This study compared the causes, laboratory findings, and management of intestinal obstruction in children and adults. It found that partial obstruction, pseudo-obstruction, and cancer were more common causes in adults, while ileus was more common in children. Children were more likely to undergo surgery and have elevated white blood cell counts than adults. The most common biochemical finding in both groups was hypokalemia. Overall, the study identified some differences in etiology and presentation of intestinal obstruction between children and adults.
This study compared the causes, laboratory findings, and management of intestinal obstruction in children and adults. It found that partial obstruction, pseudo-obstruction, and cancer were more common causes in adults, while ileus was more common in children. Children were more likely to undergo surgery and have elevated white blood cell counts than adults. The most common biochemical finding in both groups was hypokalemia. Overall, the study identified some differences in etiology and presentation of intestinal obstruction between children and adults.
This study compared the causes, laboratory findings, and management of intestinal obstruction in children and adults. It found that partial obstruction, pseudo-obstruction, and cancer were more common causes in adults, while ileus was more common in children. Children were more likely to undergo surgery and have elevated white blood cell counts than adults. The most common biochemical finding in both groups was hypokalemia. Overall, the study identified some differences in etiology and presentation of intestinal obstruction between children and adults.
2011, 83, 7, 367371 ILEUS AND INTESTINAL OBSTRUCTION COMPARISON BETWEEN CHILDREN AND ADULTS MeHran PeyVasteH 1 , sHaHnaM askarPour 1 , HazHir JaVaHerizaDeH 2 , soMaieH taGHizaDeH 1 Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahwaz, Iran 1
Arvand International Division , Ahvaz Jundishapur University of Medical Sciences 2 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 fndings 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 Khomei- ni Hospital (Ahvaz-Iran). Cases of bowel obstruction were included in this study. For each case, a questionnaire was flled. 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 di- vided 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%); adhe- sion band (17.7%), partial obstruction (16.1%), and Hirschsprungs 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%); be- zoar (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 sonogra- phy. Hundred percents of adults had upright & supine plain abdominal X-ray and 75.4% had sonog- raphy. Most change in childrens 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 ab- dominal X-ray for adult. In 45% of children 10000<WBC<15000 while most adult had WBC<10000. Hypokalemia was the most common biochemical fnding in both group. Key words: bowel obstruction, ileus, adhesion band, Hirschsprung, intussusceptions, fecal impaction, colonic pseudo obstruction, diverticulitis, hernia, imperforate anus Intestinal bowel obstruction is a common surgical emergency and commonly cause a problem in abdominal surgery (1, 2). The lead- ing cause of SBO in developed countries is post operative adhesions (60%) followed by malig- nancy, Crohn disease, gallstone (3), and her- nias, although some studies have reported Crohn disease as a greater etiologic factor than neoplasm (4). Large intestinal obstruction (LBO) is most often the result of colo-rectal malignancies. One large study found an inci- dence of 16% (5). Patients are often over 70 years old. The risk of obstruction increases the further down the bowel the lesion is sited, as the contents become more solid. Tumors are often advanced with 25% having distant me- Unauthenticated | 36.73.69.60 Download Date | 11/10/13 3:25 AM 368 M. Peyvasteh et al. tastases. Perforation can occur at the site of the