PATTERN OF SURGICAL ABDOMINAL

EMERGENCY IN CHILDREN: UNIVERSITY OF

ILORIN TEACHING HOSPITAL EXPERIENCE

DR. ABDUR-RAHMAN, LUKMAN OLAJIDE

M.B., B.S., ILORIN

A Dissertation submitted to the National Postgraduate

Medical College of Nigeria in part fulfillment of the

requirement for the award of the final Fellowship of the

Medical College in surgery.

FMCS

MAY 2012

ii

PATTERN OF SURGICAL ABDOMINAL

EMERGENCY IN CHILDREN: UNIVERSITY OF

ILORIN TEACHING HOSPITAL EXPERIENCE

DR. ABDUR-RAHMAN, LUKMAN OLAJIDE

M.B., B.S., ILORIN

SUPERVISORS:

1. Prof. O. Adejuyigbe, M.B.,B.S. (Ibadan), FMCS,

FWACS

Professor of Paediatric surgery and

Consultant Paediatric surgeon

2. Dr. J. O. Adeniran, M.B.,B.S. (Ibadan), FRCS, FWACS,

FICS, Dip.(paed. Surg.)

Lecturer/Consultant Paediatric Surgeon

iii

DECLARATION PAGE

It is hereby declared that this work is original unless otherwise

acknowledged. The work has not been presented to any college for a

fellowship nor has it been submitted elsewhere for publication.

…………………………………………….

Dr. Abdur-Rahman, Lukman Olajide

iv

ATTESTATION

We certify that Dr. Abdur-Rahman, Lukman Olajide carried out

this work while in training as a resident in the Paediatric Surgery Unit

of the Department of Surgery, University of Ilorin Teaching Hospital,

Ilorin.

Prof. O. Adejuyigbe

MBBS (Ibadan), FMCS, FWACS

Professor of Paediatric Surgery and Consultant Paediatric Surgeon

Paediatric Surgery Unit,

Department of Surgery

Obafemi Awolowo University Teaching Hospitals Complex,

Ile-Ife

………………………………….

SIGNATURE

Dr. J.O. Adeniran

MBBS (Ibadan), FWACS, FRCS, Dip. (Paed. Surg.)

Lecturer/Consultant Paediatric Surgeon

Paediatric Surgery Unit,

Department of Surgery

University of Ilorin Teaching Hospital

Ilorin

…………………………………….

SIGNATURE

v

TABLE OF CONTENTS

page

Title page i

Declaration iii

Attestation iv

Contents v

Dedication vii

Acknowledgement viii

List of tables x

List of figures xi

Summary xii

Chapter One:

(I) Introduction 1

(II) Objectives 4

Chapter Two:

(I) Literature review 5 - 18

♦ Introduction

♦Embryology and Anatomy of abdominal viscera

♦ Significance of acute abdomen

♦ Pathophysiology of abdominal pain

♦ Aetiological causes

Chapter Three: Patients & methods 19

vi

Chapter Four: Results 24

Chapter Five: Discussion 47

Chapter Six: Conclusion/ Recommendation 61

References 63

Appendix I- Ethics committee approval 71

Appendix II- Protocol 72

vii

DEDICATION

This dissertation is dedicated to one God of all children who are

subjected to surgical operations because of acute abdominal

conditions.

To my parents, Alhaji Abdur-Rahman Ajani and Alhaja

Shuaibat Akanke Salaudeen for their encouragement and sacrifice.

To my wife, Aolat, Bolanle, Abeke for her patience,

understanding and support.

To my daughters, Musharafat, Ayomide, Olabisi and Muhsinat,

Ayomikun, Bukola for their love.

viii

ACKNOWLEDGEMENT

I wish to acknowledge the detailed but prompt support and

guidance by my supervisors: Prof. O. Adejuyigbe, a talented surgeon,

a great teacher and a diligent trainer. Dr. J. O. Adeniran, an inspirer

who believed in me and supported my training in paediatric surgery.

Dr. S. A. Kuranga, CMD and Dr. A. L. Babata, Head of Surgery,

UITH- ILORIN both of whom encouraged me during my training.

Dr. A. G. Abdul-Rahman, consultant surgeon, UITH- ILORIN

deserves a special thanks for his advice, and meticulous perusal of

this work. His useful comments are very much appreciated.

