POLSKI

PRZEGLD CHIRURGICZNY 10.2478/v10035-011-0058-9

2011, 83, 7, 367371
ILEUS AND INTESTINAL OBSTRUCTION COMPARISON BETWEEN
CHILDREN AND ADULTS
MeHran PeyVasteH
1
, sHaHnaM askarPour
1
, HazHir JaVaHerizaDeH
2
,
soMaieH taGHizaDeH
1
Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahwaz, Iran
1

Arvand International Division , Ahvaz Jundishapur University of Medical Sciences
2
Bowel obstruction is the interference with movement of bowel content. Large and small in testing from
duodenum to anal region can be obstructed mechanical or non-mechanical and complete or partial.
Mechanical obstruction can presented because of obstructive causes in intestinal lumen, intestinal
wall or pressure from other tissue on intestine.
The aim of the study was to evaluate etiology, laboratory fndings of intestinal obstruction and ileus
among children and adults who discharged with good condition.
Material and methods. This retrospective study was carried out from 2001 to 2006 in Imam Khomei-
ni Hospital (Ahvaz-Iran). Cases of bowel obstruction were included in this study. For each case, a
questionnaire was flled. There are 752 cases with suspected bowel obstruction. From 752 cases, 403
patients that agreed and treated and discharged with good condition were studied. Cases were di-
vided into two groups: children (age < 15 yrs) and adults (age> 15 yrs). Data were analyzed by SPSS
Ver 16.0 (Chicago, IL, USA) and Epi-info Ver 6.00.
Results. In our study, 221 adults and 192 children were included. Mortality rate was 12.2%. Forty-
eight percent of 403 cases were children (m 61%, f 38%, ambigus genitalia 1%) and 52% were
adults (m 67%, f 33%). Etiology of bowel obstruction in children were as follows: ileus (26%); adhe-
sion band (17.7%), partial obstruction (16.1%), and Hirschsprungs disease (12%). Causes of bowel
obstruction in adults are: partial obstruction (29.9%); ileus (19%); adhesion band (18.5%); colonic
pseudo obstruction(8.5%); GI cancer (5.2%); hernia (4.7%); Crohn (2.8%); fecal impaction (3.3%); be-
zoar (2.4%), and 4.7% for other causes. Fifty-one percent of children and 36% of adults were operated.
Of all children, 91.7% had upright abdominal X-ray, 51.6% had supine X-ray, and 80.7% had sonogra-
phy. Hundred percents of adults had upright & supine plain abdominal X-ray and 75.4% had sonog-
raphy. Most change in childrens CBC was 10000<WBC<15000 and in adult for WBC<10000.
Conclusions. Partial obstruction, pseudo-obstruction, and cancer were more common in adults than
children. Ileus was the commonest cause of obstruction in children and it was partial obstruction for
adult. Children were more operated than adult. Sonography was more use for children but plain ab-
dominal X-ray for adult. In 45% of children 10000<WBC<15000 while most adult had WBC<10000.
Hypokalemia was the most common biochemical fnding in both group.
Key words: bowel obstruction, ileus, adhesion band, Hirschsprung, intussusceptions, fecal impaction,
colonic pseudo obstruction, diverticulitis, hernia, imperforate anus
Intestinal bowel obstruction is a common
surgical emergency and commonly cause a
problem in abdominal surgery (1, 2). The lead-
ing cause of SBO in developed countries is post
operative adhesions (60%) followed by malig-
nancy, Crohn disease, gallstone (3), and her-
nias, although some studies have reported
Crohn disease as a greater etiologic factor than
neoplasm (4). Large intestinal obstruction
(LBO) is most often the result of colo-rectal
malignancies. One large study found an inci-
dence of 16% (5). Patients are often over 70
years old. The risk of obstruction increases the
further down the bowel the lesion is sited, as
the contents become more solid. Tumors are
often advanced with 25% having distant me-
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368 M. Peyvasteh et al.
tastases. Perforation can occur at the site of
the tumor or in a dilated caecum (6). LBO is
an emergency condition that requires early
identifcation and intervention. The etiology
of LBO is age dependent (7). There are possible
differences between etiology of bowel obstruc-
tion in different countries because of different
nutritional habits, weather, and other factors.
