Small bowel obstruction in children – A surgical challenge

review
Small bowel obstruction in children – A surgical challenge
Zahur Hussain , Khurshid Ahmad Sheikh, Reyaz Lone, Sajad Arif, Ashuffa Rasool, Syed Mudassir,
Abdul Rouf Khawaja , Ab. Wahid Mir, Nasir Wani.
Introduction
The small bowel is a marvel of complexity and efficiency.
Amongst the disease processes involving the small bowel, obstruction still
represents the most difficult and vexing problem that a surgeon faces1,2,3.
Correct diagnosis, optimal timing of therapy and the appropriate treatment
are very challenging. One should embrace the philosophy of “Never let the
sun set or rise” towards treatment for the patients with small bowel
obstruction. Though the knowledge of this dreadful malady dates back to
antiquity, it still taxes the diagnostic ability and clinical judgment of a
surgeon to a very high degree2,4,5. In fact there are very few problems in
surgical physiology, which have earned greater attention than those
associated with intestinal obstruction24. Intestinal obstruction is responsible
for approximately 20% of surgical admissions for acute abdominal
conditions6,7. The small bowel is involved in 60-80% of cases of intestinal
obstruction . In spite of advances in imaging and a better understanding of
the pathophysiology of the small bowel, it’s obstruction is still frequently
misdiagnosed9. Despite advances in the treatment of this condition the
attendant mortality is still high and remains in the range of 5% to 11% .
Small bowel obstruction is a common problem seen in children of
Kashmir. Most of the cases are because of worm (ascariasis)
obstruction10,11,12,13. Group of patients who report with ascaridial obstruction
are very alarming and challengeable for the surgeon because of fear of
strangulation and intestinal gangrene and their migratory habit and tendency
to explore orifices and ducts leading to a variety of other dangerous
complications and poor prognosis11,14. So this problem cannot be ignored
while treating the cases of small bowel obstruction.
In a society like ours, most of the children admitted with
mechanical small bowel obstruction are from rural areas who usually
present late because they are either mismanaged in peripheries and referred
to us late or they report late because of ignorance and illiteracy and usually
present as complicated intestinal obstruction. So it is the need of hour to
avoid this dreadful condition to occur, and manage these cases at the earliest.
Types of obstruction:Small bowel obstruction is mainly of two types2,15,16. Mechanical or
Dynamic obstruction and Functional or Adynamic obstruction. Mechanical
obstruction means that luminal contents cannot pass through the gut tube
because the lumen is physically blocked or obstructed, whereas functional
obstruction means that luminal contents fail to pass because of disturbances
in gut motility that prevent coordinated transit from one region of the gut to
the next. This latter form of obstruction is commonly referred to as ileus or
pseudo-obstruction15.
Causes:Small bowel obstruction is the commonest surgical emergency
encountered in childhood17,18 ranks high in importance as an acute surgical
catastrophe in infancy and early childhood. The pathological leading points
such as polyps, Meckel’s diverticula and intestinal duplications are seen in
5% of the total number of intussusceptions19.
Volvulus20,16 of the small intestine is an infrequent cause of small
bowel obstruction. It usually occurs in the lower ileum, and is favoured by
the presence of an adhesion passing from the antimesentric border of an
intestine loop to the parieties.
Adhesions21,22 (postoperative or postinflammatory) causing
intestinal obstruction are not infrequently encountered in pediatric surgical
practice. However, some intestinal obstructions result from bands that are
8
10
Authors affiliations:
Zahur Hussain , Khurshid Ahmad
Sheikh, Sajad Arif, Reyaz Lone,
Ashuffa Rasool, Nasir Wani, Syed
Mudassir Ab. Wahid Mir,. Abdul
Rouf Khawaja
Department of Paediatric Surgery
S.K. Institute of Medical Sciences,
Srinagar – Kashmir 190011 (India)
Accepted for Publication
June 2006
Correspondence
Dr. Zahur Hussain
Senior Resident
Department of Paediatric
Surgery
SKIMS, Soura, Srinagar,
Kashmir 190011 India
JK-Practitioner2006;13(4):186-189
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not the remnants of described embryologic structures and
do not show an association with a previous intraperitoneal
insult. Postoperative adhesions giving rise to intestinal
obstruction usually involve the lower ileum. The risk of
developing an adhesive small bowel obstruction is greater
when there was more than one prior peritoneal procedure,
and when, during this prior procedure, there was already
peritonitis. In the literature, there is disagreement about the
frequency of postoperative mechanical small bowel
obstruction in children22.