I also thank the following people for their advice and

encouragement at different times: Dr. A. M. Abubakar, Consultant

Paediatric Surgeon, UMTH- MAIDUGURI, Dr. Abdul-Raheem,

Consultant Epidemiologist, UITH- ILORIN, Dr. I. A. Adigun,

Consultant Plastic Surgeon, UITH- ILORIN, Dr. B. A. Solagberu,

Consultant Orthopaedic and Trauma Surgeon, UITH- ILORIN, Dr. A.

O. Sowande, Consultant Paediatric Surgeon, and Dr. A. A. Onayade,

Consultant Epidemiologist both of OAUTHC- ILE-IFE.

My wonderful friends and colleagues in residency training at

UITH-ILORIN, OAUTHC-ILE –IFE, and UNTH- ENUGU are all

appreciated. May Almighty Allah reward my Muslim brothers and

sisters in these various community for their prayers.

ix

My parents and parent- in –law, my wife and daughter, and

my nephews Abdul-Majeed and Lukman are acknowledge for

their constant support and prayers.

My gratitude goes to Latrah Nigeria Enterprises for the

secretariat work.

The parents of and the patients who participated in this

study also deserve my appreciation.

x

LIST OF TABLES

TABLE A Structures that develop from the three regions of the gut

TABLE B Vascular supply and innervation of the regions

of the gut TABLE C Causes of acute abdominal pain TABLE D Age group and causes of acute abdomen TABLE 1 Age and sex distribution among paediatric

surgical abdominal emergencies TABLE 2 Age and causal factors in paediatric surgical

abdominal emergencies TABLE 3 Age groups and causal factors in mechanical

intestinal obstruction TABLE 4 Causal factors and interval before presentation TABLE 5 Pattern and management of appendicitis TABLE 6 Pattern and management of perforated typhoid

enteritis TABLE 7 Pattern and management of abdominal trauma TABLE 8 Summary of Anorectal malformation TABLE 9 Pattern and management of intussusception TABLE 10 Summary of other causes of mechanical

intestinal obstruction TABLE 11 Morbidity and mortality pattern among causal

factors of paediatric surgical abdominal emergencies.

xi

LIST OF FIGURES

FIGURE 1 Proportion of paediatric surgical abdominal emergencies causal factors.

FIGURE 2 Single perforation in terminal ileum in typhoid enteritis

FIGURE 3 Anorectal malformations in a male child FIGURE 4 Anal vents in one stage posterior sagittal

anorectoplasty FIGURE 5 Ileocolic intussusception brought out of

laparotomy wound

xii

SUMMARY

The study was carried out to determine the pattern of Paediatric

Surgical Abdominal Emergencies (PSAE) at the University of Ilorin

Teaching Hospital. It was a prospective study of all children aged

12years and below presenting to the paediatric surgical unit,

Department of surgery, between 1st of October 2002, and 31st

December, 2003.

Paediatric Surgical Abdominal Emergencies (PSAE) occurred

in 3.4% of all paediatric admissions during this period. Male to female

ratio was 2.5: 1. Forty (40%) of PSAE occurred most commonly

during late childhood (7yr – 12yrs), followed by 21% in neonatal

period (< 1mth) and 20% in infancy (1month to 12month).

Mechanical intestinal obstruction was the most common cause

of PSAE accounting for 44% of cases, followed by peritonitis caused

by typhoid perforation in 22% of cases. Other causes were acute

appendicitis in 15%, abdominal trauma, 7%, infantile hypertrophic

pyloric stenosis, 3% and miscellaneous group in 9%of cases.

Mortality recorded in this study was mainly due to septicaemia

and multiple organ failure.

Educating parents and guardians on the availability and safety

of surgical care in children will encourage early presentation and

reduce complications and mortality. Health care providers must

recognize their limits and refer cases early to specialist pediatric

xiii

surgeons. Government should enact laws that will cater for the rights

of children and should also fund pediatric surgical care facilities.

1

CHAPTER ONE

INTRODUCTION

Acute abdominal pain poses a diagnostic challenge to the

surgeon, internist, family practitioner, obstetrician and gynecologist,

and pediatrician1,2. The complexity of the possible causes of the

symptoms is such that a careful, methodical approach is necessary in

order to arrive at correct diagnosis, especially in children, who are

unable to explain the nature of their symptoms and may be

uncooperative during physical examination3. Sometimes the decision

to operate or not is obvious but on occasions the decision can be

difficult and fraught with pitfalls.

