.
Table 1. Clinical Presentations of The Cases
Symptoms
Number
Percentage
Pain Abdomen
45
88.23
Vomiting
46
90.19
Constipation
50
98.03
Distention
9
17.64
Lump
20
39.21
In 29(58%) cases reduction of Intussusceptions was
done, resection anastomosis was done in 14 (28%)
patients, Colostomy in 4 (8%), Ladd’s Procedure,
Duodenoduodenostomy and Adhesionolysis were done in
1(2%) patient each Respectively.
Operative procedures are summarized in Table 2.
Table 2. Summary of The Operative Procedures
Operative Procedures
Number
Percentage
Cases
Reduction of Intussusceptions
29
58
intussusceptions
Resection Anastomosis 14 28
Intussusceptions 4
Strangulated hernias 4
Meckel’s diverticulum 6
Colostomy 4 8
Imperforate anus 2
Hirschprung’s disease 2
Ladd’s Procedure
1
2
Malrotated mid gut
Duodenoduodenostomy
1
2
Annular pancreas
Adhesionolysis 1 2 Intraperitoneal adhesions
There were three mortalities in the cohort; one
Hirschprung’s and one intussusceptions died post
operatively. Only one case of intussusception died before
the operation could be undertaken.
Post operative complications were, 1 intestinal adhesion
and 1 Superficial wound infection,
Average Patient’s post operative hospital stay was 6
days. All patients were followed up for 6 months.
In all the cases operative procedures were performed
without any blood transfusion.
4. Discussions
There is a male preponderance of intestinal obstruction
in children in the cohort (ratio 1.8:1)
Imperforate anus, meconium ileus and Hirschprung’s
disease can be detected / diagnosed soon after birth.
Diversion colostomy is a good procedure for
Hirschprung’s disease and imperforate anus (high variety).
The left iliac colostomy is easier to maintain, stool being
less liquid. Out of concern for preservation of continence
and erectile functions, these patients with colostomies
were referred to specialized centers for care of
proctologists/ pediatric surgeons skilled in the field.
Intussusceptions were the major causes of acute
intestinal obstruction [5]. Review of world literature on
intestinal obstruction confirms this [5,6,7]. Intussusceptions
were seen in the weaning period from 5 months onward up
to 2 years as the children are breast fed for a longer period
in Nepal than elsewhere in the subcontinent. It is also seen
during change of season with minor febrile illnesses –
possibly of viral pathology which we have made no
attempt to establish for want of resources. However, lead
point was not readily evident except in two cases where
Meckel’s diverticulum was the lead point [8]. Mostly it
being ileo-colic type hypertrophy of the Peyer’s patches
can be incriminated. Rotavirus vaccine was not given to
any of these infants as they were not available [9].
Reduction of the intussusceptions was not attempted by
enema or hydrostatic pressure, rather surgery was
preferred to reduce it and prevent recurrence by ileo-
cecopexy. In most cases reduction was possible even
when the intussusceptions had progressed up the
descending colon.
Meckel’s diverticulums are invariably diagnosed at
laparotomy as preoperative diagnosis is next to impossible.
In the largest review of 1476 patients from 1950 to 2002,
males were affected three times more and when more than
2 cm long and in children, they were symptomatic
[10,11,12]. Annular pancreas is a rare congenital anomaly
and duodeno-duodenostomy is the right choice of
operation [13].
Delay in diagnosis and delayed surgical intervention
adds to morbidity and mortality due to dehydration,
electrolyte imbalance, and septicemia. All the patients in

56 American Journal of Public Health Research
the study received broad spectrum antibiotics plus
metronidazole.
There are a myriad of causes for the child to cry and
draw attention of the parents. A discerning parent can spot
the problem. On an average patient delay has been 36 to
48 hours.
Intestinal obstruction can put the pediatrician and
surgeon’s clinical experience to anvil and doctor’s delay
had been 2 to 4 hours including investigation time in the
study.
All general surgeons are conversant with creating
colostomy, resection and anastomosis which are the
cornerstone of effective surgical treatment of intestinal
obstruction.
5. Conclusion
Proper diagnosis and timely surgical intervention can
save many children’s lives. General surgeon with skill in
performing colostomy, resection anastomosis can handle
most of the cases even in absence of pediatric surgeons.
Abbreviations
CBC: Complete Blood Count
BT: Bleeding Time
CT: Clotting Time
PT: Prothrombin Time
SBO: Small Bowel Obstruction
DRE: Digital Rectal Examination
Declaration of Conflicting Interests
The authors declare that there is no potential conflicts
of interest with respect to the research, authorship and /or
publication of this article.
Funding
The authors received no financial support for the
research, authorship and/or publication of this article.
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