Hernias23 give rise to intestinal obstruction when
incarcerated. In children inguinal hernias are commonly
obstructed and there are high chances of strangulation or
intestinal gangrene. The postoperative complication rate is
more than 20% in incarcerated cases as compared with 1 to
2% in elective procedures.
Ascaris lumbricoids is the most common intestinal
parasite encountered in India56. Worm obstruction due to
Ascaris lumbricoides is one of the most common causes of
intestinal obstructionin children, usually under 10 years of
age16. Ascariasis remains a formidable problem in India, as a
study has shown that stools of more than 70% of children
have round worm ova24. In the Kashmir valley, the incidence
of ascariasis was observed as 85.1% of the total helmenthic
and protozoal infected cases. It affects mainly children from
rural areas, low income groups whose standards of public
health and personal hygiene are at the lowest10,24,12,13. It is the
big mass of worms which causes mechanical bolus
obstruction in the small bowel25,14.
The less frequent causes of small bowel
obstruction in children include congenital cysts (e.g.
enterogenous cyst) and tumors (e.g. non-Hodgkin
lymphoma).
Although the exact incidence figures are not
available, there is probably not a day that goes by in which
any busy clinical abdominal surgeon does not at least once
consider a possible diagnosis of small bowel obstruction .
Symptomology :The cardinal symptoms that characterize
mechanical small bowel obstruction include abdominal
pain (colicky), vomiting, abdominal distension and
obstipation (failure to pass flatus and faeces)2,15,16. Initially
pain tends to be diffuse, poorly localized, episodic and
crampy in nature. However with the onset of bowel
ischemia pain becomes constant. Vomiting occurs early in
proximal small bowel obstruction but may be absent or
develop late in distal obstruction. Character of vomitus also
differs as far as the site of obstruction is concerned. It is
bilious in high obstruction and can be feculent in distal
obstruction. Visible peristalsis may be seen in thin patients
while in others distention may be prominent which is
usually centrally placed. Abdominal auscultation usually
reveals periods of increasing or crescendo bowel sounds
with the abnormal bowel borborygmi of tinkles, splashes
and rushes that coincide with the abdominal colic.
Investigation :In addition to a very careful and thorough history
and physical examination, all patients require baseline
laboratory studies, including a complete blood count, serum
electrolytes, and a flat and upright plain film of the
abdomen, as well as any other specific tests that might be
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JK- Practitioner Vol.13, No. 4, October-December 2006
suggested by the patient’s history or concomitant medical
problems2,3,16. Plain radiograph of the abdomen is an
important diagnostic too. The cardinal findings include
dilated loops of small intestine on the supine radiograph and
multiple air-fluid levels, which often layer in a stepwise
manner on erect radiograph or lateral decubitus film. In
general, dilated loops of small intestine are defined as those
larger than 3cm in diameter15. When doubt remains contrast
studies of the gastrointestinal tract, USG & CT can help in
diagnosis.
Patients with partial small bowel obstruction may
be treated conservatively with resuscitation and tube
decompression alone26,27. In general the patients with
complete small bowel obstruction require operative
intervention28.
Certain criteria have been proposed for the
surgical intervention in patients with intestinal obstruction
(esp. ascaridial obstruction), the two important beingDayalan’s & Louw’s respectively.
Deciding about surgical intervention:A casual perusal of the literature of antiquity
suggests that bowel obstruction and its poor outlook were
known to the ancients. Persistent vomiting accompanied by
pain and abdominal distention were treated by Hippocrates
with enemas and inflation of the rectum by means of a
bladder attached to a pipe68. The earliest reasonable
authentic report of operation for intestinal obstruction is
that of Praxagoras (3 to 4 century B.C.) who created an
enterocutaneous fistula to relieve obstruction2,5.
Until the late 1800s, non-operative management
of these patients was the rule. In publishing his prize
winning monograph of 1899, Frederick Treves included
such conventional procrastinating treatments as posture and
taxis, opium, purgation (a measure he least supported),
administration of metallic mercury, electricity, enemas, and
inflation of the bowel with water, air and other gases. He
listed, without endorsement, puncturing the bowel with a
fine needle or trochar and mentioned too, the more
dangerous procedure of enterocentesis, in which the trochar
and needle is left in the bowel for varying periods of time for
temporary decompression or with the hope of establishing
an external fistula5.
In the 19 century, surgical procedures became
more frequent for intestinal obstruction. The 2 decade of
the 20 century saw the development of radiographic
techniques for the diagnosis of intestinal obstruction. The
1930s marked a beginning of the new era in the
management of intestinal obstruction with the application
of suction to indwelling gastroduodenal tubes. Antibiotics
were employed to the treatment of intestinal obstruction in
1940s and 1950s .