Surgical abdominal emergencies account for between 2.4%

and 3.1% of all pediatric admissions 4,5. Otu6, Adesola7 and Dewulf8

reported at different times about three decades ago that intestinal

obstruction due to various causes accounted for the highest cause of

acute surgical abdominal emergencies seen in Calabar, Lagos and

Kigali respectively. However, Ajao9, in Ibadan reported that acute

appendicitis was the leading cause of surgical abdominal

emergencies. None of these reports, dealt with surgical abdominal

emergency as it affects the pediatric age group. Recently, Abubakar10

reported that intestinal obstruction was the commonest cause of

surgical abdominal emergencies seen in children in Ilorin. This study

is fraught with defects characteristic of retrospective studies.

2

Delay in seeking medical treatment is generally accepted as

the major factor responsible for the high morbidity and mortality seen

in surgical abdominal emergencies in many centers3-5. Parents and

relations delay the presentation of their wards to the hospital due to

ignorance, over reliance on alternative traditional treatment and visit

to quacks. These patients later present at the hospital in debilitated

state and often require considerable period of assiduous resuscitation

before they could be stabilized for surgical intervention. To compound

the problems, parents and relations usually arrive at the emergency

room with little or no funds on them having spent so much where they

were coming from. This further delays surgical intervention.

Facilities for modern care are grossly inadequate or non –

existent in vast areas of the African continent11,12. In some situations

the doctor must share the responsibility for the poor results of

treatment because of a lack of policy for the management of the

patients, delay in arriving at the diagnosis and in resuscitation as well

as in taking a decision7.

Rapid and accurate diagnosis of acute surgical abdominal

conditions in neonates and young children is very important and any

delay in treatment results in higher rates of morbidity, mortality and

hospital costs3. To prevent these, close cooperation among paediatric

surgeons, paediatricians, laboratory and radiology departments is of

considerable benefit.

3

There is a need for proper documentation of the incidence and

pattern of distribution of causes of surgical acute abdominal

emergencies in children in our environment. There is also the need to

identify the factors influencing the outcome of surgical management

of these children. This study was embarked upon in an attempt to

define the pattern of PSAE at the UITH, Ilorin. It is hoped that the

result will assist in the planning of surgical services to prevent the

high morbidity and mortality associated with acute surgical abdominal

conditions in children at the University of Ilorin Teaching Hospital,

Ilorin.

4

(II) Objectives

1. To determine the incidence of causes of surgical abdominal

emergency conditions in children managed in UITH, Ilorin.

2. To determine factors influencing the outcome of management

of the surgical abdominal emergency in children at UITH, Ilorin

3. To determine the common complications that follows operation

on children with surgical abdominal emergency in UITH, Ilorin.

5

CHAPTER TWO

LITERATURE REVIEW

Introduction

Acute pathologic conditions of the abdomen have been

recognized since Hippocratic era and referred to by Paracelsus (1493

– 1541) and Sydenham (1624 – 1689) as iliac passion1. Acute

diseases within the abdomen are common and many children with

abdominal symptoms present everyday to doctors working in their

community. Some patients will complain of acute abdominal

symptoms after an accident. Many causes of acute abdominal pain

will require surgical operations for their definitive treatment and relief

of the pain. Due to the suddenness and unpredictability of

presentation majority of these causes are seen as surgical

emergencies.

By definition, acute abdomen is an illness that starts suddenly

with severe pain and often requires surgical intervention. It is a

condition that requires fairly immediate judgment or decision as to

management. Making a definitive diagnosis is much less important

than making the right decision2,3. In the majority of patients symptoms

arise from diseases within the abdominal cavity itself, but occasionally

they originate elsewhere in the body3. Accurate recording of the

relevant facts is vital and a clear understanding of the anatomy and

6

pathophysiology of intra-abdominal diseases is necessary for both

diagnosis and treatment1,2.

Embryology and Anatomy as related to the Gastrointestinal

system.

A good knowledge of normal and abnormal embryology and

particularly, surface anatomy of abdominal viscera is essential for

proper evaluation of abdominal pathologies. Variations within and

between individuals are obvious but normal anatomy also changes

with age, posture, respiratory disease and previous surgery13,14.

