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Gangrenous bowel
Gangrenous Bowel Benin Experience
L. Chukwuma Chiedori, MD, FWACS, Benin City, Nigeria
During the last half-century mortality due to intestinal obstruction has decreased from 50 percent to 6 to 16 percent [l-5]. However, morbidity and mortality from intestinal gangrene, a major consequence of intestinal obstruction, remain consistently high and virtually unchanged over the years [6,7]. Thus, although overall mortality for intestinal obstruction in Nigeria is about 10 to 12 percent [3-51, mortality for gangrenous bowel is about 22 to 28 percent [5,8]. This study examines the magnitude of the problem of gangrenous bowel among our patients and identifies factors that might help to improve our current level of performance in its management.
Material and Methods A retrospective study of all patients who underwent laparotomy for intestinal obstruction in the University of Benin Teaching Hospital, Benin, Nigeria between March 1973 and March 1978 was undertaken. Patients who required intestinal resection for bowelgangrenewere selected and form the basis of this study. All information was obtained from the patients’ charts and, when possible, from personal interviews.
Comments Over this review period, 273 patients, 218 male (79.8 percent) and 55 female (20.2 percent), underwent laparotomy for relief of intestinal obstruction in our hospital. Of these, 115 patients (42.1 percent) required bowel resection because of bowel gangrene. The latter group consisted of 94 male (34 percent) and 21 female patients (7.7 percent), yielding a male to female ratio of 4.5 to 1 (Table I). These patients ranged in age from 2 months to 58 years. The most common cause of bowel gangrene among our patients was hernia. Twenty percent of our laparotomies for gangrenous bowel or 47.8 percent of From the Department of Surgery, University of Benin, Benin City, Nigeria. Requests for reprints should be addressed to L. Chukwuma Chiedozi, MD, University of Benin Teaching Hospital, P.M.B. 1111, Benin City, Nigeria.
622
all gangrenous bowels were due to hernia. The finding of hernia as the leading cause of gangrenous bowel coincides with experience elsewhere [4,8]. Other causes of intestinal gangrene in our hospital are shown in Tables II and III. In terms of the absolute number of patients with bowel gangrene, the contribution of hernia to the problem is unquestionable. However, if one looks at the proportion of patients presenting with each disease who end up with gangrenous bowel, this “deadliness factor” for vo1vu1us, 0.89, tops the list (Table III). Viewed in terms of mortality, hernia, with 15 deaths, accounted for 44 percent of all deaths, versus 32.4 percent for volvulus. However, 15 of 55 patients with gangrenous bowel secondary to hernia died (mortality 27.2 percent), compared with 11 of 28 patients with volvulus (mortality 39.2 percent) (Table IV). Thus volvulus must be considered a truly dangerous cause of intestinal obstruction in our patients. The overall mortality for bowel gangrene over the review period was 29.6 percent. This figure falls within the generally reported rates of 22 to 26 percent in Nigeria [8,9] and 17 to 50 percent in the United States [IO,1 11. Since the Nigerian figures do not include patients with gangrenous bowel secondary to mesenteric insufficiency (mortality 85 to 92 percent [12,13]), our figure appears rather high. Why are these figures so high? First, experience in our hospital [14] and elsewhere in Nigeria 1151 has identified late presentation by our patients as the single most important factor contributing to high mortality in our patients with intestinal obstruction. The average age of the intestinal obstruction in the 115 patients with bowel gangrene was 3.5 days (4 days for volvulus patients), Figure 1 shows the relation of the age of the obstruction to the onset of gangrene in our patients. It is clear that patients who arrive at or 72 hours after the onset of intestinal obstruction almost inevitably have bowel gangrene. All of our patients had a rugged
The American Journal of Surgery
Gangrenous Bowel
TABLE I
Intestinal Resection n % 94 34.4
Males Females Total
TABLE II
TABLE IV
Analysis of Laparotomy for Intestinal Obstruction
21 115
7.7 42.1
No Resection n % 124 45.4
n 128
% 79.8
34 158
55 273
20.2 100
Analysis of Mortality (Overall Mortality 29.5 Percent)
Patients (n) With Gangrene Dead
Total
12.5 57.9
Disease Hernia lntussusception Adhesive bands volvulus Conaenital
55 18 15 28 2
Mortality for Disease (%)
Total Mortality (%)
27.2 22.2 26.6 39.2 0
44.0 11.8 11.8 32.4 0
15 4 4 11 0
Analysis of Laparotomy for Intestinal Obstruction in 273 Patients
Cause of Obstruction
Patients Requiring Laparotomy for Bowel Gangrene n % of Total
Total Patients (n)
Hernia lntussusception Adhesive bands volvulus Congenital anomalies Tumor
163 36 34 28 11 1
55 18 15 25 2 0
Total
273
115
TABLE Ill
20.14 8.59 5.49 9.15 0.73 0 42.1
Analysis of Causes of Gangrenous Bowel in 115 Patients in Terms of “Deadliness”
Cause of Ganarene Hernia lntussusception Adhesive bands volvulus Congenital anomalies Tumor
n 55 18 15 25 2 0
% 47.8 15.7 13.1 21.7 1.7 0
Deadliness Factor n % 551163 18136 15134 28128 2/11 0
OL _. --
I 2
1
0.33 0.50 0.44 0.89 0.18 0.0
AGE
OF
x----x
ADULTS
x----x
CHILDREN
3 BOWEL
L
5
6
OBSTRUCTION
7
(DAYS)
Figure 1. Relation of the onset of bowel gangrene to the age of intestinal obstruction on presentation In 273 patients who underwent laparotomy.
