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A prospective study of intestinal obstruction in paediatric age group

Intestinal obstruction can occur at any age in the paediatric population. Bowel obstruction in children differs from that in adults in terms of etiology, presentation and even the management. It also varies with age in children of different age groups. Paediatric surgery is a fast expanding branch and in spite of great strides it had made in last 4 decades, mortality and morbidity in children with intestinal obstruction remains apparently high. In last decades, great advances have been made in pre-and postoperative intensive care and anaesthesia. Better understanding of pathophysiology of infants and application of this knowledge to develop proper technique, improvement in diagnostic methods, and availability of better antibiotics have brought ABSTRACT


INTRODUCTION
Intestinal obstruction can occur at any age in the paediatric population. [1][2][3][4] Bowel obstruction in children differs from that in adults in terms of etiology, presentation and even the management. It also varies with age in children of different age groups. 5,6 Paediatric surgery is a fast expanding branch and in spite of great strides it had made in last 4 decades, mortality and morbidity in children with intestinal obstruction remains apparently high. In last decades, great advances have been made in pre-and postoperative intensive care and anaesthesia. Better understanding of pathophysiology of infants and application of this knowledge to develop proper technique, improvement in diagnostic methods, and availability of better antibiotics have brought Though these newer methods and sophisticated facilities are available in West, and barring a few centres in our country, most of the children who require surgery are treated by the general surgeon. When a surgeon is facing this challenge, he should be knowledgeable, well prepared and aware of different types of presentation and their physiological responses to management in this age group with intestinal obstruction.
Majority of the paediatric patients with intestinal obstruction present with common symptoms of abdominal distension, constipation or failure to pass meconium, vomiting, fluid and electrolyte imbalance etc. Majority of birth defects present in neonatal age group, but infantile hypertrophic pyloric stenosis commonly occurs around the age of 3 weeks. Intussusception is commonly seen in healthy children of 6-11 months of age. The onset of signs and symptoms of intestinal obstruction also give some idea about the diagnosis.
Various causes of intestinal obstruction in paediatric age group have been described. These causes vary from country to country and region to region. 8 In a series, Belokar et al has mentioned some common causes as intussusception, infantile hypertrophic pyloric stenosis, Hirschsprung's disease, imperforate anus, meconium ileus, malrotation and volvulus, intestinal atresia, annular pancreas etc. 12 Early diagnosis and treatment is essential in intestinal obstruction in paediatric patients, otherwise it may lead to fluid and electrolyte imbalance, perforation peritonitis, aspiration pneumonitis etc. and ultimately lead to mortality.

METHODS
This was a prospective study carried out in 50 patients at Department of Surgery in Medical College and Sir Sayajirao Gaekwad Hospital, Baroda, Gujarat, India from December 2004 to November 2006. Out of them, 25 patients were neonates (1-7 days), 7 patients were infants (1 months-1 year) and 18 patients were children (1-12 years) who presented with symptoms and signs of intestinal obstruction and diagnosis confirmed by x-ray abdomen or invertogram were included in this study.
Other investigations like ultrasonography, barium study, CT scan or MRI of abdomen were performed as per requirement of specific patients. Gangrenous appendicitis that was diagnosed on clinical and radiological examination as intestinal obstruction was also included in the study. All clinical and epidemiological data were collected on a designed proforma. All the patients were managed according to standard protocols. Complete blood count, serum electrolyte and urea level were done. Patients were initially resuscitated and once stabilized then categorized in to those who needed surgical intervention and those who can safely be treated conservatively.
Surgical procedure was performed according to the pathology and condition of the patients assessed by the operating surgeon. Some postoperative patients were managed in intensive care unit while stable patients were managed in ward. All patients were followed up on regular basis after discharge from the hospital. Data were analyzed by using SPSS version 10 for percentage and frequencies.
All patients died due to postoperative septicaemia. There was no mortality in infants and children group. Duration of hospital stay ranged from 5 to 25 days. 44 (88%) patients recovered and were discharged ( Table 6). Intestinal obstruction is the commonest surgical emergency in children apart from acute appendicitis. 13 It was the most common indication of laparotomy in paediatric patients and also forms an important cause of mortality and morbidity in them. 14,15 This similar type of study were carried out by Gangopadhyay et al in 765 cases, Park CH and Woo et al in 77 cases and Adeyemi D et al in 211 cases and they found male and female ratio was 2.3:1, 3.2:1 and 3:1 respectively while in present study, M:F ratio was 3:2 with higher female ratio as compared to other studies (Table 7). 16 [16][17][18] Gangopadhyay et al, Park CH and Woo et al and Adeyemi D et al also studied post-operative complications and mortality in their study and found complications in 26%, 34%, 42% and mortality in 20%, 22%, 35% of patients respectively while compared to present study, in which complications and mortality were in 30 % and 24% of patients respectively. 16,17 Postoperative shock, hypothermia, metabolic disturbances, prematurity and others with associated congenital anomalies were common causes of poor survival rate, thus we see that there is no much difference in established pattern of paediatric intestinal obstruction with respect to presentation, etiology, complication and mortality on comparing present study with those of similar studies in recent past.
In developing countries, significant percentage of deliveries is still carried out at home. Early recognition of congenital malformation may not be possible here in absence of adequately trained personnel. These neonates are brought to hospital only when they develop overt symptoms. Delay in surgery only serves to enhance the rate of complications.
The overall mortality rate in paediatric intestinal obstruction has been reducing with time because of increasing awareness, early diagnosis and intervention, improved paediatric anaesthesia, better antibiotics and improvement of post-operative care of paediatric patients.

CONCLUSION
In this study, there was male preponderance with M:F ratio of 3:2. Among them half of the patients were neonates. Abdominal distension (76%) was the commonest symptom than other clinical features. Congenital anorectal anomalies (42%) were more common etiology than other causes of intestinal obstruction in this study. Postoperative septicaemia (40%) was the leading complication than the others and overall mortality was 12% in patients exclusively of neonatal age.