The intestine and all its associated organs such as the liver and the

pancreas develop initially as midline structures, TABLE A. Thus,

visceral pain is usually felt along the midline of the abdomen as

epigastric, para-umbilical and hypogastric pain according to the origin

of nerve supply.

The gut also has a segmental origin so that the division into foregut,

midgut and hindgut exactly correlates with the vascular supply from

the celiac trunk, superior mesenteric and inferior mesenteric arteries

respectively14, TABLE B.

7

Table A: Structures that develop from the three regions

Foregut- esophagus, stomach to the proximal duodenum (including liver gallbladder and

head of the pancrease

Midgut – distal duodenum (from Ampulla of Vater), body and tail of pancreas, jejunum and

ileum to proximal 2/3 (two –third) of transverse colon, hepatobiliary system.

Hindgut – distal third (1/3) of transverse colon to upper anal canal, bladder.

Modified from Langman’s Medical Embryology

Table B:Vascular supply and innervation of the regions

Regions Vascular supply Innervation

Foregut Coeliac trunk Splanchnic nerve and

paravertebral ganglia via

celiac plexus (T 7-9)

Midgut Superior mesenteric

artery

Splanchnic nerve

Hind gut Inferior mesenteric

Artery

S2 – 4 (sacral

parasympathetic nerve)

Kidney & upper Ureter Renal artery T10 –L1 (splanchnic nerve

via renal plexus)

Bladder, prostate, cervix vesical via internal iliac S2 – 4 (sacral

parasympathetic nerve via

superior hypogastric plexus

Uterine uterine via internal iliac T 12 (hypogastric plexus

and presacral nerve

Ovaries ovarian artery T 10 (sympathetic N. of

ovarian artery

Modified from Langman’s Medical Embryology

The visceral peritoneum is derived from the splanchnopleural layer

and shares its blood supply, innervations, and lymphatic drainage

with the organ it envelops15, 16. The parietal peritoneum arises from

the somatopleural layer and shares a common blood supply,

innervations, and lymphatic drainage with the somatic elements of the

8

abdominal wall15, 16. Pain receptors (nociceptors) are located in the

skin, abdominal wall (muscle and parietal peritoneum) and visceral

peritoneum. Pain receptors of abdominal visceral are located in the

subserosa, muscular layers, and submucosa of hollow viscera, and

within the capsule of solid organs15.

Significance of Acute Abdomen

Abdominal pain is one of the three most common presentations for

patients seen in the emergency room or admitted to the hospital2. As

many as 40% of patients seen in the emergency room with acute

abdominal pain are discharged with a diagnosis of abdominal pain of

unknown etiology17. The percentage agreement between admission

and diagnosis of abdominal pain in Ibadan was 51.3%18. Acute

abdominal condition necessitating surgical relief accounted for 261

(2.4%) of 10,840 and 410 (3.2%) of 13,038 of pediatric admissions as

reported by Adejuyigbe4 in Ile- Ife and Taiwo5 in Ibadan respectively.

Although, there are isolated reports on the various disease

entities causing surgical acute abdomen from different regions of the

country 4-9, 12, 19- 21, there have been no comprehensive study on the

clinical pattern of causes of acute abdomen in Nigerian children.

de Dombal2, in 1991 reported that acute abdomen in 9 of 10 children

is caused by acute appendicitis (32%) or non-specific abdominal pain

(62%) in the developed world with urinary tract infection,

intussusception and other causes accounting for 2%, 1%, and 3% of

9

causes respectively. In the tropics infestation with worms is a

significant cause of abdominal colic and sometimes, intestinal

obstruction2. Also pains and tenderness in the right upper quadrant

are likely to be caused by amoebic hepatitis with a liver abscess other

than acute cholecystitis2, 9. Majority of the workers on acute abdominal

emergencies have reported late presentation of patients as a cause

of significant postoperative morbidity and mortality4-7.

