WHERE RESOURCES ARE SCARCE: OPTIMAL MANAGEMENT OF INTESTINAL OBSTRUCTION AND SIMILAR ABDOMINAL EMERGENCIES
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1. Introduction
Over the past 200 years after the Industrial Revolution blossomed in England, prosperity
still has not reached half the world’s peoples, particularly those who live in
the tropics (1). Indeed, with the concurrent growth of
globalization since the late 15th century, selected technologies have spread
exogenously to developing countries in ways that have lowered death rates and
thereby exploded population densities but without improving economic growth (2), consequently fomenting poverty and sparking civil conflict in
vicious cycles that have collectively ruined the health and well-being of
billions of people and simultaneously deprived them of the means to improve
their lot (3; 4).
Hence, particularly in sub-Saharan Africa, home to the most destitute,
yet most resourceful and resilient, people on earth, living conditions, disease
patterns and infrastructure have blended into a most challenging environment,
but one that also offers unique, encouraging opportunities for real progress.
In this review, I explore just one of those arenas, that of intestinal
obstruction and similar abdominal emergencies. On the basis of my personal
experience as a surgeon throughout the Third World over the last 12 years, I
hope to offer some guidance to doctors in Africa and other developing parts of
the globe on substituting their enormous wealth of human capital for the dearth
of other resources, to deal successfully with these difficult, abundant
clinical problems.
2. Surgical abdominal
emergencies in sub-Saharan Africa
The spectrum of abdominal pain in Africa differs from that observed in
developed countries. At a large teaching hospital in Boston, Massachusetts
(USA), for example, a total of 536 adults presenting to the emergency
department with acute, non-trauma-related abdominal pain comprised 308 men
(57%) and 228 women (43%), for a male:female ratio of 1.35:1. The five most
common diagnoses, accounting for 72% of all cases, were: urinary tract stone
(31.4%), appendicitis (23.6%), intra-abdominal abscess (17.4%), diverticulitis
(16.9%) and small-bowel obstruction (10.6%) (5).
By contrast, intestinal obstruction of all causes, acute appendicitis, typhoid
ileal perforation, perforated peptic ulcer and trauma are, according to the
available information, the most common causes of non obstetrical/gynecological
surgical abdominal emergencies in adults in sub-Saharan Africa (Table 1) (6; 7; 8; 9; 10). Of the four top
diagnoses, appendicitis and typhoid perforation occur most frequently in young
adults between 25 and 33 years, whereas the peak incidences of intestinal
obstruction and peptic ulcer perforation occur in the sixth decade (7).
In African children (by definition, patients 15 years old or younger), acute
appendicitis accounts for more than 60% of all abdominal emergencies, followed
by nearly equal frequencies of typhoid ileal perforation and intestinal
obstruction, whereas ill children presenting specifically with peritonitis tend
to suffer most commonly from typhoid fever and then from either intestinal
obstruction or appendicitis (Table 1), “Centr.
African Rep.” and “Nigeria,” respectively). In all cases, males
present with abdominal emergencies nearly twice as commonly as females, and
even more frequently in selected locations.
TABLE 1: MAIN SURGICAL CAUSES OF ACUTE ABDOMINAL
PAIN IN SUB-SAHARAN AFRICA
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Adults |
Children |
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Sierra Leone (1)
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Ghana (2)
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Centr. African Rep.(3) |
Nigeria (4)
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# Patients |
68 |
2,197 |
162 |
69 |
|
Male:Female ratio |
3.6:1 |
1.9:1 |
1.8:1 |
2.3 |
|
% Mortality |
22.1 |
9.9 |
Not reported |
11.6 |
|
% Appendicitis |
22.1 |
31.8 |
62.3 |
13.0 |
|
% Typhoid Perf. |
10.3 |
23 |
19.1 |
56.5 |
|
% Incarcer. Hernia |
22.1 |
Not Studied |
9.3 |
-- |
|
% Intussusception |
4.4 |
}17.8 |
6.8 |
5.8 |
|
% Other Int. Obstr. |
20.6 |
2.5 |
11.6 |
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% Perf. Peptic Ulcer |
11.8 |
15.6 |
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% Trauma |
8.8 |
11.8 |
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1 Adapted from (6).
This series included an additional 30 cases of reducible hernias, 43 cases of
ectopic pregnancy, 9 cases of uterine rupture, 11 cases of gynecologic
conditions and 10 others, all of which were excluded from the above tabulation.
This study also included a small minority of children, which is reflected in
the above numbers. |
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These conditions are true emergencies and require prompt
intervention. The extensive Ghanaian study found that mortality increases from
1.6% for those ill less than six hours, to 10% for patients ill for 2 days, to
14% for patients ill for 3 days (7).
Thereafter, the mortality levels off at 6% (7), perhaps because the most seriously ill
patients who delay that long die at home, without reaching the hospital. In the
experience from rural Sierra Leone, 80% of those with gastrointestinal
perforation and 33% of those with intestinal gangrene die (6).
Worldwide, the etiology of intestinal obstruction is relatively uniform, in
adults most commonly adhesions, followed by incarcerated hernias and either
volvulus or tumours in developing and developed countries, respectively, and in
children most often hernias, then intussusception and adhesions (Table 2) (11; 6; 12; 8; 13). (In African
neonates—which I will not discuss further in this review—the causes
of intestinal obstruction are anorectal malformation, 43%; Hirschsprung’s
disease, 18.7%; jejunoileal atresia (15.6%), duodenal atresia, 7.8%; hernia,
6.3%) (14). In developed countries, after adhesions the
relative frequency of the other causes often depends on the selection bias and
service populations of the reporting institutions. The Chicago data reported in
Table 2 are from an inner-city university
hospital, whereas in four nearby general hospitals in northern England with a
prominence of elderly patients, intestinal obstruction stems from adhesions in
32%, cancer in 26% and incarcerated hernias in 25% (15), and
in a Montreal referral hospital with an interest in inflammatory bowel disease,
the etiologies are adhesions in 74%, Crohn’s disease in 7%, cancer in 5% and
hernia in 2% (16).
Similarly, the relative plethora of hernias and paucity of adhesions in Sierra
Leone (Table 2) reflects political and
economic factors, as does the high case mortality rate (17).
Those data were collected from September 1992 through September 1994 (6), during the height of the civil war in the embattled Southern
Province of that impoverished country, whose per capita GDP (US$700 in
purchasing power parity) now ranks 223rd out of 229 and is half that of Ghana
and one-third that of Nigeria (18) (Figure
1). In this last country as well, during the decade following the
devastating Biafran War hernia was also the predominant cause of intestinal
obstruction (19; 20).
