Emerging pattern of emergency abdominal surgeries in Ile-ife Nigeria

George C Obonna; Olukayode A Arowolo; EA Agbakwuru; Amarachukwu C Etonyeaku

doi:10.4103/1116-5898.149600

ORIGINAL ARTICLE

Year : 2014 | Volume : 24 | Issue : 2 | Page : 31-35

Emerging pattern of emergency abdominal surgeries in Ile-ife Nigeria

George C Obonna, Olukayode A Arowolo, EA Agbakwuru, Amarachukwu C Etonyeaku
Department of Surgery, Obafemi Awolowo University Teaching Hospital, Ile Ife, Osun State, Nigeria

Date of Acceptance	15-Jul-2014
Date of Web Publication	21-Jan-2015

Correspondence Address:
George C Obonna
Department of Surgery, Obafemi Awolowo University Teaching Hospital, Ile Ife, Osun State, PMB 220005 Osun State
Nigeria

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1116-5898.149600

Abstract

Background: The pattern of abdominal surgical emergency may not be the same in different settings because of changes in demography, diet, socioeconomic or geographical factors. We present the pattern, management and outcome of such emergencies in Ile Ife, South Western Nigeria. Aim: To document the pattern of abdominal surgical emergency in our environment with a view to highlighting the management and outcome. Because, superstitiously our people mostly think toward poison as the cause of abdominal pain, it is justified to do this study. The societal meaning of poison refers to a situation whereby someone's friend or relative introduces a deadly substance or material into his drink or food which will eventually lead to morbidity or mortality. It is thought that the introduction of deadly poison could be physically done or diabolically in form of spiritual attack. Materials and Methods: This was a retrospective review of data collected in Obafemi Awolowo University Teaching Hospital Ile Ife, Osun State, Nigeria between June 2006 and June 2012. Patients with abdominal surgical emergencies exclusive of gynecological cases were consecutively entered into the study at the time of presentation and followed-up. The frequencies of different diagnosis and age distribution were recorded. The indications for operative intervention, management and outcome were also highlighted. Results: Of the 8001 cases presenting with abdominal pain in our hospital, 2408 (28.8%) required surgery. Males were 1445 (60.1%), while 963 (39.9%) were female patients with a mean age of 35.9 years. Uncomplicated appendicitis was the most common indication for surgery (61.3%), obstructed hernias constituted the most common etiological factor in intestinal obstruction (51.2%), while postoperative bands and adhesions accounted for 14.6%. Ruptured appendix and typhoid perforation accounted for 32.4% and 18.9% of peritonitis, respectively. The spleen was the most affected intra-abdominal organ in cases of abdominal trauma. Three patients had repair of the spleen. 16 (0.7%) had emergency surgery for complicated duodenal ulcer, repair of burst abdomen accounted for 48 (2.1%) cases of emergency abdominal surgery. Postoperative death was 1.1%. Delayed presentation increased mortality. Conclusions: Surgery for appendicitis is the commonest emergency abdominal surgery. Others include operations for peritonitis, trauma and strangulated inguinal hernia. Delayed presentation contributed to delayed intervention in some cases which impact negatively on treatment outcome. No single case of abdominal pain secondary to ingestion of the so called poison was seen during the study period

Keywords: Abdomen, emergency, pain, poison, superstition, surgery

How to cite this article:
Obonna GC, Arowolo OA, Agbakwuru E A, Etonyeaku AC. Emerging pattern of emergency abdominal surgeries in Ile-ife Nigeria . Niger J Surg Sci 2014;24:31-5

How to cite this URL:
Obonna GC, Arowolo OA, Agbakwuru E A, Etonyeaku AC. Emerging pattern of emergency abdominal surgeries in Ile-ife Nigeria . Niger J Surg Sci [serial online] 2014 [cited 2023 Apr 1];24:31-5. Available from: https://www.njssjournal.org/text.asp?2014/24/2/31/149600

Introduction

Severe abdominal pain can result from some medical problems and would require prompt assessment and treatment. However, emergency surgery will be needed to reduce morbidity or save the life of a patient with acute surgical abdomen.