tumor or in a dilated caecum (6). LBO is an emergency condition that requires early identifcation and intervention. The etiology of LBO is age dependent (7). There are possible differences between etiology of bowel obstruc- tion in different countries because of different nutritional habits, weather, and other factors. As one of the most important condition surgical emergency we aimed to study of etiol- ogy, laboratory fndings of intestinal obstruc- tion and ileus among children and adults who discharged with good condition. MATERIAL AND METHODS This retrospective study was carried out between 2001-2006 in Imam Khomeini Hospi- tal a tertiary referral hospital, Ahvaz, Iran. A questionnaire was flled for each case. In this study, 752 cases with diagnosis of bowel ob- struction were admitted to hospital. From these cases, 228 cases did not agree to par- ticipate in our study and excluded. From all of 752 cases, in 29 cases bowel obstruction was ruled out and transferred to other department for treatment. Ninety- two cases were died and excluded from this study. The remaining 403 cases that treated and discharged with good condition were studied. Patients were divided into two groups: children; before 15 years old and adults; after 15 years old. A questionnaire flled for each patient. Laboratory fndings were recorded for patients. Data were analyzed by SPSS Ver 16.0 (Chigaco, IL,USA) and Epi- info ver 6.0. RESULTS Four hundred and three patients were included in our study. From all patients, 192 (47.64%) patients were <15 yr and 211 (52.35%) were >15 yr. From 192 children pa- tients, 119 (61.97%) patients were male, 72 (37.5%) patients were female, and 1 (0.5%) patient had ambigus genitalia. From 211 adult patients, 142 (67.29%) patients were male and 69 (32.7%) patients were female. Of all 403 cases, 261 (64.76%) were males. Sev- enty-six (36.01%) patients from 211 adult patients and 98 (51.04%) from 192 of children patients underwent surgery. As seen in tab. 1, partial obstruction, pseudo-obstruction, and cancer were signifcantly more seen in adults than children (p<0.05). Ileus, intus- susceptions, diverticulitis, Hirschsprungs disease and atresia were more common in children than adults (p<0.05). There is no difference between children and adults for durartion of hospital staying (tab. 2). Table 1. Etiology of intestinal obstruction in children and adults Dzieci / Children (n=192) Doroli / Adults (n=211) p / p-value Ileus 50 (26,04%) 40 (18,95%) p=0,08 Adhesion band 34 (17,70%) 39 (18,48%) p=0,84 Partial obstruction with unknown etiology 31 (16,14%) 63 (29,85%) p=0,001 Pseudo-obstruction 6 (3,12%) 18 (8,53%) p=0,02 Volvulus 4 (2,08%) 3 (1,42%) p=0,89 Bezoar 1 (0,52%) 6 (2,84%) p=0,16 Hernia 4 (2,08%) 10 (4,73%) p=0,14 Fecal impaction 6 (3,12%) 6 (2,84%) p=0,86 Hirschsprung 22 (11,45%) p=0,00 Atresia 9 (4,68%) 0) p=0,004 Tuberculosis 0 3 (1,42%) p=0,2 Crohn disease 0 6 (2,84%) p=0,05 Post radiation 0 3 (1,42%) p=0,2 Gastric outlet obstruction 1 (0,52%) 3 (1,42%) p=0,6 Intussuception 13 (6,77%) 0) p=0,00 Diverticule 5 (2,60%) 0) p=0,05 Malrotation 4 (2,08%) 0) p=0,05 Imperforate anus 2 (1,04%) 0) nie dotyczy / NA Cancer 0 11 (5,21%) p=0,001 Unauthenticated | 36.73.69.60 Download Date | 11/10/13 3:25 AM 369 Ileus and intestinal obstruction comparison between children and adults Anemia was more common in children than adults while polycythemia was more common in adults. WBC<10000 was more common in adults than children (p=0.03) (tab. 3). Hyponatremia was most frequently seen in children (p=0.04). Azotemia and normal bio- chemical fndings were signifcantly common in adult cases compared to children (p<0.05) (tab. 4). Colonoscopy, endoscopy, and abdominal X-ray (supine and upright) were more fre- quently used in adults than children (p<0.05). There is no significant difference between children and adults regarding use of sonogra- phy, upper GI series, and barium enema (tab. 5). Table 