TABLE 2: MAIN CAUSES OF INTESTINAL OBSTRUCTION
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Adults |
Children |
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Country |
Ghana (1)
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Nigeria |
Sierra Leone (4)
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USA (Chicago)(5)
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Central Africa Republic (6)
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Ilesa (2)
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Ile Ife (3)
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# Patients |
391 |
128 |
99 |
32 |
238 |
30 |
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Male:Female |
-- |
1.7:1 |
1.5:1 |
3.6:1 |
-- |
-- |
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% Mortality |
-- |
8 |
14 |
18.8 |
2.7 |
-- |
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% Adhesions
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56 |
44 |
44 |
25 |
64 |
13 |
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% Incarcerated Hernia
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Not Studied |
18 |
11 |
47 |
27 |
50 |
% Intussusception
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4 |
5 |
8 |
9 |
1 |
37 |
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% Volvus
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27 |
26 |
15 |
19 |
3 |
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% Cancer
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9 |
3 |
10 |
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7 |
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% Ascaris
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4 |
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| 1 From (7). Of the
volvulus cases, 86% were of the sigmoid colon. Of the cancers, 71% were of the
colon. 2 Adapted from (11). Of the 20 total cases of intussusception, the above tabulation excludes from the original series of 142 patients the 14 (70%) that occurred in children. Of the volvulus cases, 57% occurred in the small intestine and the remainder in the colon. 3 From (13). 4 Adapted from (6). 5 Adapted from (12). The mortality quoted here excludes the 17 patients with malignant tumours, seven of whom died; including these cases, the overall mortality rises to 5.5%. The 3% incidence of volvulus includes only those of the small intestine. 6 From (8). |
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| FIGURE 1: Per Capita GDP (Gross domestic product) for 2007 in US$, at purchasing power parity (PPP) for all of the countries in Africa, with Nigeria, Ghana, Central African Republic and Sierra Leone pointed out at the down arrows. For comparison, the United States and Haiti, the richest and poorest countries in the Western Hemisphere, respectively, and the world as a whole are shown at the up arrows. Prepared with data from (18). |
In places like that of the Sierra Leone series, where surgeons,
operating rooms and, hence, surgical operations are scarce, so are adhesions.
In that same environment, unrepaired hernias are abundant (Figure 2) (21; 22;
23). Likewise, the deprivation in rural Sierra Leone explains
the high mortality observed by McConkey (Tables 1
and 2), who pointed out that one-third of deaths
occurred in extremely ill patients and that better equipped facilities and
more experienced surgeons would have reduced the mortality rate (6).
On the other hand, the Central African Republic study was carried out in
the capital, at the country’s national hospital (8); the
recent Nigerian study was carried out in Ile Ife, in the surgery department
of a major university (11), and the Ghanaian study was
carried out in Kumasi, at the country’s second largest hospital (7).
Although the best provisioned hospitals in sub-Saharan capitals and elite
cities provide the best care and produce most of the clinical literature,
only a tiny fraction of the people in their countries have access to their
expertise and other resources. For the vast majority in sub-Saharan Africa,
and the doctors and nurses who treat them, the conditions in rural Sierra
Leone are more relevant.
Mindful of this reality, after reviewing the current knowledge
about the causes of intestinal obstruction I would like to present what I
believe to be the most prudent strategy for the rural doctor in Africa and
other similar locations to deal most effectively with these difficult clinical
problems.
3.1. Adhesions
All abdominal surgeons know that adhesions occur frequently after laparotomy.
Upwards of 93% of patients who have undergone a prior abdominal operation,
particularly in the lower peritoneal cavity, have adhesions, compared to 10.4%
of those who haven’t (24; 25). The
peritoneum that produces these adhesions comprises a delicate single layer of
mesothelial cells supported by a submesothelial matrix of loose connective
tissue, which in the uninjured state manifests a fibrinolysis-thrombosis
balance weighted more to the former (26). This balance is
controlled by the local relative abundance of fibrolytic enzymes and their
inhibitors, mostly tissue plasminogen activator (tPA) and plasminogen activator
inhibitors 1 and 2 (PAI-1 and PAI-2), respectively (26; 27). Some stimuli, such as concentrated ambient CO2 as used in
laparoscopy, can up-regulate PAI-1 gene expression in human peritoneal
mesothelial cells directly, and perhaps shift this balance (28).
More commonly however, in response to the peritoneal injury of
a routine laparotomy, neutrophils surge into the abdominal fluid for the first
several days and are then replaced during the next week by monocytes, which
differentiate into macrophages (27). These activated cells in
turn release metabolites of arachidonic acid, including prostaglandin E2 (a
mediator of inflammation), thromboxane B2 (a mediator of platelet aggregation)
and various cytokines, including substance P (SP), intracellular adhesion
molecule (ICAM-1), vascular cell adhesion molecule (VCAM-1), and, most
importantly, interleukin-1 (IL-1) and transforming growth factor-ß (TGF-ß), the
last two of which spur the peritoneum to increase the local concentrations of
PAI-1 and PAI-2 relative to tPA, thereby shifting the coagulation balance more
toward the thrombosis needed for hemostasis and healing of injured tissues (27; 26). The sticky fibrin thereby exuded by
adjacent peritoneal wounds adheres to itself. Toward the end of the first
postoperative week, the cytokine mix usually returns to one favoring
fibrinolysis, but not entirely before the prevailing milieu ostensibly directs
the influx of fibroblasts (which are amply endowed with IL-1 receptors) and the
organization of fibrinous into more durable fibrous adhesions (26;
27).
Despite these interesting details, none of the methods suggested to prevent
(not just to minimize) adhesions have proven efficacious, including,
anti-coagulants, anti-inflammatories, barrier methods and even meticulous
surgical technique, and (except for the latter) most are not economical (26). This is just as well, because the same processes that form
adhesions also assure healing of anastomoses and incisions, and, furthermore,
adhesions are largely inconsequential. Between 6 and 10% of laparotomy patients
ultimately return with symptoms possibly related to adhesions, such as pain,
but in only between 5.7 and 23% of them are adhesions ultimately proven
responsible (29; 30). Patients younger than
60 have a nearly three-fold increased risk for adhesion complications, as
compared to older patients (31). According to the British
Surgical and Clinical Adhesions Research (SCAR) Group, after lower abdominal
operation there is a 5% risk of readmission within five years for
adhesion-related complications (31). Risk of such readmission
following specific lower abdominal operations are: total proctocolectomy
(15.4%), ileostomy (10.6%), total colectomy (8.8%) and appendectomy (0.9%); but
because of the high frequency of appendectomy, these patients comprise 7% of
all those readmitted (31).
Of these complications, intestinal obstruction is but a
fraction. Within one year of laparotomy, 1% of patients return to hospital with
small-bowel obstruction secondary to adhesions, half within the first
postoperative month (24); over 10 years only 3.9% require
re-exploration (30). Based on a series of 144 admissions in
1980s Australia, patients with adhesive small-bowel obstruction will have a
past history of appendectomy in 23%, colorectal resection in 21%, gynecological
surgery in 12%, upper gastrointestinal (gastric, biliary or splenic) surgery in
9%, small bowel surgery in 8%, and more than one previous abdominal operation
in 24% (25). An operation will be necessary to relieve the
obstruction in 42%, 97% of whom will have a single adhesive band causing the
blockage; but 30% will also have strangulated intestine (25).
