Acute Intestinal Obstruction in El Obeid Hospital, Western Sudan.

: Objectives: To study the pattern, causes and management outcomes of acute intestinal obstruction in El Obeid Teaching Hospital, Western Sudan. Patients and Methods: This is a descriptive retrospective study. The medical records of all patients admitted to the University Surgical Unit in El Obeid Teaching Hospital, with the diagnosis of acute intestinal obstruction in a 10-year period were studied. The data were analyzed for gender, locality, causes, operative findings and outcomes. Results: There were 198 patients (152 males and 46 females). The age ranged from one day to 85 years with the mean age of 38.9 – SD 21.9 years. Strangulated external hernias were the commonest cause (35.6%), followed by intestinal adhesions (18.2%) and sigmoid volvulus (11.6%). Indirect inguinal hernias were more frequently seen (70%), followed by para-umbilical (22.9%). Previously performed emergency operations as appendecectomy, Caesarean section and abdominal trauma were the commonest causes of intestinal adhesions. The overall mortality was 13.6%, mainly due to late presentation and scarce health facilities. Conclusions: Acute intestinal obstruction is a serious surgical emergency. In the current situation, the hospital facilities were scarce. A welcoming health delivery system providing mass elective hernia repair with health education will reduce this mortality and a lot of unnecessary morbidity.

ntestinal obstruction is a serious general surgical emergency word wide, with considerable morbidity and mortality 1, 2 . The situation was considered to be worse in developing countries where health facilities were scarce and health education was lacking, that many patients present late to hospitals after trials with local remedies were exhausted. The pattern of the disease was found to vary in different parts of the world and even in different areas in the same country, due to local factors [3][4][5] . The aetiology and outcomes of the disease change as the society and its health delivery system develop [6][7][8]  Previous reports from studies performed in Sudan showed high mortality 9, 10 , in spite of being carried out in tertiary care hospitals with the best available resources in the country. In this study, we report our local experience in the Western part of Sudan, where economic and social development has been progressing rapidly over the last few decades.

Patients and Methods:
This is a descriptive retrospective study. The medical records of all patients admitted to the University Surgical Unit (A) in El Obeid Teaching Hospital, with the diagnosis of acute intestinal obstruction for 10 years between Jan 1996 and December 2005 were studied. The age, gender, locality, causes of the obstruction, initial treatment, operative findings and the post operative outcomes were evaluated. The data collected were analyzed using SPSS computer package system.

Results
There were 198 patients in this study, 152 males (76.8%) and 46 females (23.2%) with a male: female ratio = 3.6:1. The age ranged from 1 day to 85 years (mean = 38.9 ± SD 21.9). Neonates and infants accounted for 6.6% of the patients. The majority of the patients (77.1%) came from rural areas. Acute abdominal pain, vomiting and absolute constipation were the commonest symptoms, while abdominal tenderness and abdominal distension were the leading signs. The causes of acute intestinal obstruction in this series were shown in table 1.

Discussion
This is the first study for the pattern of the disease and its management outcomes from the western Sudan, where the society is changing fast and many socio-demographic factors like drought, tribal conflicts and displacement are prevalent. Strangulated hernias constituted 35.6% of cases and adhesive obstruction 18.2%. Similar figures were reported by El Masri three decades ago from Khartoum 9 . Sourkati 20 year later, reported a slight decrease in strangulated hernias (27.7%) and a slight increase in adhesive obstruction (21%), from the same hospital in Khartoum 10 . These observations were in line with other reports from other developing countries [11][12][13][14][15][16] . A 57% adhesive obstruction and no strangulated hernia among 56 patients were reported in a district hospital from Saudi Arabia 8 . Such a high rate of adhesive obstruction was also reported from the developed countries 16 , together with marked decrease of strangulated hernias, indicating that complications of hernia may be reduced with health education and elective hernia repair 17 . That can only be achieved if the health delivery system is welcoming and the service was offered in a friendly-user style. The types of strangulated hernias in this study were similar to the findings of Sourkati in Khartoum 10 . Indirect inguinal hernias were commonest to strangulate (Fig.), followed by Para-umbilical hernias. A recent study confirmed this observation and found bowel resection was necessary in 37.5% of cases with 6.25% mortality rate 18 , compared to bowel resection in 24.1% of cases and a mortality rate of 6.2% in Ghana 19 . Strangulation was described to be associated with up to 10-fold increase in intra and postoperative mortality 20 . Appendectomy, Caesarean section and abdominal trauma laporatomies were the commonest causes for adhesive intestinal obstruction. The reason is probably because those operations were performed as emergences at incontinent times by the junior staff. Although a conservative approach was globally adopted for the treatment of adhesive intestinal obstruction, but symptoms like continuous abdominal pain and fever; signs of toxaemia, tachycardia, rebound tenderness, rigidity and absent bowel sounds may indicate the development of critical ischemia and/or gangrene. Acute sigmoid volvulus was found in 23 patients (11.6%). The clinical features and management outcomes of the condition in this community were discussed previously 21 .
Intestinal obstruction due to peritonitis occurred in 21 patients (10.6%). Intraabdominal sepsis mainly resulted in patients with perforated appendix or typhoid ulcers 22 . Bowel tumours were not uncommon accounting for 16 cases (8%) mainly at the recto sigmoid with late presentation, while intussusceptions resulted in 12 cases of bowel obstruction (6%). The clinical presentations of acute intussusceptions in this society were outlined elsewhere 23 . In this study; 46 patients (23%) had gangrenous bowel at operation (Fig. II), for which resections and anastomoses were done (Fig. III). In a similar society 32.4% of patients with gangrenous gut needed immediate resection and the procedures resulted in a mortality of 17.3% 24 . Recently in a developed community it was reported that ischaemia, necrosis and perforations accounted collectively for 28.6% of patients with bowel obstruction 25 . The majority of patients with intestinal obstruction presented late; more than 78% had received anti-spasmodic and anti-malarial drugs. The overall morality was 27 (13.6%) patients. In eight patients resuscitation failed and they died before surgical intervention, all of them were at the extremities of age i.e. neonates, infants and elderly. Nineteen patients died during or after surgery. Out of these three were elderly males who developed pneumonia, two were infants with generalized peritonitis and the rest (14) were found to have had gangrenous bowels for which resections and anastomoses were done, accounting for almost 14% of bowel resections. In a similar setting Ohene-Yeboah et al reported a mortality of 12% in patients who underwent emergency bowel resections due to ischaemia 26 . The most probable causes of death were electrolyte imbalance and septic shock. Postoperative morbidity was mainly wound infection with prolonged hospital stay.
Two patients had burst abdomen and another female patient developed an incisional hernia.

Conclusion: Acute intestinal obstruction is
a serious surgical emergency. Strangulated external hernias, adhesions and sigmoid volvulus were the leading causes, similar to patterns reported many decades ago from elsewhere. Less common causes were peritonitis, large bowel tumors and intussusceptions.
The high rate of strangulated hernias, the considerable morbidity and the high mortality reflected a poor health delivery system. This challenging situation can only be bettered by friendly and welcoming health care facilities including active plans for mass elective hernia repair.