Pathophysiology of Abdominal Pain

The sense organs for pain are the naked nerve endings found

in almost every tissue of the body. Pain impulses are transmitted to

the central nervous system (CNS) via the spinothalamic tract by two

fibers. The Aδ fibers are small (2 - 5μm in diameter) and myelinated,

conduct at rates of 12-30 m/ sec. These fast fibers conduct “bright”,

sharp and localized sensation of painful stimulus. The second system

consists of unmyelinated C fibers, (0.4-1.2μm in diameter) which

conduct at a rate of 0.5-2m/ sec. The sensation is aching, diffuse,

associated with unpleasant feeling. Both fiber groups end on the

lateral spinothalamic tract neurons, and pain impulses ascend via this

tract to the ventral posteromedial and posterolateral nuclei of the

thalamus, from there, they relay to the postcentral gyri of the cerebral

cortex22.

Since pain is the classical feature of acute abdomen,

abdominal pain has three components: 1) visceral pain, 2) somatic

10

pain, 3) referred pain2, 13, 15. Accurate assessment of the source of

abdominal pain requires the distinction between these three types of

pain15.

Visceral pain from the abdominal structures can be transmitted

over sympathetic, parasympathetic and/ or somatic pathways

resulting in variability in quality and character of symptoms

presentation1. Visceral pain is gradual in onset, diffuse and poorly

localized15. It has long been recognized that visceral organs can be

cut, crushed, or burned with little sensation23. Stimuli to visceral

nociceptors include increased tension in the wall of hollow organs

from: 1) strong contraction or spasm, 2) sudden distention against

resistance, 3) stretching of encapsulated solid organs, 4) traction of

the mesentery. Ischaemia, inflammation and chemical irritation may

also stimulate these receptors1, 15. The autonomic response to

visceral pain often presents as deep pain and may include sweating,

nausea and low blood pressure1.

Somatic pain is typically accurately localized to the abdominal

wall and is accompanied by a reflex contraction of the abdominal wall

muscle except in pelvic inflammation where the somatic nerve supply

does not supply the anterior abdominal wall muscles1. (Table 2)

Somatic pain arises from disruption, crushing, irritation, or

inflammation of the abdominal wall, parietal peritoneum, root of the

mesentery, or diaphragm15, 23.

11

Referred pain is sensed at a distance from the source. It occurs

as a result of the convergence of many primary, posterior root fibers

on only a few secondary fibres within the spinothalamic tract15.

The newborn babies have well developed neuro-anatomical

pathways for the transmission of noxious stimuli24. However, pain

assessment in neonates is difficult and distinguishing clinically

between the response to pain and the the response to hunger is not

easy25.

Aetiological causes of Acute Abdomen

The causes of acute abdomen are multiple, multifaceted and

cut across many specialties in medical practice. These could be

classified broadly based on organ sub-systems or pathogenesis and

are summarized in table C. The most common causes of acute

abdominal pain in the gastro-intestinal subsystems relate to an

inflammatory or mechanical processes1, 23.

12

TABLE C: Causes of acute abdominal pain (adapted from Harrison’s

Principle of Internal Medicine 15th edition. Manifestation and presentation of diseases)

A. PAIN ORIGINATING IN THE ABDOMEN

1. Parietal peritoneal inflammation

a. Bacterial contamination e.g. perforated appendix, perforated

typhoid, pelvic inflammatory disease.

b. Chemical irritation, e.g. perforated ulcer, pancreatitis,

mittelsmerz

2. Mechanical obstruction of hollow viscera

a. Obstruction of small and large intestine

b. Obstruction of the biliary tree

c. Obstruction of the ureter

3. Vascular disturbances

a. Embolism or thrombosis

b. Vascular rupture

c. Pressure or torsion occlusion

d. Sickle cell anemia

4. Abdominal wall

a. Distortion or traction of mesentery

b. Trauma or infection of muscles

5. Distention of visceral surfaces, e.g. hepatic or renal capsules

13

B. PAIN REFERRED FROM EXTRAABDOMINAL SOURCE

1. Thorax, e.g. pneumonia

2. Spine, e.g. radiculitis from arthritis

3. Genitalia, e.g. torsion of the testicle

C. METABOLIC CAUSES

1. Exogenous

a. Black widow spider bite

b. Lead poisoning and others

2. Endogenous

a. Uraemia

b. Diabetic ketoacidosis

c. Porphyria

d. Allergic factors (C’1 esterase inhibitor deficiency)

D. NEUROGENIC CAUSES

1. Organic

a. Tabes dorsalis

a. Herpes zoster

b. Causalgia and others

2. Functional

In children, the age and sex of the patient will provide a helpful

lead to the cause of “hot belly” as outlined below15:

14

Table D : Age-group and Causes

AGE CAUSES

Newborn Mostly congenital anomalies e.g.

duodenal atresia, Imperforate

anus, malrotation, midgut

volvulus.