Because of the high incidence of laparotomy, coupled with the low frequency of
deleterious adhesions, 3.3% of all laparotomies stem from adhesive intestinal
obstruction (24), which, as detailed in Tables 1 and 2, therefore
constitutes an important share of surgical abdominal emergencies.
3.2. Hernia
In industrialized countries, inguinal hernias manifest the highest prevalence
in infants, reach lowest levels during childhood and then increase in
prevalence and incidence continuously after age 15 (32; 33) at a cumulative incidence of 14% for men and 2% for women
followed for 20 to 35 years (34; 35) and a
lifetime cumulative incidence of 46% for men and 13% for women (32;
33), who account for only 10% of all inguinal hernia
operations (36). Incisional and other ventral hernias occur
nearly always in adults and at a much lower incidence, but at nearly equal
rates in men and women (32). In Nigeria, incisional hernias
reportedly result from approximately 3% of cesarean sections, exclusively after
midline incisions as compared to Pfannenstiels (37).
The prevalence of inguinal hernia in adult men seems to be the
same in developed countries and central Africa, approximately 25% (33;
38). As evidenced in the Netherlands (39; 40), northern Jordan (41), and Nigeria (42; 43), throughout the world between 50 and
60% occur on the right, 35-40% on the left and the remainder bilaterally, and
with the same 90% predilection for men as noted above, although the laterality
decreases as the proportion of direct hernia increases (44).
For adults presenting to the university hospital in Ile Ife, Nigeria, their
inguinal hernias tend to be large, with 31% expanding the scrotum and 22.4%
incarcerated, but they enjoy a low mortality rate of 1.6% (43).
Of the incarcerated inguinal hernias treated at the nearby Wesley Guild
Hospital in Ilesa, which comprise 26.4% of all groin hernias, 80% are in men,
76% are scrotal, 47% contain only omentum, but 14% contain gangrenous
intestine, the latter of which account for the 2.7% mortality (45).
In children 4% of inguinal hernias are incarcerated, but 75% of these cases (15
of 20 incarcerated inguinal hernias over 10 years) are also strangulated (42).
Generally in Africa, however, only 42% of hernias are repaired (21).
Hence, for patients who present with external hernias of all types to Komfo
Anokye Hospital in Kumasi, Ghana, including from the remote northern provinces
(46), 65% are suffering acute incarceration (which
Ohene-Yeboah inaccurately terms “strangulated”) of which 66% are in men, 72%
are inguinal or inguinoscrotal, 10% femoral (all in women), 11% umbilical and
8% incisional (46). Overall, 24% of these Ghanaian patients
with incarceration require intestinal resection for gangrene and 12% die, even
though 75% are younger than 50 (46). Incarcerated hernias are
particularly dangerous by causing closed-loop obstruction, in which a length of
intestine is blocked at its proximal and distal ends by the hernia orifice (or
adhesions or other pathology in cases not caused by hernias), which then
pinches off the adjacent mesenteric blood supply as the hernia swells during delay
of treatment and stragulates the contained viscera (47).
Closed loop obstruction is a particular problem with internal hernias, which
contain gangrenous intestine in more than 63% of cases (48; 49), potentially increasing the mortality to above 40% (48; 50). In these hernias, a loop of intestine
pushes through a normal orifice, such as the foramen of Winslow, or through a
fold of peritoneum or mesentery (51; 52).
They are spontaneous (also termed “congenital”) more than half the time; the
others result from peritoneal defects created by surgical operations or trauma
(48). Half of all internal hernias tend to be paraduodenal,
in which the intestine gets caught in a congenital defect near the ligament of
Treitz or, less commonly, a defect further within the base of the jejunal
mesentery; other sites are transmesocolic or transmesosigmoid, transomental or
pericecal (51; 53). They are not common,
accounting for approximately 2% of all intestinal obstruction cases not caused
by external hernias (54; 51; 48),
but occur in children (55) and adults (56).
Although internal hernias are reportedly rare causes of intestinal obstruction
in Nigeria (11), I have personally encountered two cases
during a recent three-month period in northern Uganda (Figure 3).
3.3. Volvulus
Most cases of volvulus in developing tropical countries involve the sigmoid
colon. Sigmoid volvulus is a bit of an etiologic misnomer, for the pathology
involves not an S-shaped (more accurately Σ-shaped) colon, but rather
an Ω-shaped one, in which the mesentery is elongated but anchored
on a very narrow base, around which it can easily twist (57;
58; 59). In industrialized countries,
this pathology occurs in older, institutionalized individuals suffering
from constipation (57), whereas in the “volvulus belt”
of South America, sub-Saharan Africa and South Asia, high-fiber diets are
responsible (58). Hence, in developed countries, sigmoid
volvulus accounts for less than 2% of all intestinal obstructions and only
a small minority of colon obstructions (57), as compared to Africa, where sigmoid—more accurately
“omegoid”—volvulus occurs at an annual incidence of 12/100,000 population
(60) and accounts for half of all cases of blocked colons
(61). In the former instance, only between 7 and 19% of patients
develop gangrene of the twisted bowel and the mortality is 6 or 7% (57; 58); in the latter, upwards of 95% suffer
gangrenous colon and, in the best of hospitals, 17% die (61;
62).
Occasionally the ileum wraps itself like a noose around the neck
of a sigmoid volvulus, often leading to gangrene in both lengths of bowel
(63; 64). Patients with this condition,
termed ileosigmoid knot, are very ill. In Ethiopia, for example, 90% of
such patients presenting to elite hospitals in Addis Ababa develop gangrene
in either or both loops of involved intestine, 60% suffer stormy postoperative
courses and 20% die, despite the majority of patients being relatively young
men between 30 and 50 years old (65). In the more remote
northwest of the country, two-thirds present with peritonitis, more than
40% in shock, and 44% die (66), similar to the mortality
observed in rural Ghana (67).
3.4. Intussusception
In intussusception, a length of bowel, the intussusceptum, turns inside out and
peristalsis propels it and its mesentery progressively down the lumen of the
distal bowel, the intussuscipiens. The intussusceptum swells, sheds blood and
occludes the intestinal lumen, usually causing crampy abdominal pain, vomiting
and bloody, mucoid stools and jeopardizing its own viability (68;
69). If permitted to progress long enough, the forward end of
the intussusceptum (its lead point) can advance all the way to the rectum,
where the physician can palpate it unmistakably on digital examination (70), as I did with astonishment in two patients, 4- and
6-year-old boys, who presented to me in rural Haiti.
Children suffer between 90 and 95% of all intussusceptions (71; 72), nearly always of the ileo-colic
variety, which cause more than one-third of their episodes of intestinal
obstruction (8) (Table 2).