Emergency abdominal surgery is the gold standard in the management of acute surgical abdomen; ^[1] this paper reflects the pattern of acute abdomen that require surgery in any locality. We have reviewed the emergency abdominal surgical operations carried out in our University Teaching Hospital at Ile Ife, Nigeria between 2006 and 2012 with a view to outlining the common indications for this mode of treatment and where applicable identifying any changes in the pattern of presentation. Comparison is also made with experiences elsewhere.

Abdominal surgical emergencies constitute a significant portion of a surgeon's clinical experience and often present diagnostic and treatment challenges particularly in poor communities with a lack of modern medical facilities. Investigations may improve diagnostic accuracy; however, a good differential diagnosis can be made at the bedside in the majority of patients. The major causes of abdominal emergencies vary from region to region, and even within the same region socioeconomic, cultural or geographical factors may alter the pattern. Periodic review is, therefore, necessary.

There are significant changes in the prevalence of most gastro-intestinal emergencies in tropical compared with temperate countries. ^[2] Recent reports indicate a change in the clinical spectrum of abdominal emergencies in the West African sub-region. ^[2],[3] In the past, intestinal obstruction from strangulated inguinal hernia was the leading cause of abdominal emergencies in developing countries. ^[2] Today from our experience the trend shifts toward acute appendicitis as the leading abdominal surgical emergency. This may be due to an increase in the consumption of the western diet in the tropical region and the avoidance of manual jobs, which raises intra-abdominal pressure. The prevalence of postoperative adhesions in the tropical climate have increased as the leading cause of acute intestinal obstruction in many current reports, however in this study, it is the second most common cause of intestinal obstruction after strangulated inguinal hernia. ^[2],[3] Penetrating and blunt abdominal injury has also become a common reason for emergency surgery. ^[2]

We could not establish any case of abdominal pain due to poisoning, as defined by the society.

This study was conducted to document the pattern of abdominal surgical emergencies in our hospital and also review their management and outcome.

One of the lessons learnt is that poison ingestion should not be the first thing to worry about when an African suffers abdominal pain.

Materials and methods

Case notes of patients managed between 2006 and 2012 were retrieved from hospital record department. Patients admitted as an emergency with abdominal pain, but successfully managed conservatively without surgery excluded. Furthermore, excluded were medical conditions such as sickle cell disease, abdominal tuberculosis, gastroenteritis and gynecological emergencies. Data were analysis was done using SPSS and EPI INFO statistical software (SPSS Corporation, Chicago, IL). General analysis was in terms of the indication for surgery, age and sex distribution. In addition, other conditions such as intestinal obstruction, peritonitis and abdominal trauma whose etiology are multi-factorial were reviewed for the specific causative factors.

Results

Within the period under review, out of the 8001 cases presenting with abdominal pain 2408 (28.8%) required surgery. The ages ranges from 1 day to 90 years (mean: 35 years). The male: female ratio was 2:1. Duration of symptoms before presentation to hospital ranged from 1 h to 14 days mean 2 days. The breakdown of clinical diagnosis is as displayed below, and all the 2408 cases had indicated surgery for their conditions. The mean time that elapsed between the presentation at hospital and surgical intervention was 12 h.

The duration of hospital stay ranged from 2 to 51 days (mean: 8 days). Of the patients 24 died, giving a mortality rate of 1.1%. Postoperative mortality rates were high in patients with intra-abdominal malignancy, perforated duodenal ulcer, typhoid ileal perforation and intestinal gangrene. Three HIV infected cases whose HIV status was not known preoperatively died after operation while only one case that was known died postoperatively. Screening for HIV antibodies was performed on the basis of clinical suspicion. The duration of patient follow-up in the surgical outpatient department ranged from 3 weeks to 40 months; 1800 patients (75%) were followed-up for >6 months and 604 (25%) for >12 months.