hospital course. Their preoperative problems included dehydration (100 percent), electrolyte imbalance (100 percent), fever (90 percent), gramnegative sepsis (50 percent), frank peritonitis (40 percent), hypotension (40 percent) and acid-base problems (40 percent). They required protracted preoperative preparation, which only served to worsen the problems created by the lethal exudates of dead bowel, problems that have been well documented by other investigators [16-ZO]. Figure 2 shows our patients’ postoperative complications. Our patients thus had “late intestinal obstruction syndrome.” Given our population of patients with late-presenting intestinal obstruction (average age of obstruction 2.5 days for 273 patients), the incidence of gangrenous bowel and hence the mortality should be much higher than noted. Why did many more of these patients not have gangrenous bowel?
Volume
142,
November 1981
10
CHEST
FEVER
5
,
38
-NEGATIVE
70
90
I
IMBALANCE
I
OC SEPSIS
I :
I
HYPOTENSION
I
MALARIA
1
WOUND
INFECTlON
FECAL
FISTULA
TESTICULAR ACUTE
so
lNFECT,ON
ELECTROLYTE
GRAM
30
TUBULAR
PULMONARY
3
INFARCTION NECROSIS
EMBOLISM
3 3 3
DEATH
I
0
20 %
10 OF
60
80
100
TOTAL
Figure 2. Analysis of postoperative complications.
623
Chiedozi
Of course, many variables are operative in a patient who eventually develops intestinal gangrene. One such variable is the patient’s resistance to intestinal gangrene. It has been postulated that the African is more resistant to intestinal gangrene than his European confreres [21]. It is not possible to prove this postulate from the present study. However, Figure 1 shows a very low incidence of bowel gangrene before 48 hours in Nigerian adults and none at all in children. If there is indeed resistance, its basis has not been established. The salutary effect of intestinal flora consequent to the African’s high carbohydrate diet compared with the European high protein diet [21], as well as the relatively higher globulin levels found in Africans (albumin/globulin ratio 0.9 to 1.6 [22,23]), have been mentioned as possible sources of resistance [21]. Because protein levels were unavailable for our patients, it is not possible to comment on them with respect to this study. Nevertheless, if a bona fide resistance to intestinal gangrene is the explanation for the less than expected level of gangrene in our late-presenting patients, more convincing evidence than is currently available will be required to place it in perspective.
