Introduction

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 alone^12,13. 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 1^stJune 2006 to 31^stMay 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.

Figure 1

Table 1: Age distribution of patients with mechanical small-bowel obstruction

Mean age of patients was 4.94+3.57 years.

Figure 2

Table 2: Sex distribution of patients with mechanical small-bowel obstruction

Figure 3

Table 3: Demographic distribution of patients with mechanical small-bowel obstruction

Figure 4

Table 4: Presenting symptoms of mechanical small-bowel obstruction in patients

More than one symptom was present in most of the patients.

Figure 5

Table 5: Signs of mechanical small-bowel obstruction in patients

Most of the patients revealed more than one sign.

Figure 6

Table 6: Etiology of small-bowel obstruction in patients

Figure 7

Table 7: Management strategies used in patients with small bowel obstruction

Figure 8

Table 8: Type of mechanical small-bowel obstruction in patients

Figure 9

Figure 1: Small-gut gangrene secondary to worm obstruct ion

Figure 10

Figure 2: Ileocaecal intussusception

Figure 11

Figure 3: Band causing obstruction

Figure 12

Figure 4: Abdominal X-ray with multiple air-fluid levels

Results

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+3.97 years. The causes of obstruction included round worm obstruction (figure 1) in 108 patients (77.14%), adhesion obstruction in 105 patients (10.71%), intussusception (figure 2) in 70 patients (7.14%), obstructed hernia in 21 patients (2.14%), congenital bands (figure 3) in 21 patients (2.14%) and enterogenous cyst in 7 patient (0.71%). Abdominal pain was the predominant symptom in 82.14% of the patients followed by vomiting in 74.28% and constipation in 62.14%. Abdominal tenderness was the most frequent physical sign in 74.28% followed by tachycardia in 68.57% and abdominal distension in 59.28%. Plain abdominal radiography (figure 4) suggested the diagnosis in 80% of cases. Most of the patients (59.78%) had strangulation obstruction and 40.22% had simple obstruction. Among those with strangulation obstruction, 61.82% had viable gut and 38.18% had non-viable gut. Operative management was needed in 92 (65.71%) patients and 48 (34.28%) were managed conservatively.