As one of the most important condition
surgical emergency we aimed to study of etiol-
ogy, laboratory fndings of intestinal obstruc-
tion and ileus among children and adults who
discharged with good condition.
MATERIAL AND METHODS
This retrospective study was carried out
between 2001-2006 in Imam Khomeini Hospi-
tal a tertiary referral hospital, Ahvaz, Iran. A
questionnaire was flled for each case. In this
study, 752 cases with diagnosis of bowel ob-
struction were admitted to hospital. From
these cases, 228 cases did not agree to par-
ticipate in our study and excluded. From all of
752 cases, in 29 cases bowel obstruction was
ruled out and transferred to other department
for treatment. Ninety- two cases were died and
excluded from this study. The remaining 403
cases that treated and discharged with good
condition were studied. Patients were divided
into two groups: children; before 15 years old
and adults; after 15 years old. A questionnaire
flled for each patient. Laboratory fndings
were recorded for patients. Data were analyzed
by SPSS Ver 16.0 (Chigaco, IL,USA) and Epi-
info ver 6.0.
RESULTS
Four hundred and three patients were
included in our study. From all patients, 192
(47.64%) patients were <15 yr and 211
(52.35%) were >15 yr. From 192 children pa-
tients, 119 (61.97%) patients were male, 72
(37.5%) patients were female, and 1 (0.5%)
patient had ambigus genitalia. From 211
adult patients, 142 (67.29%) patients were
male and 69 (32.7%) patients were female. Of
all 403 cases, 261 (64.76%) were males. Sev-
enty-six (36.01%) patients from 211 adult
patients and 98 (51.04%) from 192 of children
patients underwent surgery. As seen in tab.
1, partial obstruction, pseudo-obstruction,
and cancer were signifcantly more seen in
adults than children (p<0.05). Ileus, intus-
susceptions, diverticulitis, Hirschsprungs
disease and atresia were more common in
children than adults (p<0.05). There is no
difference between children and adults for
durartion of hospital staying (tab. 2).
Table 1. Etiology of intestinal obstruction in children and adults
Dzieci / Children
(n=192)
Doroli / Adults
(n=211)
p / p-value
Ileus 50 (26,04%) 40 (18,95%) p=0,08
Adhesion band 34 (17,70%) 39 (18,48%) p=0,84
Partial obstruction with unknown etiology 31 (16,14%) 63 (29,85%) p=0,001
Pseudo-obstruction 6 (3,12%) 18 (8,53%) p=0,02
Volvulus 4 (2,08%) 3 (1,42%) p=0,89
Bezoar 1 (0,52%) 6 (2,84%) p=0,16
Hernia 4 (2,08%) 10 (4,73%) p=0,14
Fecal impaction 6 (3,12%) 6 (2,84%) p=0,86
Hirschsprung 22 (11,45%) p=0,00
Atresia 9 (4,68%) 0) p=0,004
Tuberculosis 0 3 (1,42%) p=0,2
Crohn disease 0 6 (2,84%) p=0,05
Post radiation 0 3 (1,42%) p=0,2
Gastric outlet obstruction 1 (0,52%) 3 (1,42%) p=0,6
Intussuception 13 (6,77%) 0) p=0,00
Diverticule 5 (2,60%) 0) p=0,05
Malrotation 4 (2,08%) 0) p=0,05
Imperforate anus 2 (1,04%) 0) nie dotyczy / NA
Cancer 0 11 (5,21%) p=0,001
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369 Ileus and intestinal obstruction comparison between children and adults
Anemia was more common in children than
adults while polycythemia was more common
in adults. WBC<10000 was more common in
adults than children (p=0.03) (tab. 3).
Hyponatremia was most frequently seen in
children (p=0.04). Azotemia and normal bio-
chemical fndings were signifcantly common
in adult cases compared to children (p<0.05)
(tab. 4).