In less than 10% of these cases can a definite mass lesion be found at the lead
point to have dragged the intussusceptum through the intussuscipiens, usually a
Meckel’s diveritculum or a hamartomatous polyp (68), although
these culprits seem to cause more than 40% of those rare cases limited more
proximally in the small intestine and not progressing into the colon (69). The remainder are said to be idiopathic, although viral
enteric infections, which cause mass-like enlargement of ileal Peyer’s patches,
are likely responsible (73). In developed countries, various
non-surgical options are available to diagnose and treat the problem, such as
reduction under fluoroscopy by barium enema, fluoroscopic air reduction and
sonographically guided hydrostatic reduction (74; 75), which can replace a surgical operation in upwards of half
of children but are unavailable or impractical in Africa where all these
children need laparotomy urgently (68). As compared with
small children at selected inner city and referral children’s hospitals in
America, those in western Nigeria present with twice the duration of symptoms
(3.8 days), more than twice as often (68%) with a palpable abdominal mass and
more than three times as often (20%) with a palpable intra-rectal
intussusceptum (68). Nigerian children develop nonviable
bowel in 36% of cases, as compared with 14% and 28% in the referral and
inner-city American hospitals, respectively, associated with a delay in treatment
twice (at 5.7 days) that of the African patients with viable intussusceptum (68). Of those Nigerian children with necrotic intestine, 39%
die, contributing to an overall 18% mortality (68). In the
selected American hospitals, these children don’t die, even those with
gangrenous bowel (68). Delay is deadly in Africa, as those
who succumb are often misdiagnosed as suffering tropical enteric infections for
upwards of one week before finding their way to remote hospitals capable of
correctly identifying and correcting the problem (68).
As children grow into adolescents and young adults,
intussusception occurs more rarely and those that do occur increasingly reveal
a definite pathologic lead point, the majority of which are benign (76). In Addis Ababa the mortality in these older patients
matches that in Nigerian children (76; 68).
By middle age intussusception is distinctly uncommon—busy referral
surgical services in America (71; 77),
France (78), Turkey (79) and Singapore (80) rarely see more than one or two such cases
annually—and almost always occur in association with pathologic lesions (71; 77; 79; 78;
80). These cases account for merely 1% of intestinal
obstruction (71) and begin in the small bowel between
two-thirds (77; 78) and three-fourths of
the time (71; 79). Regardless of where in
the gastrointestinal tract they start, the inciting lesions are malignant
nearly half the time (71; 79; 78;
80). In the colonic intussusceptions, the malignant causes
are nearly always primary adenocarcinoma (71; 77;
79; 78; 80) associated
with a 33% mortality. The malignancies causing enteric adult intussusceptions
are mostly metastatic, usually malignant melanoma but also lymphomas and
sarcomas, with a poor prognosis and therefore associated with mortality in 52%
(71; 78). For these reasons,
intussusceptions in adults should be resected, except for the rare idiopathic
and definitely benign case, which simply need be reduced surgically (71; 77; 79; 78;
80).
More than 30 years ago, benign idiopathic ceco-colic
intussusception was the commonest cause of intestinal obstruction in Nigeria,
where it is now unusual (81; 82; 83; 84), consistent with the frequencies in
Table 2, above. In rural Rwanda until 26 years ago, this problem caused 57% of
intestinal obstruction in adults, followed by external hernia in 29%, sigmoid
volvulus in 5% and adhesions in 2% (85), an etiologic pattern
suggestive of poverty, as noted above for McConkey’s observations in Sierra
Leone (6; 17) and perhaps explaining the
increasing rarity of this entity in Nigeria as its economy has improved over
the years. Destitution might cause ceco-colic intussusception through altered
gut motility related to irregular eating and Ascaris infestation (85;
17).
3.5. Ascaris
The soil-transmitted roundworm Ascaris lumbricoides occurs throughout the
tropics, but is most prevalent in niches with warm, but not too-hot, moist
soils that favor embryonation of the geohelminth’s eggs, which small children
deprived of adequate hygiene then swallow, eventually enriching the soil with
the next generation of eggs in their feces (86; 87;
88; 89). These ecological limitations seem
to make Ascariasis more of a problem in subequatorial tropical countries such
as India (90) and Colombia (91), rather
than in those in sub-Saharan Africa, where the occurrence is much spottier. In
Cameroon, for example, the prevalence of Ascaris in the more humid south is
66%, as compared to the 42% prevalence in the country as a whole and a much
lower level in the arid north closer to the Sahara Desert (87;
92; 93). And in Kenya, Uganda and South
Africa, Ascariasis is largely limited to small ecological pockets of dense
vegetation near the Great Lakes or major rivers, areas with shadier, moister,
slightly cooler soils (94; 88; 89).
Moreover, the mass treatment of school children in endemic areas with
antihelminthics, such as albendazole, has reduced very effectively and
economically the prevalence and intensity of Ascaris and other geohelminth
infestation (95; 96; 97; 98). Ascariasis, therefore, has become a less important cause of
intestinal obstruction in Africa over the years, especially where the etiologic
pattern of intestinal obstruction reflects improved socio-economic conditions (99; 100) (Table 2).
Nonetheless, the rural tropical doctor must be prepared to
assuage the morbidity and mortality inflicted largely on children by A.
lumbricoides, especially where the typical socio-economic and environmental
factors converge. The larvae from swallowed eggs can settle not only in the
small intestine, but also in the pancreatico-biliary tree or liver before
growing into adult worms that measure between 12 and 16 inches long (101). Patients can, therefore, present with obstructive
jaundice, hepatic abscess or pancreatitis (101; 17).
In the gut, the worms compete with their host for the available luminal
nutrients, causing malnutrition and stunted growth (95). If
more than 60 adult worms crowd into the bowel lumen, the host usually suffers
intestinal obstruction, the most common complication of Ascariasis for which
patients present emergently to hospital (102; 103).
Most of these patients are children less than five years old, but adults can
also be affected (104). Often they have defecated or even
vomited adult worms; they exhibit all of the symptoms and signs of intestinal
obstruction and plain abdominal radiographs frequently reveal a wormy “swirl”
shadow within the dilated gut (91). Nearly three out of every
four patients present without signs of peritonitis or toxicity and can be
treated conservatively, with nasogastric suction, intravenous infusion and then
vermifuge with oral antihelminthics (90; 91).
The others are very ill and sometimes—but not always—up to half die
even with urgent laparotomy, at which any gangrenous bowel needs resection
(12-32% of cases), the obstructing worms need to be extracted via enterotomy
(13 to 58% of cases) or milked into the colon, which is possible and sufficient
in 10 to 48% of cases, depending on patient population and locality (90; 104; 91).
3.6. Tumour
In African Americans, the annual incidence of colon adenocarcinoma is 60 per
100,000 population, as contrasted to less than 1 per 100,000 in native
sub-Saharan Africans (105), apparently related more to the
carcinogenic effects of the large quantities of red meat and animal fat in the
Western diet than to the protective effects of fiber (106; 107; 108; 109). Hence,
not surprisingly, in regions of increasing affluence in Africa, as judged by
the proxy of rising motor-vehicle ownership and related accidents, colon cancer
has become a more noticeable, albeit still minority, cause of intestinal
obstruction (99; 110; 111;
112) (Table 2).