Discussion

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+3.57 years, which is almost the same as reported by Villamizar et al.¹⁶who recorded a mean age of 4.6 years. In our series of 980 patients (Tables 1 & 2), 448 (45.71%) were males and 532 (54.29%) were females. These results correlate well with those noted by Villamizar et al.¹⁶who reported figures of 44.8% males and 55.2% females. In our study (Table 3), 693 (70.71%) patients belonged to rural and 287 (29.28%) to urban areas. Thus forms a rural-to-urban ratio of 1:0.41. This difference seems to be due to rampant ascariasis in the rural population, the reason being lack of health education, poor hygiene and sanitation, poverty and low standard of living. In our study (Tables 4 & 5), the predominant symptom was abdominal pain (82.14%) followed by vomiting (74.28%), constipation (62.14%) and other symptoms with less frequencies. Our findings are at par with those reported by Brolin et al.¹², Budhraja et al.¹⁷and Mucha¹. Abdominal pain was predominantly colicky in nature to start with and in the umbilical region, radiating to the whole abdomen (602 of 805, i.e. 74.78%). While continuous type of pain was present in 203 of 805 patients, i.e. 25.21%, vomiting was one of the commonest symptoms in our study present in 74.28%, particularly with reference to ascaridial obstruction, as this form of obstruction topped the list of etiology of small-bowel obstruction in our study. Of the patients with ascaridial obstruction, 469 of 728 patients (64.24%) had history of vomiting of worms. Our findings are at par with Villamizar et al.¹⁶who also reported history of vomiting of worms in 49% of patients of ascaridial obstruction. Bleeding per rectum or its presence on the examining finger was seen in 91 of 980 patients (9.28%), out of which 77 had gangrenous small bowel and 14 had acute intussusceptions. Thus it is important to perform digital rectal examination of every patient of small-bowel obstruction to rule out or to support the diagnosis of the above mentioned etiological factors. Pyrexia (>100F) was present in 147 of 980 (15.0%) patients in our study. It was present in 98 of 385 (25.45%) patients with strangulation of 49 of 259 (18.91%) with simple obstruction. Our findings were almost the same as those observed by Shatila et al.¹⁸who reported figures of 24% and 19%, respectively. In our study, the physical sign most frequently present was abdominal tenderness (74.28%) followed by tachycardia (68.57%). These were at par with those observed by Lefall et al.¹⁹who reported abdominal tenderness in 82% and tachycardia in 71%. As in their study, nothing was gained from these clinical findings in differentiating simple from strangulation obstruction of small bowel in our study. Various clinical criteria have been described to establish that^19,20. In our study, most of these criteria were present in simple obstruction as well. In our study, direct tenderness was present in 74.28%, rebound tenderness in 9.28%, tachycardia in 68.57%, fever in 15.0% and bowel sounds were absent in 19.28%. Strangulation obstruction of the small bowel was established in 59.78% in our study. It is quite evident that the majority of these clinical criteria like rebound tenderness, tachycardia, fever, and absent bowel sounds were not seen in all patients of strangulation obstruction nor were they absent in all cases of simple obstruction. Therefore, in the majority of cases in our study, differentiation between simple and strangulation obstruction on clinical grounds was not possible and was confirmed only after surgery. Similar conclusions were drawn by Shatila et al.¹⁸, Sarr et al.²⁰and Silen et al.²¹. In our study, plain abdominal radiography remained the first step in diagnostic evaluation of the patients with suspected small-bowel obstruction. Both standing and lying-down films were taken in all the patients and diagnosis was suggested in 80% (784 of 980). Our observations are almost at par with those of Suri et al.²²where plain radiography of the abdomen was able to diagnose 77% of patients. In our study (Table 6), ascaridial obstruction (round worms) was the most common etiology occurring in 756 of 980 patients (77.14%). These observations are at variance with those recorded in the Western literature where adhesion obstruction is the most common etiology^{1,18,19,23,24}. Also these are at variance with some of the reported Indian services by Rao et al.⁷and Dayalan et al.¹⁴who reported intussusception as the commonest cause of small-bowel obstruction in children. Dayalan et al.¹⁴reported ascariasis as the second most common cause of intestinal obstruction in children. The reason for our observation could be that since most of these children reside in rural areas with poor sanitation and personal hygiene, they get commonly infested with this parasite in this part of the country, resulting in worm obstruction. Also because of favorable climatic conditions for the parasite in this part of the country, ascariasis infestation is very common here. Most of the cases in our study were due to mechanical factors caused by a bunch of adult worm remaining stationary in the lumen of the bowel. This observation was at par with that of Dayalan et al.¹⁴in their published series. Adhesion obstruction was the second commonest etiology occurring in 105 of 980 patients (10.71%). The cause of adhesions were post-operative in 63 patients (60%), post-inflammatory in 35 patients (33.33%) and post-traumatic in 7 patient (6.66%). Intussusception was third in the list of etiology of mechanical small-bowel obstruction in children occurring in 70 of 980 patients (7.14%). The causes of intussusception were idiopathic in 56 patients (80%) and enlarged lymphnode in 14 patients (20%). Thus, leading points initiating intussusceptions were seen in 20% of cases. Obstructed hernia was next in list occurring in 21 of 980 patients (2.14%). Obstructed inguinal hernias were present in 14 patients (1.42%) and obstructed umbilical hernias in 7 (0.71%). Other infrequent causes were congenital bands in 21 patients (2.14%) and enterogenous cyst in 7 (0.71%). At our institution, we have continued to pursue the philosophy of ‘never let the sun set or rise’ in the treatment of the patients with mechanical small-bowel obstruction, but not to the extent that it implies automatic surgery in every case. Based on this philosophy (Table 7), 644 of 980 patients (65.71%) were managed operatively and 336 of 980 patients (34.28%) were managed conservatively, the reason being that our institution is a tertiary health care centre and most of the cases were referred from first and second referral units when the conservative management failed there. The most common etiological group which successfully responded to conservative treatment was worm obstruction, i.e. 294 of 756 (38.88%). The patients with worm obstruction were operated as per Dayalan’s¹⁴and Louw’s¹⁵criteria. In our series of 980 patients (Tables 8 & 9), 644 patients (65.71%) were operated, 259 (40.22%) had simple and 385 (59.78%) had strangulated obstruction. At operation, viable strangulation was noted in 238 of 385 patients (61.82%) and non-viable strangulation (42 with gut gangrene) in 147 of 385 patients (38.18%). These observations were different from those reported by Sarr et al.²⁰in their series of 51 patients, where 30 patients (38.62%) had simple and 21 (41.17%) had strangulation obstruction. The reason for this difference is that in our study the cases with strangulation obstruction were referred from first and second referral units of rural areas and they reached our tertiary care centre after the failure of conservative management attempted at first and second referral units.

Conclusion

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”.