CAUSES AND TREATMENT OUTCOME OF NONTRAUMATIC ACUTE ABDOMEN

AMONG SURGICAL WARD ADMITTED PATIENTS IN GELEMSO ZONAL

HOSPITAL OROMIA NATIONAL REGIONAL STATE, ETHOPIA

Alebachew Bere, Tesfaye Gobena, H/Georges Feleke.

ABSTRUCT

Background: Surgical acute abdomen is commonly encountered condition both in developed and

developing nations. But its relative incidence varies among populations; Socio-economic status, age, sex

and residence are the factors for observed difference. Preoperative diagnosis, preoperative care and

timely, intervention of acute abdomen is crucial to minimize the morbidity and mortality especially

where the diagnostic facilities are limited.

Objective: To assess the causes and treatment outcome of non traumatic acute abdomen among patients

admitted to Gelemso zonal hospital between Nov15, 2008 to Nov15, 2013.

Methodology: This was a Five year retrospective study conducted on patients admitted in

Gelemso Zonal hospital. A total of 415 patients diagnosed with acute abdomen underwent emergency

laparotomy was included in this study. Samples taken from all patients admitted with non traumatic

acute abdomen. Data was collected with checklist. First descriptive statistics then logistic regression

analysis were used to measure association between the dependent and independent variables. For all

statistical tests P ≤ 0.05 was used as cut off point for statistical significance.

Results: A total 415 emergency laparotomy (72.7%) were male and (28.3%) were female. The mean

age of the patients was 31.17; range of 2-82 years and with male to female ratio of 2.6:1. Acute

appendicitis was the leading cause of acute abdomen accounts 53.7% followed by intestinal

obstruction (37.4%), (PPUD) (4.1%) and other (peritonitis 4.8%). There were 49 deaths giving an

overall mortality rate of 11.8%. A higher mortality rate was observed in patients who presented

late.

Conclusion: The study shows that acute abdomen i s a commonly encountered condition surgical

emergency procedure done in the department. Appendicitis found the leading cause of non traumatic

acute abdomen operated in the hospital. A significant number of patients had died of acute abdomen

with male to female mortality ratio of 1:1.13. The overall mortality rate of acute abdomen in this study

was 11.8% which was high and could be attributed by late presentation. Early diagnosis, adequate

resuscitation and timely intervention would help to reduce the observed mortality.

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Key word: Non traumatic acute Abdomen

INTRODUCTION

Acute abdomen is defined as a recent or sudden onset of abdominal pain that may or may not need

surgical intervention. It is a clinical condition characterized by severe abdominal pain, requiring the

clinician to make an urgent therapeutic decision, (Robin Smith et al, 2003). Abdominal pain is a

common presentation to emergency department (Dr.Marjan coal and Sina, 2009), or from surgical

point of view abdominal pain is the most cardinal symptom of acute abdomen (Mohamed Asif, 2008).

Abdominal Pain represents 5% of emergency room visits. Only 10% of these evaluations require

surgery. Acute abdomen accounts for 10% of malpractice claims (Laal, Marjan; Mardanloo, Amitta,

2009). Acute abdomen diagnosis is based on complete history taking, physical examination and

investigation tools including laboratory tests and radiological findings. The investigative modalities are

good guidance and helpful to confirm the diagnosis. For example, when suspicious to intestinal

obstruction, one can perform abdominal X-ray which would be a great help in diagnosis confirmation

or ultrasound guidance for the diagnosis of cholecystitis. A preoperative accurate diagnosis prevents

from negative laparotomy. Nowadays, despite availability of different diagnostic tools and progress in

new imaging methods like ultrasound (US) and computed tomography scanning (CT), correct pre-

operative diagnosis of acute abdomen still remains challenging (Laal, Marjan; Mardonloo, Armita,

2009).