Summary A retrospective study of 115 patients who presented to the University of Benin Teaching Hospital with intestinal gangrene over a 5 year period is presented. Although hernia is the most common cause of bowel gangrene, more patients with volvulus end up with gangrenous bowel. Because Nigerian patients present with late intestinal obstruction, more dead bowel would have been expected than is currently noted. Is it possible that the African is resistant to intestinal strangulation? Acknowledgment: I thank the members of our Deof Surgery for permitting me to include their in this study, Mr. Ogunje and his team in the Medical Illustration Unit, and Tony Elumelu for secretarial help. partment patients
624
References 1. Schwartz SI, Storer EH. Manifestations of gastrointestinal disease. In: Schwartz S, ed. Principles of surgery. New York: McGraw-Hill, 1974:980. 2. Colcock GJ, Brasch JW. Surgery of the small intestine in adults. In: Major problems in surgery. Vol. 7. Philadelphia: WB Saunders, 1968:45. 3. Adekunle 00. Acute intestinal obstruction. Nigeria Med J 1977;7:37. 4. Solanke TF. Intestinal obstruction in ibadan. West Afr Med J 1968;17:191. 5. Badoe EA. Acute intestinal obstruction in Ghana. Ghana Med J 1965;4:128. 6. Becker WF. Acute adhesive ileus. Surg Gynecol Obstet 1952;95:472. 7. Leffall LD, Syphox B. Clinical aids in strangulation obstruction. Am J Surg 1970;120:756. 8. Omo-Dare P. Observations on strangulated herniae in Nigeria patients. J Nigeria Med Assoc 1966;3:289. 9. Adesola AO. Intestinal obstruction in Africa. West Afr Med J 1968;17:185. 10. Barnett WO. Gangrenous bowel obstruction. J Miss State Med Assoc 1978;19:1. 11. Nemir P Jr. Intestinal obstruction. Ann Surg 1952;135:367. 12. Skinner DB, Zarins CK, Mossa AR. Mesenteric vascular disease. Am J Surg 1974;128:835. 13. Otlinger LW, Austen GW. A study of 136 patients with mesenteric infarction. Surg Gynecol Obstet 1967; 124:251. 14. Chiedozi LC. Aboh IO. Piserchia NE. Mechanical bowel obstruction. Review of 316 cases in Benin City. Am J Surg 1980;139:389-93. 15. Cole GC. Review of 436 cases of intestinal obstruction in Ibadan. Gut 1965;6:151. 16. Barnett WO, Oliver RI, Elliott RL. Elimination of lethal properties of gangrenous bowel segment. Ann Surg 1968;167:912. 17. Barnett WO, Morris L. In vivo effects of peritoneal fluid resulting from strangulated intestinal obstruction. Am J Surg 1958; 96:387. 18. Evans El. Mechanism of shock in intestinal strangulation: an experimental study. Ann Surg 1943; 117:28. 19. Arid I. Morbid influence in intestinal obstruction and strangulations. Ann Surg 1941;114:385. 20. Miller LD, Machie JA, Rhoads JE. The pathophysiology and management of intestinal obstruction. Surg Clin North Am 1962;42: 1285. 21. Davey WW. Companion to surgery in Africa. Edinburgh: Churchill Livingston, 1973:289. 22. Holmes EG, Stairier MW, Thompson MD. The serum protein pattern of Africans in Uganda. Trans Roy Sot Trop Med Hyg 1955;49:376. 23. Davey WW. Companion to surgery in Africa. Edinburgh, London: Churchill Livingstone, 1973.
The American Journal of Surgery
L. Chukwuma Chiedori, MD, FWACS, Benin City, Nigeria
During the last half-century mortality due to intestinal obstruction has decreased from 50 percent to 6 to 16 percent [l-5]. However, morbidity and mortality from intestinal gangrene, a major consequence of intestinal obstruction, remain consistently high and virtually unchanged over the years [6,7]. Thus, although overall mortality for intestinal obstruction in Nigeria is about 10 to 12 percent [3-51, mortality for gangrenous bowel is about 22 to 28 percent [5,8]. This study examines the magnitude of the problem of gangrenous bowel among our patients and identifies factors that might help to improve our current level of performance in its management.
Material and Methods A retrospective study of all patients who underwent laparotomy for intestinal obstruction in the University of Benin Teaching Hospital, Benin, Nigeria between March 1973 and March 1978 was undertaken. Patients who required intestinal resection for bowelgangrenewere selected and form the basis of this study. All information was obtained from the patients’ charts and, when possible, from personal interviews.
Comments Over this review period, 273 patients, 218 male (79.8 percent) and 55 female (20.2 percent), underwent laparotomy for relief of intestinal obstruction in our hospital. Of these, 115 patients (42.1 percent) required bowel resection because of bowel gangrene. The latter group consisted of 94 male (34 percent) and 21 female patients (7.7 percent), yielding a male to female ratio of 4.5 to 1 (Table I). These patients ranged in age from 2 months to 58 years. The most common cause of bowel gangrene among our patients was hernia. Twenty percent of our laparotomies for gangrenous bowel or 47.8 percent of From the Department of Surgery, University of Benin, Benin City, Nigeria. Requests for reprints should be addressed to L. Chukwuma Chiedozi, MD, University of Benin Teaching Hospital, P.M.B. 1111, Benin City, Nigeria.