Colonoscopy, endoscopy, and abdominal
X-ray (supine and upright) were more fre-
quently used in adults than children (p<0.05).
There is no significant difference between
children and adults regarding use of sonogra-
phy, upper GI series, and barium enema
(tab. 5).
Table 2. Frequency of hospital staying in patients with
intestinal obstruction
Children
(n=192)
Adults
(n=211)
p-value
<5 days 32 (16,66%) 44 (20,85%) p=0,28
5-10 days 112 (58,33%) 111 (52,60%) p=0,24
10-15 days 37 (19,27%) 37 (17,53%) p=0,65
>15 days 11 (5,72%) 19 (9%) p=0,21
DISCUSSION
In our study, of all 403 cases, 261(64.76%)
were males. Of 192 children cases and 211
adult cases, 119 (61.97%) cases and 142
(67.29%) cases were males respectively.
Male constitute 74% and female 26% of
intestinal obstruction in Malik et al. study
and similar to our study (8). In adult cases,
partial obstruction (29.85%), adhesion band
(18.48%), and ileus (18.95%) were the most
common causes of bowel obstruction. Marko-
giannakis et al., reported adhesions (64.8%)
were the most common causes of intestinal
obstruction among adult cases (9). Adhe-
sions, incarcerated hernias, and large bowel
cancer constitutes the most frequent causes
of bowel obstruction (10). This difference
between the current study and other studies
may be due to partial obstruction in our
study.
Ileus (26.04%), adhesion bands (17.70%),
partial obstruction (16.64%), and Hirschs-
prung (11.45%) were the most common etiol-
ogy of children intestinal obstruction in our
study. Ogundoin et al., reviewed etiology of
intestinal obstruction in 130 cases. Major
causes of intestinal obstruction were intus-
susceptions (29.23%), anorectal malforma-
tions (22.31%), obstructed inguinoscrotal
hernia (16.92%) and Hirschsprungs disease
(13.85%) (11).
A number of recent studies, have found
adhesive obstruction to be replacing obstruc-
tive hernias as the most common cause (8, 12,
13).
Table 3. CBC changes in patients with intestinal
obstruction
CBC changes
Children
(n=192)
Adults
(n=211)
p-value
WBC <10 000 74
(38,54%)
104
(49,28%)
p=0,03*
WBC 10 00015 000 87
(45,31%)
83
(39,33%)
p=0,22
WBC >15 000 31
(16,14%)
24
(11,37%)
p=0,16
Anemia 67
(34,89%)
53
(25,11%)
p=0,03*
Polycythemia 15 (7,81%) 31
(14,69%)
p=0,03*
Table 4. Biochemical fndings in the bowel obstruction
Children
(n=192)
Adults
(n=211)
p-value
Hypoglycemia 10 (5,20%) 4 (1,89%) p=0,06
Hyperglycemia 7 (3,64%) 15 (5,68%) p=0,33
Hyponatremia 23 (11,97%) 13 (6,16%) p=0,04*
Hypernatremia 3 (1,56%) 2 (0,94%) p=0,9
Hypokalemia 71 (36,97%) 97 (45,97%) p=0,06
Hyperkalemia 8 (4,16%) 4 (1,89%) p=0,18
Azotemia 10 (5,20%) 32 (15,16%) p=0,001*
Normal 94 (26,04%) 89 (42,18%) p=0,0006*
Table 5. Radiologic procedures performed in patients
Procedure
Children
(n=192)
Adults
(n=211)
p-value
Abdominal X-ray
(supine)
176
(93,61%)
211
(100%)
<0,001
Abdominal X-ray
(upright)
99
(52,65%)
211
(100%)
<0,001
Upper gi series 14 (7,44%) 8 (3,79%) 0,122
Barium enema 20
(10,63%)
22
(10,42%)
0,990
Colonoscopy 0 35
(16,58%)
<0,001
Endoscopy 0 21
(11,17%)
<0,001
Sonography 155
(82,44%)
159
(75,35%)
0,089
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370 M. Peyvasteh et al.