The most common symptoms are abdominal pain and vomiting whereas tenderness and guarding are the

most frequent clinical signs (Sentayehu Tsegaye et at., 2006). The causes of acute abdomen are several

and their relative incidence varies in different populations. Several factors are described to be

responsible for these differences. Socio-economic factors and diet have mostly been incriminated to be

responsible for the observed differences (Birhanu Kotiso and Zeki Abdurrahman, 2006). In the

developed world acute abdomen is most common in age group 20 to 29 years with male predominance.

Acute appendicitis is the most common cause of surgical condition (Laal, Marjan; Mardonloo, Armita,

2009). On the other hand in several African countries the leading cause of acute abdomen was intestinal

obstruction. The leading cause of intestinal obstruction in Africans has mostly been hernia and volvulus

whereas adhesions are most frequent in the developed world. There is however some African studies

which are pointing to a change in these established patterns (Birhanu Kotiso and Zeki Abdurrahman,

2006). In Ethiopia, very little is known about the causes and the treatment outcome of non traumatic

acute abdomen. This study was conducted with the aim of assessing the causes, and treatment outcome

of non traumatic acute abdomen in Gelemso zonal hospital

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General objective

1. To assess the causes and treatment outcome of non traumatic acute abdomen among patients

admitted to Gelemso Zonal Hospital (GZH) between November15, 2008 to November 15, 2013.

Specific objectives

1. To assess the most frequent causes of non traumatic acute abdomen in Gelemso zonal hospital.

2. To determine the outcomes of non traumatic acute abdomen in Gelemso zonal hospital.

Study Area and Period

This study was conducted at Gelemso Zonal Hospital which is found 376 km East from Addis Ababa

and 270 km from Harar. The hospital is found in Chiro Zone at Habro district. The number of beds in the

hospital is 141. The study was covered five year hospital based retrospective study between Nov15,

2008 to Nov 15, 2013 and data was retrieved from the chart of the patients from Februray15, 2014 to

March 30, 2014. The Study population were all patients who admitted to surgical ward with diagnosis of

non traumatic acute abdomen and operated at GZH from Nov15, 2008 to Nov15, 2013.

Sample size determination

Sample size was calculated using the single population proportion technique based on the following

assumptions, estimated proportion (P) = (43.4%), Z=95%CI (1.96), d=5% and non respondent 10%=38.

So that total sample size (n) = 377+38=415

Sampling techniques

The study subjects’ charts were selected by systemic random sampling technique. The list of the patient

on the log book was used as sampling frame. Then from the total 910 patients, 415 patients’ chart were

selected, K=N/n, thus every other chart was selected. The first char was selected by lottery method.

Data Analysis and Interpretation

There were 415 patients diagnosed with acute abdomen underwent emergency laparotomy were

retrieved which formed the basis of this study. Data was processed by carrying out descriptive

statistical tests, like frequency, mean and range; then bivariate using crude odds ratio with 95%

confidence interval, cross-tabulation chi-square test and finally multivariate logistic regression model

used to determine the independent factors of the outcome variable. For all statistical tests P value < 0.05

was taken as a cut off point for statistical significance. Statistical tests were performed using SPSS

version 20.

Study variable

Dependent variable: Treatment outcome of non-traumatic acute abdomen (improved or death).

3

Independent variables: Age, sex, residence, awareness, underline diseases, cause of obstruction, duration

of illness, malnutrition or diet, skilled health personnel, X.ray, ultra sound and other

RESULTS

4.1 Socio-Demographic Characteristics of Respondents

A total 415 patients diagnosed with acute abdomen underwent emergency laparotomy was included in

this study from these 299 (72.7%) were male and 116(28.3%) were female. About 71.6% of patients in

this study found between 18 to 50 years old and mean age of the patients was 31.17, a range of 2-82

years and with male to female ratio of 2.6:1. Majority of patients 354(85.3%) came from rural area and

61(14.7%) came from urban.