Furthermore, in regions endemic with Schistosoma mansoni, patients afflicted
with Schistosomal colitis appear to develop histologically more aggressive
colorectal cancers, associated with alterations in the expression of the p53
tumour suppressor gene, and present at a younger age with more clinically
advanced disease (113).
In my own experience in Africa’s lymphoma belt, young patients
occasionally present with colon obstruction secondary to Burkitt’s lymphoma (114) (Figure 4).
Children and young adults can also suffer acute abdomen with intestinal
obstruction from the benign tumour, mesenteric cystic lymphangioma (115; 116) (Figure
5).
|
FIGURE 4: Obstructing
tumor of the transverse colon in a 20-yearold man. The proximal transverse
colon, in the photo’s left, is dilated from the obstruction. The distal transverse
colon, below the clamp at right, is collapsed (arrow). Upon resecting the transverse
colon and opening the bowel, the waxy tumor proved to have destroyed the
adjacent colonic mucosa. Histologically, it demonstrated the “starry sky” appearance of Burkitt’s lymphoma. (Northern Uganda, May 2008. Author’s
photo.)
|
|
FIGURE 5: Kishnath,
an 8-month-old boy who presented to the hospital with four days of worsening
abdominal distension and lethargy (left). On examination, his temperature was
102 °F and he mustered no response exceptwhen I palpated a grapefruit-sized
mass in his right lower abdomen, which resulted in a faint whimper. His
leukocyte count was 30,000. He underwent an immediate laparotomy and was
found to have an obstructing cystic lymphangiona of the mesentery to the
right colon. He was treated by resecting the mass en bloc with the right
colon (center). The terminal ileum is at lower right, the cecum is along the
top and the multilocular cystic lymphangioma is visible at the lower left of
the photo (arrow). Kishnath woke up from the anesthesia fully alert immediately after
the operation and went home 10 days later (right). (Batticaloa, Sri Lanka,
October 1996. Author’s photo)
|
Physicians in developing countries faced with cases of intestinal obstruction
and other abdominal emergencies must, as explained above, consider their
economic environment and the consequent local disease patterns, available
technological resources and surgical expertise. However, any savvy, dedicated
physician with a minimum of surgical experience and only rudimentary operating
facilities can—and should—successfully mitigate the morbidity and
mortality attendant to abdominal emergencies, notwithstanding limitations of
technology and experience. To do so, the doctor must commit to just two aims:
1. Never find intestinal perforation or gangrene in any patient whose operation
was delayed to provide for a period of observation.
2. Never have any patient die whose operation was denied or delayed to provide
for a period of observation.
In achieving these goals, the responsible physician must
understand that the more limited the resources in the community and hospital,
the lower must be his or her threshold to carry out prompt exploratory
laparotomy.
Patients with intestinal obstruction complain of colicky abdominal pain, nausea
and/or vomiting, abdominal distension and obstipation (117).
Surgeons often characterize the blockage as either proximal (“high”) or distal
(“low”) and either complete or partial, depending on the onset of vomiting
relative to the pain and the degree of obstipation, respectively (117),
but for doctors working in challenging environments these distinctions are
irrelevant. More importantly, the physician must determine the duration of
symptoms before presentation to hospital and if the patient has previously
undergone a laparotomy, and for what reason. Women must be questioned carefully
about their obstetrical and recent menstrual history.
On physical examination, the physician must know the patient’s
vital signs accurately, particularly assessing for fever and tachycardia. The
degree of dehydration manifests itself in the quality of facial skin turgor and
moistness of the conjunctivae and tongue. The abdomen is usually distended.
Sometimes, the physician can see or feel the dilated intestine contract
vigorously through an emaciated abdominal wall or even feel an obstructing mass
(117). On auscultation, the bowel sounds are often
hyperactive, with the unmistakable high-pitched sounds of fluid rushing to and
fro under pressure. Occasionally, however, the abdomen may be as silent as an
echo chamber, in which the physician’s gentle tapping at one end transmits
quickly to the other, where the examiner can hear it crisply with a
stethoscope, accompanied by the patient’s wincing. In such cases, the abdomen
is locally if not diffusely tender from obvious peritonitis. In all but the
most extremely ill of patients, the physician must carry out a digital rectal
examination and a bimanual pelvic examination in all women, in both cases to
assess for tenderness and masses, including an unmistakable intussusceptum in
children. Lastly, the examiner must note any abdominal scars and search for any
hernias in them, the umbilicus and groins.
The astute physician needs nothing more than this—a
stethoscope and focused clinical intellect—to arrive at a proper working
diagnosis and treatment plan. A leukocyte count is useful but not necessary. If
available, I find that a single upright abdominal radiograph is also very
helpful, but no physician should ever be deterred or delayed by the lack of
laboratory tests or radiography. The upright abdominal film distinguishes the
characteristic aspects of small bowel obstruction from simple ileus and
visceral perforation (Figure 6), notwithstanding the few
reservations expressed about the value this single radiographic view in
developed countries, with access to radiologists and unlimited technology (118; 117; 47).
Furthermore, the upright radiograph is often diagnostic for sigmoid volvulus,
the commonest cause of colon obstruction in the developing world (57)
(Figure 7).
|
FIGURE 6: Upright abdominal radiographs in a case of
small-bowel obstruction (left) and pneumoperitoneum (right). At left,
the radiograph shows at least seven loops of dilated small intestine.
In the limbs of the inverted “U” of each loop, the air-fluid levels
are at different heights (e.g., arrows), causing an overall “laddering”
pattern, characteristic of a higher intraluminal pressure at the downstream
side of each loop (closer to the blockage) than the upstream side,
which overflows into the stomach. This and the total absence of gas
shadows in the colon (compare with Figure 7)
are diagnostic of complete small-bowel obstruction. At laparotomy,
this patient proved to have adhesions. In the radiograph at right,
there are no air-fluid levels other than a very small one comprising
the gastric bubble (small black arrow). The crescentic air shadow
at the large black arrow is not limited inferiorly by an air-fluid
level, which would appear as a perfectly straight, horizontal line,
but rather the serosal surface of the convex gastric fundus. Hence
that lucent shadow must represent gas between the undersurface of
the left hemidiaphragm and the outside of the stomach, i.e., a pneumoperitoneum.
