Acute Abdomen at El Obeid Hospital , Western Sudan

Background: Acute abdominal pain is the presenting complaint in emergency departments of all hospitals worldwide, resulting in a huge drain of human and non-human resources. Objectives: To study the pattern, causes and management outcomes of patients presenting with acute abdomen to El Obeid Hospital, Western Sudan. Patients and Methods: This was a prospective study. All patients who presented with acute abdomen to the University Surgical Unit at El Obeid Hospital between January 1999 and December 2000 were included. The patient characteristics, clinical features, investigations, management and postoperative care were recorded in a pre-designed sheet. Results: There were 421 patients. 242 were males (57.5%). Acute appendicitis was the commonest cause accounting for 63% of the patients, followed by acute intestinal obstruction 20.4% and abdominal trauma 11.6%. One third of the patients with acute appendicitis reported with complications. The majority of acute intestinal obstruction cases were due to obstructed and/or strangulated hernia. Acute cholecystitis and perforated duodenal ulcers were not common. Perforated typhoid ulcers and tuberculous peritonitis were less frequent but had high mortality. The overall mortality was 8.5% and those deaths occurred mostly in patients presenting late with generalized peritonitis. Conclusions: Acute abdomen was a common surgical emergency at El Obeid Hospital, Western Sudan. The leading causes were acute appendicitis, acute intestinal obstruction and abdominal trauma. Awareness of the seriousness of the condition and better hospital facilities and care may reduce an unacceptable high mortality.

cute abdomen is a common surgical emergency accompanied with high morbidity and mortality, if not managed properly 1 .The pattern of this condition is changing fast in different African countries, probably due to the new lowresidue diet, the new life-style and the stress of a new developing modern society 2,4,5 .In this communication, we present our experience regarding patients with acute abdominal emergencies seen in the University Surgical Unit at El Obeid Hospital, Western Sudan.

Discussion:
Acute appendicitis was the commonest cause of surgical abdomen in the developed world 2 .
It was also the most common cause of acute abdominal emergency (63%) in this study.That contradicted previous reports describing the condition as uncommon in Western Sudan two to three decades ago 3,4 .This dramatic change was probably due to the change in the life style of the people especially the town inhabitants; in particular consumption of a low-residue diet and the stress of a new modern society 4,5 .Most of the patients (78%) were town dwellers, many of whom were brought to urban life by drought, desertification, displacement, tribal conflicts and war.Acute appendicitis was reported to account for 47% to 22.4% of surgical admissions for acute abdominal pain at similar developing communities [6][7][8] .It was the most frequent diagnosis in patients presenting with acute abdominal pain worldwide 9 .
In this study a third of patients presenting with acute appendicitis were found suffering from complications of the disease.The frequency of perforated appendicitis was 20.4%, much higher than reported from Khartoum (13.9%) 2,3 .10% of the patients with acute appendicitis had appendicular mass.They were treated conservatively and booked later for elective appendicectomy.Only 4.5% of the appendices removed were found to be clinically normal, compared to 9.6% in a similar society 3 .
Many patients presented late due to poor awareness about the condition and its seriousness among the people, but many others were misdiagnosed at primary health care settings and were under treatment for malaria and colitis before being seen at the surgical casualty [10][11][12] .The easy access to self medication compounded the problem.The undue delay in diagnosis and mis-diagnosis often resulted in serious life threatening complications 13,14 .Alvarado postulated a clinical score to eliminate possible diagnostic errors 15,16 .Its value in our situation and similar developing communities can not be over stressed.Six patients reporting in late peritonitis died post-operatively, accounting for 2.3% of all patients with acute appendicitis.However, they constitute 11.1% of those with perforated appendicitis and 37.5% of those with generalized peritonitis.The mortality in Khartoum was 1.5% of all patients with acute appendicitis and 28.5% of those with generalized peritonitis 3 ; the difference can be attributed to the better health facilities in Khartoum.
In this study acute intestinal obstruction was the second cause of acute abdomen (20%), much commoner than reported from some African countries [7][8][9] .The pattern of the disease was similar to previous reports from Khartoum 17,18 However, the frequency of external herniae was more common in El Obeid, where as bands and adhesions were commoner in Khartoum, due to more elective surgery performed there.The high mortality (20%) may be reduced if active plans for elective hernia repair in a user-friendly style were adopted [19][20][21] .
The features and complications of sigmoid volvulus in this community were discussed before 21,22 .Intestinal obstruction due to malignancy was less frequently seen in El Obeid than in Khartoum 21 .Bowel obstruction due to abdominal tuberculosis was still prevalent in this community (9.3%) and should be included in the differential diagnosis.Tuberculous peritonitis was more common in children 23 and the elderly 24 , where as intestinal tuberculosis was more seen in patients between 30 and 60 years old 24 .
Patients with traumatic acute abdomen in our study (11.6%), were more than the reported from Ghana (8.3%) 8 .Stab wounds (45%) were less than those reported from Khartoum (67%) 3 ; whereas gun-shots (18%) were more common than in Khartoum (3.3%) 3 .This was due to the easy availability of guns in our community and the common frequency of their use in fights and social ceremonies.Many victims were injured in other parts of the body, which was out of the scope of this study.Some victims were so seriously injured that they never reach hospital care.Blunt abdominal injures were 37% compared to 29% in Khartoum study.The spleen was most commonly injured in our study (41%) while the small bowel was more frequently injured (41.9%) in Khartoum 3 .
The overall mortality of acute abdomen in this study was 8.5%.It was higher than that reported from Khartoum (6.2%) 3 .The difference can be explained by the late presentation of patients in El Obeid and the better health facilities and surgical care in Khartoum.In a similar study conducted in a developed community, the overall mortality of acute abdominal pain admissions was 0.4% 25 .The gap between the outcomes can only be narrowed by more awareness of the people about the seriousness of acute abdomen, by training health providers at primary health care settings to refer patients to nearby surgical firms promptly and by the provision of efficient and welcoming health care facilities in hospitals.

Conclusions:
Acute abdomen was a common surgical emergency at El Obeid Hospital, Western Sudan; expectedly draining great deal of resources.As the society was changing fast the pattern of the disease has also changed.Acute appendicitis, acute intestinal obstruction and abdominal trauma were the leading causes.Late presentation and inaccuracy in the prompt diagnosis of acute appendicitis were associated with increased morbidity and mortality.Health education and active plans for mass hernia repair may reduce the incidence, morbidity and mortality of acute intestinal obstruction.

Table 1 :
Causes of acute abdomen.

Table 2 :
The causes of intestinal obstruction.