Table 1. Socio-economic and demographic characteristics of study population in GZH, 2014 (n=415)

Characteristics Number Percent

Age Category by year

0 – <18 81 19.5

18– 50 297 71.6

>50 37 8.9

Sex

M 297 72.7F 116 28.3

ResidenceUrban 61 14.7

Rural 354 85.3

4.2. Clinical Features of Acute Abdomen

As indicated on Table 2, abdominal pain and vomiting were the most frequent symptoms (100% and

77% respectively) whereas tenderness and distention were the most frequent clinical signs (77.8%

and 53.5% respectively).

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Table 2. Clinical features of non traumatic acute abdomen in GZH, 2014

Clinical Feature and Frequency.

Symptoms Number % Signs Number %

Abdominal pain 415 100 Tenderness 323 77.8

Abdominal distention 212 51 A/distention 222 53.5

Vomiting 319 77 hypotension 203 48.9

Constipation 231 56 Empty rectum 123 29.6

Others 41 10 Other 64 15

As shown on Figure1, from total of 415 emergency operated, acute appendicitis was the most common

cause of acute abdomen 223(53.7%) followed by intentional obstruction 155(37.4%), perforated duodenal

ulcer 17(4.1%) and other 20 (4.8%). Acute appendicitis accounted for just over half of the cases

( 53.4%), of whom 153 (68.6%) were males and 70 (31.4%) were females (M: F =2.2:1) and the

mean age of the patient was 31.2 year

5

Percent

Figure 2: Causes of acute abdomen in GZH, 2014 (N=415)

The frequency and causes of intestinal obstruction are shown on table3; Small bowel obstruction due

to adhesion was the leading causes of intestinal obstruction 27% followed large bowel due to

sigmoid volvulus 26.5%, small bowel volvulus 21.9%. Intussusceptions 11%, ileo- sigmoid knotting

5.8% and hernia2.6%

Table 3.The frequency and causes of intestinal obs t ruc t ion in GZH 2014 (n=155)

Cause of intestinal obstruction Number of cases

NUMBER %

Large Intestinal

Obstruction .

Sigmoid volvulus 41 26.5

Ileo- sigmoid knotting 9 5.8

Caecal volvulus 8 5.2

Small

Intestinal

Obstruction

Adhesion 42 27

Volvulus 34 21.9

Intussusceptions * ( I-I, I-C, &I_S 17 11

Hernia 4 2.6

* Intussusceptions: I-I =Ileoilial, I-C =ileocolic and IS=ileosaecal

As indicated in the Table 4, patients whose age greater than fifty years were found the leading mortality

(27%). From a total of 49 deaths, 45 (12.7%) found in rural and only 4(6.6%) found in urban. The

mortality ratio of acute abdomen in this study was 11.8 with male to female ratio of 1:1.13.

Table 4: Mortality of non traumatic acute abdomen by age, sex and residence category in

GZH, 2014(n=415)

CharacteristicSurgical Outcome of acute Abdomen

TotalImproved Died Number % Number % Number %

Age <18 year 18-50year

>50year

Total

70 86.4

269 90.6

27 73

366 88.2

11 13.6

28 9.4

10 27

49 11.8

81 19.5

297 71.6

37 8.9

415 100

SexMaleFemale

265 88.6 101 87.1

34 11.415 12.9

299 72.1 116 27.9

Residence UrbanRural

57 93.4309 87.3

4 6.645 12.7

61 14.7354 85.3

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As indicated in Table 5 below, the leading causes of death were large intestinal obstruction 27.6%

followed by perforated duodenal ulcer (23.5%) peritonitis (20%), small bowel obstruction (18.6%) and

acute appendicitis (3.1%)

Table 5. The relationship between cause of acute abdomen and mortality GZH, 2014(n=415)

Diagnosis Died

Total cases

Intra -Operative Dx

Number %

Number

SBO 18 18.6 97

LBO 16 27.6 58

Appendicitis 7 3.1 223

PPUD 4 23.5 17

Other * 4 20 20

Total 49 11.8 415 * Peritonitis due typhoid & TB perforation.