To confirm this finding, the right hemidiaphragm (white arrow) is
contrasted by air on both sides, in the lung above and in the peritoneal
cavity above the liver. At operation, this 42-year-old man proved
to have a perforated duodenal ulcer. (Left, rural Haiti, July 2004;
right, northern Uganda, March 2008. Author’s photos.) |
With this small amount of important information, the physician
must arrive at only one treatment decision: does the patient need a laparotomy
emergently, or will observation suffice? Most patients in destitute areas who
travel to remote hospitals have already subjected themselves to a period of
observation at home, and have only presented to the doctor because they have
not improved and are seriously ill. Hence, as noted above for Ghana, mortality
increases from 1.6% for those ill less than six hours before presenting to hospital,
to 10% for patients ill for 2 days, to 14% for patients ill for 3 days (7). The doctor must consider whether the patient manifests the
physical signs of fever, tachycardia, abdominal tenderness or leukocytosis (if
leukocyte counting is available). Patients with severe abdominal complaints who
have none or just one of these signs almost never prove to harbor intestinal
gangrene; 25% of those with two or three of these are found to have gangrenous
bowel and two-thirds of those with all four of these signs have necrotic bowel
(12). By definition, anyone with two or more of fever,
tachycardia or leukocytosis is suffering from the systemic inflammatory
response syndrome (“SIRS”) (see, http://www.ptolemy.ca/members/archives/2008/Shock/index.htm)
and will succumb to a serious illness unless the doctor rapidly alleviates the
underlying pathology (119; 120).
Hence, especially for the less expert physician practicing in
more remote locations with facilities to perform laparotomy but limited
supplies of nurses, monitors and medications, the doctor should commit to
operating early on any patient with abdominal pain, vomiting and obstipation,
unless the patient has been symptomatic for less than two days and displays
none or just one of fever, tachycardia, abdominal tenderness or leukocytosis (121).
Notice that this criterion should exclude from operation all
patients with bacillary or amebic dysentery, cholera and most of those with
simple typhoid fever, who are not obstipated and can should all be treated with
intravenous fluids and parenteral antibiotics. Additionally, young women with
pelvic pain and fevers starting within one week after a menstrual period, who
also demonstrate cervical motion tenderness and pus at the cervical os, are
suffering from acute salpingitis and can also be treated exclusively (at least
initially) with intravenous antibiotics. Except for these patients, the
physician practicing in resource-poor locations should never administer
parenteral antibiotics to any patient with abdominal pain, unless the patient
will proceed shortly thereafter directly to the operating theatre.
Of course, certain other findings constitute absolute
indications for a surgical operation, even in the absence of SIRS. Children
with a palpable abdominal mass and/or a palpable intrarectal intussusceptum
need urgent laparotomy. Patients with pneumoperitoneum, as revealed in an
upright abdominal radiograph, need laparotomy without delay (122).
Similarly for patients with radiographic signs of sigmoid volvulus (57). From my personal experience I firmly believe that, in
hospitals with limited resources, patients ill for more than 2 days and with
unequivocal signs of intestinal obstruction on a plain upright radiograph
(e.g., Figure 6, left) should undergo
expeditious laparotomy, even in the absence of other worrisome signs. Although
surgeons in industrialized countries advocate that these patients may initially
be observed, in that setting observation frequently fails, and approximately
30% of these patients will require bowel resection (120),
making anything other than early laparotomy too risky in developing countries.
In any setting, patients with intestinal obstruction, no prior laparotomies and
no external hernias are suffering from internal hernias or other conditions,
such as volvulus, associated with a higher incidence of closed-loop obstruction
and intestinal gangrene and need expeditious laparotomy (118;
49). Of course, any patient with intestinal obstruction and a
hernia incarcerated in the abdominal wall or groin also needs an operation
urgently.
Patients needing emergency laparotomy must be readied and
resuscitated within one or two hours in the emergency department. In rapid
sequence, the patient must be provided with nasogastric drainage tube, which
likely will discharge more than a liter of bilious fluid immediately, Foley
transurethral catheter, likely to yield only several milliliters of
concentrated urine, and intravenous infusion. Because these patients have lost
large quantities of gastric acid by vomiting, the best fluid to counteract the
resulting metabolic alkalosis is normal saline. Infuse two liters rapidly (or
the equivalent proportion in children) and then continue rapid infusion until
the urine output appears less concentrated and flows at least 5 cc every 10
minutes.
Next, all of these patients need intravenous antibiotics. In
general, a regimen of ampicillin, gentamicin and metronidazole will cover
synergistically the usual gram negative enteric aerobic and anaerobic flora.
It’s best to administer the full daily dose of gentamicin undivided, which
usually means a full 240 mg (4-7 mg/kg if renal function is normal) for the
typical adult on presentation, before operation, and 5-7.5 mg/kg for children
with normal renal function. Children and young adults severely ill with obvious
signs of peritonitis, including all of those with pneumoperitoneum on the
upright radiograph (e.g., Figure 6, right),
might have perforated a gangrenous closed loop but are most likely to have
suffered typhoid ileal perforation (7) (Table 1, “Nigeria”) and must receive a different
antibiotic regimen to cover for Salmonella typhi. My first preference for these
patients is ceftriaxone (2 gm. intravenously for adults, 50-75 mg/kg in
children), in addition to gentamicin and metronidazole (123).
If ceftriaxone is unavailable, intravenous ciprofloxacin is a good alternative,
followed by chloramphenicol if the physician has neither ceftriaxone nor
ciprofloxacin (124; 123). As cautioned
above, all of these patients, for whom the doctor has felt the need to
prescribe parenteral antibiotics, must proceed not to the ward but directly to
the operating theatre.
For understandable reasons, I have sometimes (but not always) observed the
opposite in developing countries, where overworked young or inexpert doctors
bear responsibility for the care of seriously ill patients, as have other
Western surgeons such as McConkey (6). Of course, because of
the realities of a crushing patient load, a paucity of nursing and ancillary
personnel, an absence of suitable mentors and the doctor’s own personal lack of
confidence in his or her ability to deal with a frighteningly ill patient
surgically, it is all too tempting simply to give these patients intravenous
antibiotics, admit them to the ward and hope for the best. But patients thusly
treated almost always die (Figure 8). I
urge the doctor saddled with the daunting task of caring for these patients to
remember that no patient is too ill to undergo, and no doctor is too
inexperienced to perform, a lifesaving surgical operation.
Any intelligent, caring doctor able to perform a cesarean
section can also manage successfully in the operating theatre all of these
other dire abdominal emergencies, even with a paucity of fully trained
anesthetists (125). If you are one of these doctors, your
success will increase with experience, both the good ones and the bad ones. If
you to operate expeditiously despite your own personal reservations, at first
perhaps two-thirds of your patients with abdominal emergencies will die quickly
and one third will survive. But if you avoid operating, all of these patients
will die.
With persistence, reflection and continuing surgical
experience, you will save half and eventually two-thirds or more, most of whom
will be able to return home within one or two weeks. And none of these
patients, even those who die, will suffer needlessly or waste time in the
hospital and impoverish their families. Of course, I also urge that you avail
yourself of the best expertise available to you and that you not operate on
patients such as those in Figure 2, who
are not acutely ill and for whom an operation risks more harm than good, but
only on those with severe, persistent abdominal complaints and objective signs
of SIRS (e.g., Figure 5). Any patient
whom you choose to observe should be noticeably improved after 12 hours; if
not, you must proceed to laparotomy without delay. Occasionally you might
operate on some of these patients and find simple typhoid fever or acute
salpingitis or other pathology that would have resolved solely with intravenous
fluids and antibiotics, but in such cases after ruling out surgical pathology
you can simply and easily close the incision and rest assured that your patient
will recover. This is a small, and appropriate, price to pay to avoid losing
any patient, like the little boy in Figure 8, that you could have saved if you
operated or operated sooner (Figure 5).