2. Frequency of hospital staying in patients with intestinal obstruction Children (n=192) Adults (n=211) p-value <5 days 32 (16,66%) 44 (20,85%) p=0,28 5-10 days 112 (58,33%) 111 (52,60%) p=0,24 10-15 days 37 (19,27%) 37 (17,53%) p=0,65 >15 days 11 (5,72%) 19 (9%) p=0,21 DISCUSSION In our study, of all 403 cases, 261(64.76%) were males. Of 192 children cases and 211 adult cases, 119 (61.97%) cases and 142 (67.29%) cases were males respectively. Male constitute 74% and female 26% of intestinal obstruction in Malik et al. study and similar to our study (8). In adult cases, partial obstruction (29.85%), adhesion band (18.48%), and ileus (18.95%) were the most common causes of bowel obstruction. Marko- giannakis et al., reported adhesions (64.8%) were the most common causes of intestinal obstruction among adult cases (9). Adhe- sions, incarcerated hernias, and large bowel cancer constitutes the most frequent causes of bowel obstruction (10). This difference between the current study and other studies may be due to partial obstruction in our study. Ileus (26.04%), adhesion bands (17.70%), partial obstruction (16.64%), and Hirschs- prung (11.45%) were the most common etiol- ogy of children intestinal obstruction in our study. Ogundoin et al., reviewed etiology of intestinal obstruction in 130 cases. Major causes of intestinal obstruction were intus- susceptions (29.23%), anorectal malforma- tions (22.31%), obstructed inguinoscrotal hernia (16.92%) and Hirschsprungs disease (13.85%) (11). A number of recent studies, have found adhesive obstruction to be replacing obstruc- tive hernias as the most common cause (8, 12, 13). Table 3. CBC changes in patients with intestinal obstruction CBC changes Children (n=192) Adults (n=211) p-value WBC <10 000 74 (38,54%) 104 (49,28%) p=0,03* WBC 10 00015 000 87 (45,31%) 83 (39,33%) p=0,22 WBC >15 000 31 (16,14%) 24 (11,37%) p=0,16 Anemia 67 (34,89%) 53 (25,11%) p=0,03* Polycythemia 15 (7,81%) 31 (14,69%) p=0,03* Table 4. Biochemical fndings in the bowel obstruction Children (n=192) Adults (n=211) p-value Hypoglycemia 10 (5,20%) 4 (1,89%) p=0,06 Hyperglycemia 7 (3,64%) 15 (5,68%) p=0,33 Hyponatremia 23 (11,97%) 13 (6,16%) p=0,04* Hypernatremia 3 (1,56%) 2 (0,94%) p=0,9 Hypokalemia 71 (36,97%) 97 (45,97%) p=0,06 Hyperkalemia 8 (4,16%) 4 (1,89%) p=0,18 Azotemia 10 (5,20%) 32 (15,16%) p=0,001* Normal 94 (26,04%) 89 (42,18%) p=0,0006* Table 5. Radiologic procedures performed in patients Procedure Children (n=192) Adults (n=211) p-value Abdominal X-ray (supine) 176 (93,61%) 211 (100%) <0,001 Abdominal X-ray (upright) 99 (52,65%) 211 (100%) <0,001 Upper gi series 14 (7,44%) 8 (3,79%) 0,122 Barium enema 20 (10,63%) 22 (10,42%) 0,990 Colonoscopy 0 35 (16,58%) <0,001 Endoscopy 0 21 (11,17%) <0,001 Sonography 155 (82,44%) 159 (75,35%) 0,089 Unauthenticated | 36.73.69.60 Download Date | 11/10/13 3:25 AM 370 M. Peyvasteh et al. In the current study no cases of intussucep- tion were seen in adults. In the Croomes study, 2-3% of obstruction was due to intussuception (14). In the current study, the rate of intus- susceptions in children was 6.77%. In Kaiser et al. study, the most common cause of intes- tinal obstruction in children was intussucep- tion (15). Hernia is the 6 th cause of intestinal obstruc- tion in adults and 7 th in children. the current study. In the study which carried out by Moon et al., hernia was reported as the 3 rd common cause of intestinal obstruction (16). Madziga and Nuhu also reported hernia as the most common causes of intestinal obstruction (17). Adhesions may be acquired or congenital; however, most are acquired as a result of peri- toneal injury, the most common cause of which is abdominal pelvic surgery (18). Intra ab- dominal adhesions are the most common cause of SBO in some reports, accounting for ap- proximately 65% to 75% of cases (19, 20). Kssi et al. studied post operative adhesion induced obstruction from 1.1.1999 to 