622
all gangrenous bowels were due to hernia. The finding of hernia as the leading cause of gangrenous bowel coincides with experience elsewhere [4,8]. Other causes of intestinal gangrene in our hospital are shown in Tables II and III. In terms of the absolute number of patients with bowel gangrene, the contribution of hernia to the problem is unquestionable. However, if one looks at the proportion of patients presenting with each disease who end up with gangrenous bowel, this “deadliness factor” for vo1vu1us, 0.89, tops the list (Table III). Viewed in terms of mortality, hernia, with 15 deaths, accounted for 44 percent of all deaths, versus 32.4 percent for volvulus. However, 15 of 55 patients with gangrenous bowel secondary to hernia died (mortality 27.2 percent), compared with 11 of 28 patients with volvulus (mortality 39.2 percent) (Table IV). Thus volvulus must be considered a truly dangerous cause of intestinal obstruction in our patients. The overall mortality for bowel gangrene over the review period was 29.6 percent. This figure falls within the generally reported rates of 22 to 26 percent in Nigeria [8,9] and 17 to 50 percent in the United States [IO,1 11. Since the Nigerian figures do not include patients with gangrenous bowel secondary to mesenteric insufficiency (mortality 85 to 92 percent [12,13]), our figure appears rather high. Why are these figures so high? First, experience in our hospital [14] and elsewhere in Nigeria 1151 has identified late presentation by our patients as the single most important factor contributing to high mortality in our patients with intestinal obstruction. The average age of the intestinal obstruction in the 115 patients with bowel gangrene was 3.5 days (4 days for volvulus patients), Figure 1 shows the relation of the age of the obstruction to the onset of gangrene in our patients. It is clear that patients who arrive at or 72 hours after the onset of intestinal obstruction almost inevitably have bowel gangrene. All of our patients had a rugged
The American Journal of Surgery
Gangrenous Bowel
TABLE I
Intestinal Resection n % 94 34.4
Males Females Total
TABLE II
TABLE IV
Analysis of Laparotomy for Intestinal Obstruction
21 115
7.7 42.1
No Resection n % 124 45.4
n 128
% 79.8
34 158
55 273
20.2 100
Analysis of Mortality (Overall Mortality 29.5 Percent)
Patients (n) With Gangrene Dead
Total
12.5 57.9
Disease Hernia lntussusception Adhesive bands volvulus Conaenital
55 18 15 28 2
Mortality for Disease (%)
Total Mortality (%)
27.2 22.2 26.6 39.2 0
44.0 11.8 11.8 32.4 0
15 4 4 11 0
Analysis of Laparotomy for Intestinal Obstruction in 273 Patients
Cause of Obstruction
Patients Requiring Laparotomy for Bowel Gangrene n % of Total
Total Patients (n)
Hernia lntussusception Adhesive bands volvulus Congenital anomalies Tumor
163 36 34 28 11 1
55 18 15 25 2 0
Total
273
115
TABLE Ill
20.14 8.59 5.49 9.15 0.73 0 42.1
Analysis of Causes of Gangrenous Bowel in 115 Patients in Terms of “Deadliness”
Cause of Ganarene Hernia lntussusception Adhesive bands volvulus Congenital anomalies Tumor
n 55 18 15 25 2 0
% 47.8 15.7 13.1 21.7 1.7 0
Deadliness Factor n % 551163 18136 15134 28128 2/11 0
OL _. --
I 2
1
0.33 0.50 0.44 0.89 0.18 0.0
AGE
OF
x----x
ADULTS
x----x
CHILDREN
3 BOWEL
L
5
6
OBSTRUCTION
7
(DAYS)
Figure 1. Relation of the onset of bowel gangrene to the age of intestinal obstruction on presentation In 273 patients who underwent laparotomy.
hospital course. Their preoperative problems included dehydration (100 percent), electrolyte imbalance (100 percent), fever (90 percent), gramnegative sepsis (50 percent), frank peritonitis (40 percent), hypotension (40 percent) and acid-base problems (40 percent). They required protracted preoperative preparation, which only served to worsen the problems created by the lethal exudates of dead bowel, problems that have been well documented by other investigators [16-ZO]. Figure 2 shows our patients’ postoperative complications. Our patients thus had “late intestinal obstruction syndrome.” Given our population of patients with late-presenting intestinal obstruction (average age of obstruction 2.5 days for 273 patients), the incidence of gangrenous bowel and hence the mortality should be much higher than noted. Why did many more of these patients not have gangrenous bowel?
Volume
142,
November 1981
10
CHEST
FEVER
5
,
38
-NEGATIVE
70
90
I
IMBALANCE
I
OC SEPSIS
I :
I
HYPOTENSION
I
MALARIA
1
WOUND
INFECTlON
FECAL
FISTULA
TESTICULAR ACUTE
so
lNFECT,ON
ELECTROLYTE
GRAM
30
TUBULAR
PULMONARY
3
INFARCTION NECROSIS
EMBOLISM
3 3 3
DEATH
I
0
20 %
10 OF
60
80
100
TOTAL
Figure 2. Analysis of postoperative complications.