A breakdown of the broad indications for surgery is shown in [Figure 1]. Emergency appendectomy for uncomplicated appendicitis accounted for about 60% of all emergency surgeries. Intestinal obstruction accounted for 328 (13.9%) of emergency abdominal surgeries done while peritonitis and abdominal trauma were responsible for 296 (12%) and 248 (10%) respectively of emergency operations done as shown in [Figure 1]. Age distribution of patients that had appendectomy are as shown in [Figure 2] with the highest number of patients 640 (45%) in the range of 21-30 years. Thus, there was a steady increase in age up to the third decade before a decline. Causes of intestinal obstruction are as follows: Strangulated inguinal hernia 168 patients (51.2%), adhesions 48 patients (14.6%), neoplasm 40 patients (12.2%), intussusceptions 32 (9.8%), congenital anomalies 24 (7.2%) and volvulus 16 patients (4.9%) as shown in [Table 1]. Ruptured appendix ranked as the highest cause of peritonitis 96 patients (32.4%), while other causes include typhoid perforation 56 (18.9%), perforated duodenal ulcer 48 (16.3%) as shown in [Figure 3]. Abdominal trauma constituted the 4 ^th commonest cause of emergency abdominal surgery, and intra-abdominal viscus are injured as follows: Spleen 88 patients (36%), liver 40 (16%), urinary bladder 40 (16%), small and large intestine 40 (16%), others 40 (16%) as shown in [Figure 4].

Figure 1: Diagnosis in 2408 emergency abdominal surgery

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Figure 2: Age distribution of patients that had appendicectomy

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Figure 3: Causes of peritonitis

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Figure 4: Injured abdominal structure

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Table 1: Causes of intestinal obstruction

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Discussion

Globally, acute appendicitis constitute the commonest abdominal emergency. ^[2],[3] The treatment is surgical. Emergency appendectomy is thus the most commonly performed emergency abdominal surgery. Appendicitis involves mostly young adults between 1 and 30 years (78%), but rare in the extremes of life. ^[4] This is because the lumen of the appendix, wide in the very early stage of life and almost obliterated in the elderly will not give room for obstruction which is the genesis of inflammation in the appendix. In this series appendectomy for appendicitis was more prevalent in females (60%) than males (40%), Females have more differential diagnosis for right ileac fossa pain. Results of histology confirmed all, but one male case as appendicitis while 88 (10%) of female cases had a normal appendix. The negative appendectomy rate of 7% compares favorably with other reports. ^[3] Because of late presentation 32.4% of our patients presented with advanced disease, similar to other reports from our sub-region, ^[3],[4] These patients presented with gangrene or perforation of the appendix leading to generalized peritonitis, which are associated with increased mortality

strangulated inguinal hernia remains the most common cause of intestinal obstruction. It requires operative management (51.22%). ^[4],[5],[6] In most developed countries, there is a pattern toward bands and adhesions as the most common cause of emergency abdominal surgery. ^[7],[8],[9] Patients with bands and adhesions routinely undergo initial conservative management. This involves nasogastric intubation, correction of fluid and electrolyte anomaly and antibiotic therapy. Surgical intervention becomes inevitable when there is no appreciable improvement in the condition of the patient in spite of the conservative treatment; particularly when strangulation proves imminent. ^[10] On the other hand, obstructed inguinal hernia almost invariably requires surgery. ^[11] Only the case of intestinal obstruction was high-level obstruction due to duodenal stenosis.

Neoplasia, intussusception, volvulus and congenital obstruction are less common causes of intestinal obstruction in our environment. Management involves laparotomy for relief of obstruction after preliminary resuscitation.

Ruptured appendix and typhoid perforation were found to be the most common causes of bacterial peritonitis requiring surgery in this study. Typhoid perforation is known to carry a high mortality rate if managed conservatively. ^[12] Laparotomy for peritonitis involves peritoneal lavage, dealing with the primary causes, coupled with the administration of intravenous fluids and antibiotics after resuscitation and correction of fluid and electrolyte balance. Laparotomy should be carried out to close the perforation by simple two-layered closure after debridement of the perforated ulcer.

Resection and anastomosis of the small intestine may be indicated when there are multiple perforations in a segment of the intestine or in case of wide perforation more than 2 cm in size.