As shown from Table, the commonest fatal cause of death was ileo- sigmoid knotting 55.6%, followed

by intussusceptions 47%; caecal volvulus 25%, sigmoid volvulus 22% and adhesion were

19.5%.There is no death observed intestine obstruction due to hernia.

Table 6. The frequency of causes of intestinal obs t ruc t ion and morta l i ty

Total cases (n)=155 Total died (34)

Cause of intestinal obstruction Number % Number % Large Bowel Obstruction due to n=58 (37.4%)

Sigmoid volvulus 41 70.7 9 22 Caecal Volvulus 8 13.8 2 25

Ileosigmoid knotting. 9 15.5 5 55.6 Small intestinal obstruction due to n=97(62.6)

Volvulus. 34 35 3 8.8

Adhesion 42 43.3 7 19.5

Intussusceptions * ( I-I, I-C, &I_S 17 17.5 8 47

Hernia

4 4.1 0 0

Intussusceptions: I-I =Ileoilial, I-C =ileocolic and IS=Ileocaecal

7

As shown from Table: patients presented to hospital early or within two days of illness found mortality

rate of 13 per 1,000, where as those presented late found mortality rate of 256 per 1,000 population.

Table7: The relationship between duration of illness and mortality in GZH, 2014(n=415)

Duration of illness All patients Patient died

Mortality

per 1000

<= 2 Days 236 3 13

> 2 Days 179 46 256

Total 415 49 118

As shown in the Table, There were 137(33%) cases that developed post operative complication.

Sepsis was the most fatal frequently identified post operative complication and cause of death 16 (55%)

followed by followed by aspiration pneumonia 5 (50%), Intra-abdominal abscess 17 (43.6) and

anastmosis leak 5(41%).

Table 8: The relationship between post operative complication and number of deaths in GZH,

2014 (n=137)

Complication observed Total cases by number

Died Number %

Intra-abdominal abscess 39 17 43.6

Sepsis 29 16 55.2

Surgical site infection (SSI) 23 3 13

Urinary tract infection (UTI 14 0 0.0

Anastmosis leak 12 5 41

Aspiration pneumonia/ARDS 10 5 50

Other 10 3 30

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Factors Associated with the Outcome of Acute Abdomen

Crude analysis was done by applying chi-square test to asses any association between age category, sex,

residence, patient referral and duration of illness, with outcome of acute abdomen. Among these

variables age category, residence and patient referral had no significantly associated with outcome of

acute abdomen (p-value>0.05); But duration of illness and cause of acute abdomen had significant

association with outcome of acute abdomen (p-value<0.05). Moreover; Multivariate analysis also show

duration of illness and cause or operative diagnosis had significantly associated with outcome of acute

abdomen but age category, sex, residence, and patient referral had no significant association with

outcome of acute abdomen.

Table9: Association of independent variables with dependent variable

Variables

Outcome of acute abdomen COR(95%CI AOR(95%CIDied Improved

Age <18 Year 11 70 1.00 1.00

18-50 Year 28 269 0.7(0.3,1.4) 0.5(0.1,1.7)

>50 Year 10 27 2.4(0.9, 6.2) 1.3(0.1,15.8)

Sex male 34 265 1.00 1.00

female 15 101 1.2(.0605,2.216) 1.3(0.59,2.9)

Duration of illness

<=2 days 3 233 1.00 1.00

2> days 46 133 26 (8.2, 88.05) 19(5.1,72.9)

Residence urban 4 57 1.00 1.00

rural 45 309 2.1(0.72, 6) 1.2(0.31,3.7)

Referral Has referral 21 100 1.00 1.00

Self referral 28 266 0.5(0.3,0.9) 0.6(0.27,1.2)

Operative Dx

Or cause of

acute abdomen

Appendicitis 7 216 1.00

SGV 9 32 8.7(3.0,24.9)

Caecalvolvulus 2 6 10.3(1.8,60.3)

SBV 3 31 3(0.73,12.2)