In the current study no cases of intussucep-
tion were seen in adults. In the Croomes study,
2-3% of obstruction was due to intussuception
(14). In the current study, the rate of intus-
susceptions in children was 6.77%. In Kaiser
et al. study, the most common cause of intes-
tinal obstruction in children was intussucep-
tion (15).
Hernia is the 6
th
cause of intestinal obstruc-
tion in adults and 7
th
in children. the current
study. In the study which carried out by Moon
et al., hernia was reported as the 3
rd
common
cause of intestinal obstruction (16). Madziga
and Nuhu also reported hernia as the most
common causes of intestinal obstruction
(17).
Adhesions may be acquired or congenital;
however, most are acquired as a result of peri-
toneal injury, the most common cause of which
is abdominal pelvic surgery (18). Intra ab-
dominal adhesions are the most common cause
of SBO in some reports, accounting for ap-
proximately 65% to 75% of cases (19, 20). Kssi
et al. studied post operative adhesion induced
obstruction from 1.1.1999 to 31.12.1999 on 123
hospitalizations. The most prevalent single
initial operation causing adhesion induced
intestinal obstructions were colorectal, upper
abdominal, and female reproductive system
procedure (21).
The overall mortality rate was 1.6%, and
the mortality rates in conservative therapy
and surgical intervention groups were 1.3%
and 1.7% respectively (22).
In the current study, paralytic ileus, adhe-
sion, and partial obstruction are the most
common causes of intestinal obstruction in
children.
In the current study, obstruction due to
cancer is 5.2% of adult patients. Wyoski and
Kryzan showed that intestinal obstruction due
to cancer has 17.2% (23).
Obstruction due to bezoar was seen in 2.4%
of adult cases and half of them were more than
50 years old.
Crohn disease accounting for 3-7% of small
bowel obstruction in some studies (24). In the
current study, Crohn was indentifed in 2.84%
of cases.
In our study, malrotation was found in 4
(2.08%) of children and no adult cases. in up
to 90%, malrotation develop during the 1
st
year
of life (25). So, malrotation in unusuall fndings
after childhood period.
Volvulus was found in 2.08% of children and
1.42% of adults. Volvulus can be primary pa-
thology or secondary to malrotation of the in-
testine (26, 27).
There were 57.6% of the patients underwent
the surgical treatment. In our study, 51.04%
of children and 36.01% of adults underwent
surgical treatment.
Overall mortality rate in our study was
12.2%. In another study carried out in Poland,
mortality rate was 13.8%, but these patients
had intestinal obstruction due to large intes-
tine malignancy (28). Higher rate of diagnosis
of intestinal obstruction may be due to more
easy use of diagnostic procedure such as en-
doscopy and colonoscopy in adults than chil-
dren. The higher rate of malignancy in adults,
may be another cause.
In the current study all of the patients with
intestinal obstruction due to hernia was male.
Dakubo et al. showed that there is male/female
ratio was about 8/1 (29). The number of the
patients with hernia in our study was too low
to be reasonable.
In our study, 100% of patients with partial
obstruction were treated by conservative man-
agement.
In Jeong et al. study 80% of patients with
partial obstruction were treated by non surgi-
cal management. In Teon et al. study, patients
had previous history of primary cancer and
this may be the result of difference in surgical
and non surgical treatment (30).
CONCLUSIONS
Ileus, adhesion band, and partial obstruc-
tion are the most common causes in children.
Partial obstruction, ileus, and adhesion band
are the most frequent causes of intestinal ob-
struction in adults. Most of patients were ad-
mitted between 5-10 days. Children were more
operated than adult. Sonography was used
more commonly in childrens but plain ab-
dominal X-ray for adult. In 45% of children
10000<WBC<15000 while most adult had
WBC<10000. Most of the patients has normal
biochemistry results. Hypokalemia was the
most common biochemistry finding among
children and adults.
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371 Ileus and intestinal obstruction comparison between children and adults
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Adress correspondence: Imam Khomeini Hospital, Azadegan St., Shaahada Square, Ahvaz, Iran
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