The clinical and radiological features of perforated duodenal ulcer may mimic those of a ruptured appendix due to tracking of secretions through the right paracolic gutter into the right iliac fossa. It is said to occur commonly in middle age with an almost equal sex distribution. Our patients, however, cut across all age groups (17-69; mean: 39.6 years) and were exclusively males. There is a place for conservative management of perforated duodenal ulcer, especially in the elderly. However, because our patients presented late after the onset of bacterial peritonitis, they routinely undergo laparotomy, peritoneal lavage and closure of the perforation with omental patch using unabsorbable suture.

Patients with intra-abdominal injury following trauma usually present with hypovolaemic shock and clinical evidence of intra peritoneal hemorrhage. The spleen has remained the most commonly injured intra-abdominal organ. ^[13] Formally management involves the resuscitation with intravenous fluids, blood transfusion and splenectomy. However, owing to the associated complications of splenectomy, particularly overwhelming postsplenectomy infection, splenorrhaphy is now the preferred management in mild to moderate splenic injuries, ^[13],[14] The Procedure for splenorrhaphy ranges from simple suturing with catgut in capsular tears to use of omental patch in partial splenectomy. Hemostasis is achieved with topical use of agents such as avitene or surgicel, fibrin glue, electrocautery, and an argon beam coagulator. After securing hemostasis, splenorrhaphy can also be performed by using absorbable suture and pledgets. Pledgets allow the appropriate amount of tension to be applied to the suture, while preventing splenic capsular tears. ^[15] For the splenic conservation, some surgeons advocate the use of absorbable mesh wrap. This procedure is sometimes referred to as "bagging the spleen" care to be taken to keyhole the mesh round the splenic hilum. The spleen is then encircled by the mesh, which is sewn together. The goal is to appropriately and adequately tamponade any bleeding from the injured spleen. Of the 88 patients in the series, 3 were amenable to splenorrhaphy. This is in keeping with the nature of splenic injuries encountered in our setting whereby most were damaged beyond the stage of repair. Management of ruptured urinary bladder consists of laparotomy, identification of the injury, debridement and repair followed by peritoneal lavage and catheterization. Stab injuries breaching the peritoneum and abdominal gunshot injuries have routinely been managed by exploratory laparotomy after resuscitation. Currently, however, the case has been made for conservative management of abdominal gunshot injuries in selected cases. ^[16] All the cases of burst abdomen were seen after laparotomy for peritonitis. Burst abdomen is a complication of wound healing that requires prompt treatment. No age group is exempted, and it is alarming to both the patient and the attending staff. ^[17] However, in as much as surgical site infection have been implicated, 46 out of 48 cases of burst abdomen resulted from laparotomy done by residents doctors, thus indicating that limited surgical experience and poor surgical technique are the major causes of burst abdomen in this study. Treatment involves reassurance, covering the prolapsed loop of gut with gauze soaked in warm normal saline, intravenous infusion and emergency reinstitution of the wound in the theatre.

Elsewhere, gastro intestinal hemorrhage has been found to be the most lethal emergency accounting for just 13% of all abdominal surgery carried out in the elderly. ^[18] In our study, there were 16 cases (0.7%) of bleeding duodenal ulcer that required surgery. They were discovered to have bleeding duodenal ulcer after upper gastrointestinal endoscopy. Initially, they were managed conservatively with blood transfusion, proton pump inhibitors, antibiotics and use of octreotide, a synthetic somatostatin analog. However because severe hemorrhage continued they had truncal vagotomy and pyloroplasty after undermining the ulcer base. Some acute abdominal conditions that require emergency surgery such as acute mesenteric ischemia, inflammatory bowel disease and diverticulitis are common in the developed world, but rare in Africa. ^[19],[20] This is reflected in this study as no confirmed report involving any of these was encountered during the study period.

Conclusion

The indications for emergency abdominal surgery are usually serious, and the pattern in this study showed that the surgery for appendicitis is the commonest emergency abdominal surgery, however, quick attention by way of investigations and treatment reduces the possible morbidity and mortality. There is an urgent need for a massive health education from the public health perspective to let our people know that the death from abdominal pain does not necessarily mean that the dead were poisoned. Often times, there is a cause as outlined above. It is expected that residents in surgery improve their ability in the management of these acute abdominal conditions, particularly under the less than ideal conditions that obtain in developing countries. The authorities are expected to provide excellent facilities for management of these emergencies.

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