Adhesions 7 35 6(2.04,18.7)*

Intussusceptions 8 9 27(8,92)

ISK 5 4 38.6(8.75,157)

PPUD 4 13 9.5(2.5,36.6)

Typh/Peritonitis 4 10 12(3.1,49)

9

DISCUSSION

Acute abdomen morbidity is more common productive age groups, for instance in this study 297/415

(71.6%) were found productive age groups (18 to 50 years old) with male predominance which is similar

study done by (Marjan caal and Sina, 2009). Acute appendicitis was the leading cause of acute abdomen

more observed in males ( 67%), than females 34% and the majority of cases were in the 2 nd and 3rd

decade of life and mortality of male to female ratio nearly similar (M:F=1:1.13). This is differ the

study done in Tikur Anbesa hospital, Gonder university hospital and Pakistan in which male to female

ratio were 3.2: 1, 2:1 and 3.3: 1 respectively .This is different is due to males in the rural more decision

maker than females to attained hospital early but not true great city. Patients in this study presented

symptom and signs of abdominal pain, vomiting and tenderness 100%, 77% and77.8% respectively. This

is similar to the study done in Tikur Anbesa and Gonder University hospital in which abdominal pain,

vomiting and tenderness were most frequent symptom and signs (Sentayehu Tsegaye et al., 2006).

In this study the operative diagnosis or cause of acute abdomen and duration of illness were

found to be strongly associated with outcome of acute abdomen. Patients whose operative diagnosis

were sigmoid volvulus found 8.7 times more likely to died as compared acute appendicitis [AOR=8.7,

95%;CI; (3.0, 24.9)] and patients who came to hospital more than two days of illness were 19 times

more likely to died as compared to those patients who came within two days of onset [AOR =19,

95%;CI;( 5.1,72.91)] which agree the study done in Tikur Anbesa hospital (Birhanu kotiso and Zeki

Abdurrahman, 2006) .The reason for late presentation to the institution delivering the s u r g i c a l

treatment needs to b e studied further. The fact that majority (85.3%) of the patients had come out

of Gelemso and far from hospital encountered different problems either due to lack of transport or

little awareness. Moreover some patients (38%) who came outside Gelemso had visited different health

institution once or more may indicate lack of appropriate institution or surgeon to handle acute

abdominal problems which in turn might have played a role in the delay presentation. As the study

done in Nigeria shows delay in hospital was due to financial constraints in majority of cases (N.Mbah et

al., 2006).

Common things that occur commonly; the most common surgical cause of acute abdominal pain in

patients admitted anywhere in the world was acute appendicitis. My study also revealed that acute

appendicitis is the most common cause followed by intestinal obstruction due to adhesion and volvulus

accounts 27% and 26.5% respectively. This study is similar to the study done in Tikur Anbesa hospital

(Birhanu Kotiso and Zeki Abdurrahman, 2006), in Nazareth, central Ethiopia, (Ethiopian Medical

A s s o c i a t i o n (EMA),1998), in Nigeria by Ajao and Zaire by Okoro, 1981 and1987 respectively and

10

Laal Marjan; Mardanloo, Amita,2009 also International Journal of Collaborative Research on Internal

Medicine & Public Health (IJCRIMPH) shows similar results. . Thus acute appendicitis accounted for

just over half of the cases 223 (53.7%), of whom 153 (68.6%) were males and 70 (31.4%) were

females (M: F =2.2:1). The majority of the cases were in their second and third decades of life. A total

of 49 deaths, seven patients died of acute appendicitis.