Neonates Infantile hypertrophic

pyloric stenosis,Hirschsprung’s

disease, hernia

Late infancy Intussusception, Meckel

diverticulum

Childhood and adolescents Incarcerated hernia, appendicitis,

cholecystitis,Post-operative

Adhesive small bowel obstruction

Other medical conditions as listed in table C and especially,

mesenteric adenitis in children can perplex the physician during

diagnosis of acute abdominal conditions 26, 27.

Surana et al 28 observed that establishing a diagnosis may be

difficult because of communication difficulties and atypical

presentations in younger children. The approach to the patient

depends largely on the age. There is usually paucity of historic data in

the very young and often, young parents are not as perceptive as the

grand parents in detailing accurate history of the young child’s

15

symptoms. Moreover, children may be placed in daycare centers and

a detailed history may actually be unknown to the parents. Physical

examination then becomes the anchor in such circumstances but this

can prove to be difficult in a frightened and apprehensive child.

Children and parents consulting a hospital doctor are usually

concerned, anxious and worried, especially when faced with an

emergency situation where the nature of the problem is uncertain.

Patience, tact and confidence on the part of the doctor will yield the

best results28.

A thorough physical examination has been found to provide

essential ingredient for making the diagnosis, determining the

urgency of the condition, assessing the patient as an operative risk,

and making a sound management plan15, 29, 30.

Normal physiology is rapidly disrupted by the onset of acute

intra-abdominal disease. Many patients vomit, and gastrointestinal

secretion, absorption and motility all change in the presence of

obstruction, luminal infection, or peritonitis. Urine is reduced in

volume and altered in content, usually secondary to redistribution of

fluid in the body compartments and sometimes because of a direct

toxic effect on the kidneys.

Atwell 31, in 1971 classified the classical signs and symptoms of

intestinal obstruction into primary, which include abdominal pain,

vomiting and absolute constipation, or secondary, such as

16

dehydration, loss of weight, biochemical imbalance, distension, visible

peristalsis, increased bowel sounds and tenderness due to

perforation of the bowel. Several special signs are helpful in patients

with acute abdomen 32-34, such as Rovsing’s, Psoas and obturator

signs in acute appendicitis and Murphy’s sign in acute cholecystitis.

The urgency of acute abdominal conditions usually precludes

cumbersome investigations35. There are only a few specific tests or

examinations, which may be relied upon to give clear-cut answers to

the exact cause of the acute condition. Hence, the elucidation of

many of the causes of acute abdominal pain is clinical. However, the

intelligent use of laboratory studies can provide valuable clues to the

correct diagnosis1, 3. Serum electrolytes (especially sodium and

potassium) and urea derangements occur early in patients with

severe vomiting or patients with third space loss 36, 37. Rapid and

accurate definitive diagnosis of sickle cell disease can be achieved by

hemoglobin electrophoresis, 26, 38 which will assist in differentiating a

vaso-occlusive from other causes of acute abdomen.

Following the history and physical examination, plain film

radiographs have traditionally been one of the first and most useful

methods of further investigation especially in intestinal obstruction

and perforation of the viscus. Radiological diagnosis depends on gas

pattern in or outside the bowel35. Interpretation of plain films in the

acute abdomen may present a formidable challenge to the radiologist

17

for; while in many cases a specific diagnosis can be made, not

infrequently the appearance are non-specific or even positively

misleading and further investigations using contrast media,

ultrasound, radionuclide CT or MRI may be required39. Abdominal

radiographs may demonstrate dilated bowel loops, air-fluid levels in

intestinal obstruction, calcified gallstones in calculus cholecystitis or

the presence of free air under the diaphragm as seen in 50-70% of

cases of perforated typhoid or perforated duodenal ulcer35, 39.

Abdominal ultrasound is a very useful non-invasive imaging

technique, which assists in demonstrating collections, masses and

delineation of hepatobiliary, renal and tubo-ovarian pathologies1, 2, 36,

39, 40.

