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Ileus and Intestinal Obstruction - Comparison Between Children and Adults

Article  in  Polish Journal of Surgery · July 2011

DOI: 10.2478/v10035-011-0058-9 · Source: PubMed

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POLSKI
PRZEGLĄD CHIRURGICZNY 10.2478/v10035-011-0058-9
2011, 83, 7, 367–371

Ileus and intestinal obstruction – comparison between

children and adults

Mehran Peyvasteh1, Shahnam Askarpour1, Hazhir Javaherizadeh2,

Somaieh Taghizadeh1
Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahwaz, Iran1
Arvand International Division , Ahvaz Jundishapur University of Medical Sciences2

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 findings 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 filled. 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 Hirschsprung’s 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 children’s 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 finding 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 neoplasm (4). Large intestinal obstruction

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
(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-
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
identification 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 findings 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 filled 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
filled for each patient. Laboratory findings
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 significantly more seen in
adults than children (p<0.05). Ileus, intus-
susceptions, diverticulitis, Hirschsprung’s
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 Dorośli / Adults

p / p-value
(n=192) (n=211)
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
 Ileus and intestinal obstruction – comparison between children and adults 369

Table 2. Frequency of hospital staying in patients with

Discussion
intestinal obstruction

Children Adults In our study, of all 403 cases, 261(64.76%)

p-value
(n=192) (n=211) were males. Of 192 children cases and 211
<5 days 32 (16,66%) 44 (20,85%) p=0,28 adult cases, 119 (61.97%) cases and 142
5-10 days 112 (58,33%) 111 (52,60%) p=0,24 (67.29%) cases were males respectively.
10-15 days 37 (19,27%) 37 (17,53%) p=0,65 Male constitute 74% and female 26% of
>15 days 11 (5,72%) 19 (9%) p=0,21 intestinal obstruction in Malik et al. study
and similar to our study (8). In adult cases,
partial obstruction (29.85%), adhesion band
Anemia was more common in children than (18.48%), and ileus (18.95%) were the most
adults while polycythemia was more common common causes of bowel obstruction. Marko-
in adults. WBC<10000 was more common in giannakis et al., reported adhesions (64.8%)
adults than children (p=0.03) (tab. 3). were the most common causes of intestinal
Hyponatremia was most frequently seen in obstruction among adult cases (9). Adhe-
children (p=0.04). Azotemia and normal bio- sions, incarcerated hernias, and large bowel
chemical findings were significantly common cancer constitutes the most frequent causes
in adult cases compared to children (p<0.05) of bowel obstruction (10). This difference
(tab. 4). between the current study and other studies
Colonoscopy, endoscopy, and abdominal may be due to partial obstruction in our
X-ray (supine and upright) were more fre- study.
quently used in adults than children (p<0.05). Ileus (26.04%), adhesion bands (17.70%),
There is no significant difference between partial obstruction (16.64%), and Hirschs­
children and adults regarding use of sonogra- prung (11.45%) were the most common etiol-
phy, upper GI series, and barium enema ogy of children intestinal obstruction in our
(tab. 5). study. Ogundoin et al., reviewed etiology of
intestinal obstruction in 130 cases. Major
causes of intestinal obstruction were intus-
Table 3. CBC changes in patients with intestinal susceptions (29.23%), anorectal malforma-
obstruction tions (22.31%), obstructed inguinoscrotal
Children Adults
hernia (16.92%) and Hirschsprung’s disease
CBC changes p-value (13.85%) (11).
(n=192) (n=211)
WBC <10 000 74 104 p=0,03* A number of recent studies, have found
(38,54%) (49,28%) adhesive obstruction to be replacing obstruc-
WBC 10 000–15 000 87 83 p=0,22 tive hernias as the most common cause (8, 12,
(45,31%) (39,33%) 13).
WBC >15 000 31 24 p=0,16
(16,14%) (11,37%)
Anemia 67 53 p=0,03*
(34,89%) (25,11%)
Polycythemia 15 (7,81%) 31 p=0,03* Table 5. Radiologic procedures performed in patients
(14,69%)
Children Adults
Procedure p-value
(n=192) (n=211)
Abdominal X-ray 176 211 <0,001
Table 4. Biochemical findings in the bowel obstruction (supine) (93,61%) (100%)
Abdominal X-ray 99 211 <0,001
Children Adults (upright) (52,65%) (100%)
p-value
(n=192) (n=211)
Upper gi series 14 (7,44%) 8 (3,79%) 0,122
Hypoglycemia 10 (5,20%) 4 (1,89%) p=0,06
Barium enema 20 22 0,990
Hyperglycemia 7 (3,64%) 15 (5,68%) p=0,33 (10,63%) (10,42%)
Hyponatremia 23 (11,97%) 13 (6,16%) p=0,04* Colonoscopy 0 35 <0,001
Hypernatremia 3 (1,56%) 2 (0,94%) p=0,9 (16,58%)
Hypokalemia 71 (36,97%) 97 (45,97%) p=0,06 Endoscopy 0 21 <0,001
Hyperkalemia 8 (4,16%) 4 (1,89%) p=0,18 (11,17%)
Azotemia 10 (5,20%) 32 (15,16%) p=0,001* Sonography 155 159 0,089
Normal 94 (26,04%) 89 (42,18%) p=0,0006* (82,44%) (75,35%)
370 M. Peyvasteh et al.
In the current study no cases of intussucep-
tion were seen in adults. In the Croome’s 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 6th cause of intestinal obstruc-
tion in adults and 7th in children. the current
study. In the study which carried out by Moon
et al., hernia was reported as the 3rd 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). Kőssi
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 indentified 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 1st year
of life (25). So, malrotation in unusuall findings
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 children’s 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.
 Ileus and intestinal obstruction – comparison between children and adults
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