The rapid scientific advances made after the first
and second World Wars led to a better understanding of the
pathophysiological aspects of intestinal obstruction and in
turn to the concept of the rapid correction of patients
physiologic deficits before any surgical intervention. The
result was a decrease in the mortality but since then, the
problem of morbidity remains unresolved despite a
satisfactory decrease in the mortality. That intestinal
obstruction is due to multiple causes has been established
by many studies1,17,3,29. Furthermore, major causes of
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intestinal obstruction vary from country to country and at
times within smaller geographic areas1.
The modern day surgical management of small
bowel obstruction continues to focus appropriately on
avoiding operative delay whenever surgery is indicated .
“Frederic Treves” of the London Hospital, in his
monograph of 1899 said, “It is less dangerous to leap from
the Clifton Suspension Bridge (250-275 feet above the
Avon River) than to suffer from acute intestinal obstruction
and decline operation”5. The wisdom of the adage “never let
the sun set or rise on a small bowel obstruction” remains a
most practical guideline whenever any uncertainty exists3.
The most important complication, which has been
constantly bothering the surgeons, in intestinal obstruction,
is strangulation, when the urgent surgical interference
becomes mandatory, but it is not always possible to decide
preoperatively about the presence or absence of this
gruesome complicaiton,31,28,32. The high mortality rate
associated with this jeopardized vascularity of the gut is
quite well known.
Prompt recognition of the need for operative
intervention when clinically indicated remains the
cornerstone of the modern day surgical management of
acute small intestinal obstruction .
Louw (1966) ; studied the abdominal
complications of Ascaris lumbricoides infestation in
children aged 1 – 12 years. He found intestinal obstruction
as the commonest complication (in 68 out of 100 patients).
In the majority of cases the obstruction was incomplete and
responded to conservative therapy, but in about one-sixth
there was complete occlusion or strangulation due to
intraluminal blockage, intussusception, volvulus or
associated bands. In 2 cases worms per se caused necrosis
of the intestinal wall. He concluded that the treatment
should be conservative in the first place, but laparotomy
should be performed in the following circumstances:a)
The passage of blood per rectum.
b)
A very ill child with tense abdominal distention
and rebound tenderness.
c)
The presence of multiple fluid levels on
abdominal radiographs.
d)
Unsatisfactory response to conservative therapy.
He also concluded that the worms should be
dispersed without opening the bowel, but there should be no
hesitation to resect bowel when necessary.
Dayalan et al (1976) ; studied the pattern of intestinal
obstruction with special preference to ascariasis. The study
3
3
comprised of 2295 cases of intestinal ascariasis studied
retrospectively for nine years. Out of these 2295 cases 159
(7%) were classified as having ascaridial obstruction. Some
guidelines for recognition of failure of conservative
management and hence indication of surgery were laid
down, which included:
a)
Persistence of mass in the same site or fixity of the
mass for more than 24 hours.
b)
Persistent abdominal pain and tenderness.
c)
Rising pulse rate in the absence of any mass.
d)
Toxemia out of proportion to the severity of
obstruction.
It was concluded that by using these criteria for
indication of surgery in ascaridial obstruction significant
decrease in mortality and morbidity can be achieved, in
such patients.
Khurshid A Sheikh et al (1998) ; reported round worms as
the most common cause of intestinal obstruction in children
of Kashmir. He presented a study of 81 cases of intestinal
obstruction due to round worms over a period of 2 years. 55
cases were managed conservatively and 26 including 5
cases initially managed conservatively, were taken for
surgical intervention as per Dayalan criteria. Mass
deworming was suggested.
Worm obstruction is the most common cause of
small gut obstruction in the paediatric population in this part
of the world. Most of these patients are from rural areas with
lack of health education, poor hygiene and sanitation,
poverty and low standard of living. Majority of the patients
with worm obstruction can be managed conservatively and
patients should be operated as per Dayalan criteria. As
worm obstruction inflicts lot of morbidity, it is mandatory
that proper health education via mass media, regarding
personal hygiene, route of entry of the parasite and periodic
deworming of the children is imparted, so as to reduce the
incidence of this problem in our society. Further also it
accounts for a large number of hospital admissions in our
institution and the consequent high economic burden on the
state, therefore again it is important to start the health
education regarding prevention of this infection right from
the admission of such patients, as this is the best time when,
they and their relatives are very much receptive to the health
advise.
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