Fortunately, operations for adhesive intestinal obstruction are often
relatively easy, because the pathology usually involves just a single
obstructing band or a few adhesions of the intestine to the laparotomy
incision, prior surgical site or another loop of bowel (24; 25). In these and most other abdominal emergencies not caused by
external hernias, the doctor should enter the peritoneal cavity through a
midline incision from the midepigastrium to slightly below the umbilicus,
taking care to cut with dissecting scissors any adhesions to the peritoneal
surface of the incision and thereby avoid injuring the underlying viscera. If
possible, gently deliver the small bowel through the incision onto the anterior
abdominal wall (as in Figure 8, right)
and then trace the viscera, always markedly dilated and boggy because of the
downstream blockage, from the ligament of Treitz as far distally as possible.
Then find the ileo-cecal valve in the right lower quadrant; if the adjacent
terminal ileum is collapsed, the point of obstruction lies between this site
and the distended proximal intestine. Working from both ends, palpate and
compress between the thumb and index and middle fingers of your non-dominant
hand the scar tissue adjoining the loops of bowel. Some of these adhesions will
simply fall apart with this maneuver; those that do not you should cut with
Metzenbaum or Mayo scissors in your other hand. In the easy cases, this
“enterolysis” will take you 10 or 15 minutes, when you will then observe a
distinct transition point between the obstructed (bloated) and unobstructed
(collapsed) intestine and can easily trace the jejunum and ileum from the
duodeno-jejunal ligament (of Treitz) to the ileo-cecal valve. Once you have run
the jejunum and ileum between your hands several times from one end to the
other, looking and feeling for any blockages, gangrene, perforations or other
injuries, it’s best (if the bowel proves to be non-defective) to milk the
intraluminal contents back into the stomach and then through the nasogastric
tube (by gently compressing the distended stomach against the posterior
abdominal wall). Replace the viscera within the peritoneal cavity and draw the omentum
over the gut immediately posteriorly to the incision, which you are now ready
to suture closed.
In a significant minority of cases at the other extreme of the
spectrum, upon opening the abdomen the physician will be confronted with an
overwhelming mass of scar tissue and nothing that even resembles normal
intestine. In these cases, the surgeon needs no additional resources other than
patience and understanding that the principles are the same as just described
for the easier operations. Simply start cutting and hand-dissecting adhesions
wherever most convenient and easiest, and then shift to the next easiest
location and so on. At first, this process moves along with discouraging
slowness. But as you define loops of bowel the enterolysis accelerates and
becomes increasingly easier, until you find yourself in the more familiar
situation of the typical simple case.
When operating for intestinal obstruction or any other
abdominal emergency, upon opening the peritoneal cavity and dividing adhesions,
the doctor may encounter the complications of enterotomies—holes that he
or she has created in the intestine, which occurs in the complicated cases even
in the best of hands (126)—perforation, usually from
typhoid ileitis or peptic ulcer disease, or gangrene of a closed loop
obstruction (Figure 9). If you make a hole in the
obstructed bowel, control the leakage between your fingers and then allow
the enteric contents to run into a small sterile bowl, from which the foul
fluid can be serially discarded until the gut is empty. Then suture the defect.
When dealing with any perforation, whether iatrogenic or from typhoid ileitis,
you must remember to close the hole transversely, not longitudinally, so as not
to narrow the intestinal lumen and risk a postoperative obstruction or
dehiscence of the repair. Any flimsy lengths of bowel riddled with enterotomies
or typhoid enteritis, and any lengths of bowel afflicted with gangrene or
tumour, you must resect, and then reestablish intestinal continuity by sewing
an anastomosis or, in difficult situations, create an ostomy at the skin
surface. Before closing the abdomen in these cases, rinse out the peritoneal
cavity, including above and below the liver and spleen and in the pelvis, with
at least several liters of sterile saline. The beginner should read about each
of these techniques and other aspects of laparotomy in the Oxford textbook,
Primary Surgery, Volume 1, Chapter 9, “Methods of abdominal surgery” (available
online at: http://ps.cnis.ca/wiki/index.php/Methods_for_abdominal_surgery)
(127).
In any operation in which you encounter intestinal perforation
(either iatrogenic or pathological), gangrene or purulent infection (so called
“dirty wounds” (128)), when closing the abdomen suture the
fascia and peritoneum in a single layer, but leave the more superficial
(subcutaneous and skin) layers open and packed with saline-moistened gauze
dressings, which should be changed daily. The skin will be fully healed in
approximately one week. If you suture the skin closed, at least 60% of the time
the incision will become infected (12). In my experience in
developing countries, before the pus comes bursting out of the skin wound, it
first destroys the underlying fascia and leads to a difficult, prolonged
convalescence that strains not only the patient, but also his or her family and
the already overworked nursing staff, followed by an incisional hernia with all
of its potential future catastrophes. It’s much better to avoid these disasters
where resources are limited, especially with such easy strategies as leaving
open the superficial wound and operating before gangrene sets in. Although it
might be tempting to close the skin incision after dealing with intestinal
perforation, gangrene or purulent infection, based on personal experience in
remote locations I recommend leaving the skin and subcutaneous tissues open,
for secondary closure on daily moist dressings, unless you are an experienced
surgeon whose patient population and resources permits you to close these
wounds with no or few infections and no dehiscences.
Operating on internal hernias is not much different from dealing with
adhesions, except that the stricture is caused by a peritoneal defect rather
than a band of scar tissue, and the physician is more likely to find gangrene (49; 48; 50; 51).
The pathologic anatomy can be confusing, however. If you find yourself
disoriented, simply find the dilated proximal intestine and the collapsed
distal bowel and then trace them both inwardly, where they will converge at the
stricturing hernia defect. Because the incarcerated or strangulated intestinal
loop will be edematous, you will not be able to reduce it without first
identifying the margins of the peritoneal defect and enlarging the hole by
incising the peritoneum, while taking care not to cut any mesenteric or other
nearby vessels (Figure 3). Then you
will be able easily to pull the herniated bowel back through the enlarged
defect, which you must sew closed to prevent a recurrence. Thereafter, you need
to assess viability of the hernia contents and resect them if necessary.
When diagnosed by its typical radiographic appearance, sigmoid
volvulus can often be reduced and decompressed by passing a sigmoidoscope,
which, if successful, yields a blast of gas and stool and converts an emergency
laparotomy to an elective one, provided the patient’s pain and obstipation
resolve and there are no other signs of gangrene (58).