The major cause of acute abdomen in this study based on residence of patients in urban acute appendicitis

(18.8%) followed by large intestinal obstruction due to sigmoid volvulus and Tuberculosis perforation

(17%) and 16.7% respectively .But in rural intestinal obstruction due to small volvulus and sigmoid

volvulus and acute appendicitis were 94%, 83%, and 81.2 % respectively. These differences due to the

causes of acute abdomen relative incidence vary in different populations at different places. As the study

done in Tikur Anbesa hospital shows socio-economic factors and diet has mostly been incriminated to be

responsible for observed difference (Birhanu Kotiso and Zeki Abidurhaman, 2006). Sigmoid volvulus

was the leading cause of colonic obstruction 41/58 (70.7%); from this 13.8% & 86.2% were found

urban and rural respectively. Adhesions were the most frequent cause of small intestinal obstruction

42/97(43.3), from this 85.7% rural and urban only14.3% and the second cause of small intestinal

obstruction is small bowel volvulus 34(35%).These study similar to Gonder University hospital

(Sentayehu Tsegaye et al., 2006). But in Uganda and Rwanda the leading cause of intestinal obstruction

was hernia which accounts 40.2% and 39% respectively G.Ntakiyiruta and B.Mukarugwiro, 2009. This

variation is due to populations Socio-economic status and diet was incriminated. In general leading cause

of intestinal obstruction adhesion 42/155 (27%) followed by sigmoid volvulus 41/155 (26.4%). It is also

similar in different studies in Africa as it shows sigmoid volvulus is a common cause of intestinal

obstruction (Sentayehu Tsegaye, 2006; Mohamed Kedir Ali, 1998; T.R.Okello et al., 2009). For instance

in Sudan 33%, in Zimbabwe 31%, and in Nigeria 39 %( Roberto Cirocchi et al., 2010).

The leading fatal cause of acute abdomen in this study was obstruction due to ileo-sigmoid knotting; its

mortality rate was found 55%. This is much higher than Tanzania, West Tanzania and Malawi in which

its mortality ratio were 10.7%, 29.8%, and 33% respectively. This difference is due to late presentation

and pattern of obstruction or cause of obstruction brings higher mortality.

In general leading mortality rate of acute abdomen was large bowel obstruction 27.6%, followed by

duodenal perforation, peritonitis and small intestine obstruction account 23.5%, 20% and

18.6%respectively. This result is similar by order or rank but differs by magnitude study done in Tikur

Ambesa hospital (Birhanu Kotiso and Zeki Abidurhaman, 2006) that 35.2%, 28.5%, 22.2% and 21.5%

respectively. In this study there is no perforated duodenal ulcer as well as death associated to peptic ulcer

disease in the urban; because patients in the urban has good health seeking behavior and early Dx and

triple therapy at this moment can prevent morbidity and mortality associated to peptic ulcer disease.

11

In this series study the mortality of patients with acute abdomen treated surgically was 11.8% which

higher than Gonder university hospital (9.3%), but good outcome compared other study done in Africa

by Datubo, Zelalem and; Birhanu Kotiso and Zeki Abdurhaman, 2006) (13.3%), (13.5%) and 14%

respectively. The difference is due to significant increase of health seeking behavior of the patient,

increase referral system and Proper management of surgical patients at the community.

CONCLUSION AND RECOMMENDATION

Acute appendicitis and intentional obstruction were the common cause of non traumatic

acute abdomen in the hospital. A significant number of patients had died of acute

abdomen. The morbidity and mortality of acute abdomen high in rural than urban and

higher mortality ratio of acute abdomen was observed in patients who presented late and

who had rural residency. The overall mortality rate of acute abdomen in this study was

11.8%. Early diagnosis, adequate preoperative resuscitation and proper post operative care

would help to reduce the observed mortality.

Recommendations

Improving the knowledge of mid and lower level health professionals on the diagnosis,

resuscitation and importance of early referral to higher center. Health education or health promotion

must address in the community to increasing public awareness on clinical features of acute abdomen

moreover health officials and health care providers must give special attention about patient referral

system and should be strengthened surgical services.

ACKNOWLEDGMENTS

I would like to acknowledge:

Haramaya University

My advisors, Tesfaye Gobena (MPHM, PhD) and H/Georges Feleke (MD, General

Surgeon

Redwan (MD), Gynecologist and MIES coordinator

Gelemso hospital Administrative and Surgical staffs

12

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