31.12.1999 on 123 hospitalizations. The most prevalent single initial operation causing adhesion induced intestinal obstructions were colorectal, upper abdominal, and female reproductive system procedure (21). The overall mortality rate was 1.6%, and the mortality rates in conservative therapy and surgical intervention groups were 1.3% and 1.7% respectively (22). In the current study, paralytic ileus, adhe- sion, and partial obstruction are the most common causes of intestinal obstruction in children. In the current study, obstruction due to cancer is 5.2% of adult patients. Wyoski and Kryzan showed that intestinal obstruction due to cancer has 17.2% (23). Obstruction due to bezoar was seen in 2.4% of adult cases and half of them were more than 50 years old. Crohn disease accounting for 3-7% of small bowel obstruction in some studies (24). In the current study, Crohn was indentifed in 2.84% of cases. In our study, malrotation was found in 4 (2.08%) of children and no adult cases. in up to 90%, malrotation develop during the 1 st year of life (25). So, malrotation in unusuall fndings after childhood period. Volvulus was found in 2.08% of children and 1.42% of adults. Volvulus can be primary pa- thology or secondary to malrotation of the in- testine (26, 27). There were 57.6% of the patients underwent the surgical treatment. In our study, 51.04% of children and 36.01% of adults underwent surgical treatment. Overall mortality rate in our study was 12.2%. In another study carried out in Poland, mortality rate was 13.8%, but these patients had intestinal obstruction due to large intes- tine malignancy (28). Higher rate of diagnosis of intestinal obstruction may be due to more easy use of diagnostic procedure such as en- doscopy and colonoscopy in adults than chil- dren. The higher rate of malignancy in adults, may be another cause. In the current study all of the patients with intestinal obstruction due to hernia was male. Dakubo et al. showed that there is male/female ratio was about 8/1 (29). The number of the patients with hernia in our study was too low to be reasonable. In our study, 100% of patients with partial obstruction were treated by conservative man- agement. In Jeong et al. study 80% of patients with partial obstruction were treated by non surgi- cal management. In Teon et al. study, patients had previous history of primary cancer and this may be the result of difference in surgical and non surgical treatment (30). CONCLUSIONS Ileus, adhesion band, and partial obstruc- tion are the most common causes in children. Partial obstruction, ileus, and adhesion band are the most frequent causes of intestinal ob- struction in adults. Most of patients were ad- mitted between 5-10 days. Children were more operated than adult. Sonography was used more commonly in childrens but plain ab- dominal X-ray for adult. In 45% of children 10000<WBC<15000 while most adult had WBC<10000. Most of the patients has normal biochemistry results. Hypokalemia was the most common biochemistry finding among children and adults. Unauthenticated | 36.73.69.60 Download Date | 11/10/13 3:25 AM 371 Ileus and intestinal obstruction comparison between children and adults REFERENCES 1. Mucha P Jr: Small intestinal obstruction. surg clin north am 1987; 67: 597-620. 2. Miller G, Boman J, shrier i et al.: Natural hi- story of patients with adhesive small bowel obstruc- tion. Br J surg 2000; 87: 1240-47. 3. Muthukumarasamy G, Venkata sP, shaikh ia, et al.: Gallstone ileus: surgical strategies and cli- nical outcome. J Dig Dis 2008; 9 (3): 156-61. 4. nobie Ba. Small bowel obstruction. Available at: http://www.emedicine.com/emerg/topic66.thm 5. Philps rk, Hittinger r, Fry Js et al.: Malignant large bowel obstruction. 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Adress correspondence: Imam Khomeini Hospital, Azadegan St., Shaahada Square, Ahvaz, Iran Unauthenticated | 36.73.69.60 Download Date | 11/10/13 3:25 AM