623
Chiedozi
Of course, many variables are operative in a patient who eventually develops intestinal gangrene. One such variable is the patient’s resistance to intestinal gangrene. It has been postulated that the African is more resistant to intestinal gangrene than his European confreres [21]. It is not possible to prove this postulate from the present study. However, Figure 1 shows a very low incidence of bowel gangrene before 48 hours in Nigerian adults and none at all in children. If there is indeed resistance, its basis has not been established. The salutary effect of intestinal flora consequent to the African’s high carbohydrate diet compared with the European high protein diet [21], as well as the relatively higher globulin levels found in Africans (albumin/globulin ratio 0.9 to 1.6 [22,23]), have been mentioned as possible sources of resistance [21]. Because protein levels were unavailable for our patients, it is not possible to comment on them with respect to this study. Nevertheless, if a bona fide resistance to intestinal gangrene is the explanation for the less than expected level of gangrene in our late-presenting patients, more convincing evidence than is currently available will be required to place it in perspective.
Summary A retrospective study of 115 patients who presented to the University of Benin Teaching Hospital with intestinal gangrene over a 5 year period is presented. Although hernia is the most common cause of bowel gangrene, more patients with volvulus end up with gangrenous bowel. Because Nigerian patients present with late intestinal obstruction, more dead bowel would have been expected than is currently noted. Is it possible that the African is resistant to intestinal strangulation? Acknowledgment: I thank the members of our Deof Surgery for permitting me to include their in this study, Mr. Ogunje and his team in the Medical Illustration Unit, and Tony Elumelu for secretarial help. partment patients
624
References 1. Schwartz SI, Storer EH. Manifestations of gastrointestinal disease. In: Schwartz S, ed. Principles of surgery. New York: McGraw-Hill, 1974:980. 2. Colcock GJ, Brasch JW. Surgery of the small intestine in adults. In: Major problems in surgery. Vol. 7. Philadelphia: WB Saunders, 1968:45. 3. Adekunle 00. Acute intestinal obstruction. Nigeria Med J 1977;7:37. 4. Solanke TF. Intestinal obstruction in ibadan. West Afr Med J 1968;17:191. 5. Badoe EA. Acute intestinal obstruction in Ghana. Ghana Med J 1965;4:128. 6. Becker WF. Acute adhesive ileus. Surg Gynecol Obstet 1952;95:472. 7. Leffall LD, Syphox B. Clinical aids in strangulation obstruction. Am J Surg 1970;120:756. 8. Omo-Dare P. Observations on strangulated herniae in Nigeria patients. J Nigeria Med Assoc 1966;3:289. 9. Adesola AO. Intestinal obstruction in Africa. West Afr Med J 1968;17:185. 10. Barnett WO. Gangrenous bowel obstruction. J Miss State Med Assoc 1978;19:1. 11. Nemir P Jr. Intestinal obstruction. Ann Surg 1952;135:367. 12. Skinner DB, Zarins CK, Mossa AR. Mesenteric vascular disease. Am J Surg 1974;128:835. 13. Otlinger LW, Austen GW. A study of 136 patients with mesenteric infarction. Surg Gynecol Obstet 1967; 124:251. 14. Chiedozi LC. Aboh IO. Piserchia NE. Mechanical bowel obstruction. Review of 316 cases in Benin City. Am J Surg 1980;139:389-93. 15. Cole GC. Review of 436 cases of intestinal obstruction in Ibadan. Gut 1965;6:151. 16. Barnett WO, Oliver RI, Elliott RL. Elimination of lethal properties of gangrenous bowel segment. Ann Surg 1968;167:912. 17. Barnett WO, Morris L. In vivo effects of peritoneal fluid resulting from strangulated intestinal obstruction. Am J Surg 1958; 96:387. 18. Evans El. Mechanism of shock in intestinal strangulation: an experimental study. Ann Surg 1943; 117:28. 19. Arid I. Morbid influence in intestinal obstruction and strangulations. Ann Surg 1941;114:385. 20. Miller LD, Machie JA, Rhoads JE. The pathophysiology and management of intestinal obstruction. Surg Clin North Am 1962;42: 1285. 21. Davey WW. Companion to surgery in Africa. Edinburgh: Churchill Livingston, 1973:289. 22. Holmes EG, Stairier MW, Thompson MD. The serum protein pattern of Africans in Uganda. Trans Roy Sot Trop Med Hyg 1955;49:376. 23. Davey WW. Companion to surgery in Africa. Edinburgh, London: Churchill Livingstone, 1973.
The American Journal of Surgery