Otherwise, including for all of the cases that lack access to sigmoidoscopy,
proceed urgently to the operating theatre. After untwisting the colon the
remainder of procedure depends on the condition of the sigmoid. Gangrenous
colon must be resected. Usually, the proximal and distal resection margins
will nearly touch each other (i.e., Ω) and can be anastomosed primarily
without needing to mobilize the descending colon. However, it is probably
safer, especially in less experienced hands, to free up the distal descending
colon and exteriorize the proximal resection margin in the left lower quadrant
as an end colostomy, while suturing the distal end closed as a blind rectal
pouch—the so-called Hartmann procedure (129). If
the volvulus is viable, the redundant sigmoid can be resected and the remaining
ends anastomosed. Alternatively, you can carry out a mesosigmoidoplasty,
in which the mesentery to the volvulus is incised along its long axis (in
an area free of vessels) and then sutured transversely, so as to widen its
base and make it less likely to re-twist (59). Both methods
are probably equally effective (129), but the mesenteric
procedure is quicker and avoids sewing a poorly prepared colon distended
with feces (59).
With most intussusceptions, upon following the jejunum
distally you will find that the small intestine leads into an invaginated,
foreshortened colon (Figure 10). The
cecum and appendix will not be visible, and in the extreme cases neither will
the remainder of the colon all the way to the left lower quadrant. This entire missing bowel comprises the intussusceptum. To
reduce it, pulling on the small intestine will not work. Instead, you must
follow the intussuscipiens distally until you can feel the lead point within
it. Then, with the thumb opposed to the index and middle fingers of each hand
across the colon just distal to the lead point, gently push the lead point
back, as if squeezing toothpaste from the bottom of the tube toward the cap.
The intussusception will reduce. If you find gangrenous bowel or pathology that
caused the telescoping, such as a polyp or Meckel’s diveritculum, you must
resect it. Otherwise, after reducing intussusceptions in children, remove the
appendix and then close the laparotomy incision.
Four principles govern the operation on any hernia anywhere in the body: (a)
dissect the sac free from the surrounding structures, (b) open the sac and
reduce its contents, (c) close and reduce the sac and (d) repair the defect
through which the sac herniated. The beginner should read about the details in
the Oxford textbook, Primary Surgery, Volume 1, Chapter 14, “Hernias”
(available online at: http://ps.cnis.ca/wiki/index.php/Hernias)
(130). When patients present with intestinal obstruction
secondary to incarcerated external hernias, proceed urgently to the operating
theatre, so as to avoid the increasing likelihood of gangrene associated with
delay (46). Don’t try to reduce any tender hernia, because if
the contents are already gangrenous the reduction will convert a contained
extra-abdominal calamity into an uncontained intra-abdominal catastrophe.
Gangrenous hernia contents can usually be resected through the hernia incision.
Most importantly, doctors working in remote areas with limited resources must
endeavor to repair all groin and other hernias of the abdominal wall
electively, before these patients return with horrid complications (19; 46; 131), including
giant hernias like that in Figure 2.
Even in older patients with co-morbidity, the mortality is a low 1.6% for
elective hernia repair (43), but soars to 12% for emergency,
incarcerated hernias, even in patients mostly younger than 50 (46).
Postoperatively, all patients treated for abdominal
emergencies will need intensive surveillance. Except for those patients with no
findings of acute bacterial infection, the intravenous antibiotics will need to
continue for another week. Intravenous fluids will be needed in large volumes
so as to maintain a brisk urine output. If blood is available for transfusion,
it should be given if the hematocrit falls below 20% in children and most
adults or 30% in patients with evidence of ischemic cardiovascular disease or
diabetes mellitus. The bilious nasogastric drainage might remain elevated over
1 liter daily for upwards of 10 days before gastrointestinal activity returns
and the bowels move, but during this time the patient’s overall status should
gradually and continuously improve (120).
However, patients treated for intestinal perforation, gangrene
or other conditions requiring intestinal resection are particularly prone to
suffer postoperative complications such as anastomotic disruption and
subphrenic and other intra-abdominal abscess (132; 6). In industrialized countries, patients have ready access to
advanced technology such as CT scanning, which can help diagnose these problems
accurately (133). In hospitals where resources are scarce
the lack of advanced technology must be replaced with hyper-vigilance and a
much lower threshold to re-operate. Any patient who initially improves and then
relapses into fever, tachycardia, hypotension, dyspnea, diaphoresis or other
serious signs should be re-explored without delay.
5. Conclusions
The same economic, geographic and climatic factors that prevented sub-Saharan
Africa and other tropical locations from keeping pace with the growing
affluence of the world’s richest countries have also affected the spectrum of
abdominal emergencies, their etiology, their severity and the resources
available to cope. Among these consequences is the relative paucity of surgeons
trained to the exacting standards of those in North America, Europe and East
Asia. But these hurdles should not deter any doctor with limited resources from
tackling successfully the problems presented by any patient with intestinal
obstruction or similar abdominal emergencies. Even if consigned to a remote
facility as the only doctor, you should not give up on any of these patients by
sending them to the ward without a fighting chance. If you can carry out a
cesarean section, you have everything you need to reduce to admirable levels
the morbidity and mortality of the acute abdomen. Although you might lack the
latest of modern technology and more senior colleagues, you have unique,
privileged access to a wealth of the most challenging clinical material. If you
apply the above recommendations to that rare asset, you will become among the
most skilled, artful and seasoned of surgeons anywhere in the world. I wish you
the best of success.
6. Summary of
Recommendations
1. On physical examination, assess for fever, tachycardia, abdominal tenderness
and leukocytosis. Always examine the groins, umbilicus and incisions for hernias.
Always do pelvic and digital rectal examinations, unless the patient is too ill
to reposition.
2. Operate early (within two hours) on any patient with abdominal pain,
vomiting and obstipation, unless the patient has been symptomatic for less than
two days and displays none or just one of fever, tachycardia, abdominal
tenderness or leukocytosis.
3. Except for patients with bacillary or amebic dysentery,
cholera, simple typhoid fever or pelvic inflammatory disease, the physician
practicing in resource-poor locations should never administer parenteral
antibiotics to any patient with abdominal pain, unless the patient will proceed
shortly thereafter directly to the operating theatre.
4. In children and young adults with pneumoperitoneum or
severe peritonitis, include intravenous antibiotic coverage for Salmonella
typhi, using either ceftriaxone, ciprofloxacin or chloramphenicol in
conjunction with gentamicin and metronidazole.
5. If you encounter intestinal perforation (either iatrogenic
or pathological), gangrene or purulent infection, which results in either a
“contaminated” or “dirty” wound, when closing the abdomen suture the fascia and
peritoneum in a single layer, but leave the more superficial (subcutaneous and
skin) layers open and packed with saline-moistened gauze dressings, which
should be changed daily until the wound heals.
6. Re-explore promptly any
patient who deteriorates postoperatively.
Steven H. Untracht, M.D., Ph.D., F.A.C.S.
Johnstown, Pennsylvania, USA
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4. Meredith, Martin. The Fate of Africa: From the Hopes of
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