M Mir, M Bucch, U Younus, G Sheikh, B Bali
ascaris lumbricoides, enterotomy., mechanical obstruction, strangulation
M Mir, M Bucch, U Younus, G Sheikh, B Bali. Clinical Study Of Mechanical Small-Bowel Obstruction In Children In Kashmir. The Internet Journal of Surgery. 2012 Volume 28 Number 2.
Mechanical small-bowel obstruction is a common surgical emergency and is a frequently encountered problem in abdominal surgery1. It constitutes a major cause of morbidity and financial expenditure in hospitals around the world2. Intestinal obstruction belongs to the severe conditions requiring a quick diagnosis as well as an immediate rational and effective therapy3. Accurate easy recognition of intestinal strangulation in patients with mechanical small-bowel obstruction is important to decide on emergency surgery or to allow safe non-operative management of carefully selected patients. One should embrace the philosophy of “Never Let the Sun Set or Rise” towards the treatment for the patients with small-bowel obstruction. Intestinal obstruction is responsible for approximately 20% of surgical admissions for acute abdominal conditions.4,5The small bowel is involved in 60-80% of cases of intestinal obstructions.5In spite of advances in imaging and better understanding of pathophysiology of small bowel, its obstruction is still frequently misdiagnosed5. Despite advances in the treatment of this condition, the attendant mortality is still high and remains in the range of 5-11%6. Small-bowel obstruction is the commonest surgical emergency encountered in childhood7. The usual causes being intussusceptions, volvulus, adhesions or bands, obstructed hernias and worm obstruction. Intussusception8ranks high as an acute surgical catastrophe in infancy and early child hood. The pathological leading points are polyps, lymphnodes, Meckel’s diverticula and intestinal duplications. Hernias9usually give rise to intestinal obstruction when incarcerated. Among hernias in children, inguinal hernias are common and when obstructed there is a high chance of strangulation or gangrene. Ascaris lumbricoides is the most common intestinal parasite encountered in India.10Worm obstruction due to ascariasis is one of the most common causes of intestinal obstruction in children. Ascariasis remains a formidable problem in India, as a study in India has shown that more than 70% of children have round worm ova in their stool samples10. In Kashmir valley, the incidence of ascariasis was observed as 85.1% of the total helminthic and protozoal infested cases. It affects mainly children from rural areas, low-income groups whose standard of public health and personal hygiene is low10. It is the big mass of worms which causes mechanical bowel obstruction in the small intestine11. Patients with partial small-bowel obstruction may be treated conservatively with resuscitation and tube decompression alone12,13. The most important complication which has been constantly bothering the surgeons in intestinal obstruction is strangulation, where surgical intervention becomes mandatory. Certain criteria have been proposed for the surgical intervention in patients with intestinal obstruction, especially ascaridial obstruction. The two important ones being Dayalan’s and Louw’s criteria.
Patients and Methods
This prospective study included 980 consecutive children under the age of 14 years with small-bowel obstruction who reported to the Department of General Surgery, Government Medical College, Srinagar, over a period of five years from 1stJune 2006 to 31stMay 2011. Patients with adynamic obstruction, age >14 years and large-bowel obstruction were excluded from the study. After a detailed history and clinical examination, laboratory investigations, radiological and sonological assessment, the diagnosis was made in each patient. On the basis of clinico-radiological grounds, conservative or operative management was decided. Data collected was tabulated and subjected to appropriate statistical analysis.
Mean age of patients was 4.94
More than one symptom was present in most of the patients.
Most of the patients revealed more than one sign.
In our study of 980 children with small-bowel obstruction, males and females were almost equally affected with a male-to-female ratio of 1:1.187 and there was a rural preponderance with a rural-to-urban ratio of 1:0.41. The mean age of the children was 4.94
In our series of 980 patients, 315 (32.14%) presented in the age group of 0-2 years and the incidence decreased with increase in age (Tables 1 & 2). A similar decreasing trend was observed in the study by Rao et al.7and the maximum of cases in his study belonged to the age group of 0-2 years. The mean age in our study was 4.94
Hence we concluded in our study that small-bowel obstruction due to ascariasis constituted the major cause of intestinal obstruction leading to considerable morbidity in children of the valley of Kashmir. Hence, efforts should be made to eradicate ascariasis in endemic areas through proper sanitation, proper health education regarding personal hygiene and route of entry of the parasite, and periodic deworming of children with antihelminthics, so as to reduce the incidence of the problem in our society. It is important to start the health education regarding prevention of this infestation right from the admission of such patients, as this is the best time when they and their relatives are very receptive to health advice. We should follow the saying that “prevention is better than cure”.