All patients with acute abdomen need proper assessment and

simultaneous supportive treatment36, which includes resuscitation with

intravenous fluid to correct fluid and electrolyte imbalance and ensure

normal hemodynamic status37. Except in a case of severe prostrating

pain, narcotic analgesic is not advised until a diagnosis is established

to prevent masking of important clinical features. In acute infective

conditions empirical broad-spectrum antibiotics should be

commenced after obtaining a blood culture sample and when a

diagnosis is fairly well established.

The surgical procedure carried out would depend on the

diagnosis, clinical state of the patient and the operative findings3, 41.

18

Post-operative complications following acute abdomen ranges from

wound infection, wound dehiscence, anastomotic leaks, intra-

abdominal collection, prolonged ileus, adhesive intestinal obstruction

incisional hernia, respiratory tract infection, multiple organ failure and

ultimately death4, 5, 10, 21, 42, 43.

Most of these complications follow cases with extensive

peritoneal soilage, bowel strangulation and severe malnutrition.

These are often brought about by late presentation at the hospital 3-5

Adejuyigbe et al 42 in 1991, reported that diseases of the gastro-

intestinal tract are responsible for the majority of intraperitoneal

abscesses seen at Obafemi Awolowo Teaching Hospital Complex,

Ile-Ife42. Association of intra-abdominal abscess with remote organ

failure, postoperative anastomotic leakage, non-localization of the

abscess within the peritoneal cavity and gastrointestinal perforation

due to typhoid enteritis was found to portend poor prognosis 21, 42.

Patients who develop complications often spend long time on

admission and these also lead to higher hospital costs 3-5.

19

CHAPTER THREE

Patients and methods

Permission to carry out this study was obtained from the

Research and Ethics Committee of the University of Ilorin Teaching

Hospital, Ilorin after obtaining the consent of the Consultant

Paediatric Surgeon.

One hundred consecutive patients between birth and 12 years

of age with confirmed diagnosis of surgical abdominal emergency

conditions, seen by the pediatric surgery unit at the emergency

pediatric unit (EPU), accident and emergency room (A&E), neonatal

intensive care unit (NICU), and pediatric in-patients ward (ward 3)

between 1st of October, 2002 and the 31st of December, 2003 formed

the population for the study.

All patients who were discharged against medical advice in the

cause of treatment and all patients who had initial surgical

intervention before referral were excluded from this study. Formal /

written consent was obtained from the parents or guardians of the

patients included in this study.

Study Population

Ilorin is the Capital City of Kwara state of Nigeria located on

latitude 80 30’ North and Longitude 40 34’ east in the Guinea Savanna

belt. The climate supports tall grass vegetation, which is interspersed

with short scattered trees.

20

The indigenous people of Ilorin, who are predominantly Moslems, are

the Negroid Yorubas, Hausas, Nupe, Gobirs and Fulanis. However,

people from other tribes and ethnic groups in Nigeria also live

permanently in Ilorin.

The strategic location of Ilorin, as a gateway city between the

Northern and the Southern parts of the country, its designation as a

state capital and the establishment of a large number of higher

institutions has contributed to the tremendous increase in its

population. The 1991 census, which is the most recent, put the

population at 576,429 with estimated annual population growth rate of

2.5 percent.

The economy of the area is mostly pre-industrial with the major

occupation of the people being peasant farming and cloth weaving.

The educated citizens are employed in the civil service and a sizeable

number of the population is engaged in commerce, and small scale

industrial enterprises.

The University of Ilorin Teaching Hospital is a federal

government institution that came into existence in 1980. It started

operation at the temporary teaching hospital sites comprising the

former Ilorin General and Maternity Hospitals released on lease

agreement between Kwara – State Government and the Federal

Ministry of Health in 1981.

21

The neonatal intensive care unit (NICU), Emergency Paediatric

Unit (EPU) and General outpatient department receive patients

coming directly from home and referral from hospitals within and

outside Ilorin. Furthermore, the University of Ilorin Teaching Hospital

also acts as a main reference centre for paediatric surgical conditions

in the middle belt zone of Nigeria. Its main catchment areas include

Niger, Oyo, Ekiti, Kogi and Osun States.

Methods

Demographic data such as age, sex, tribe, weight, and home

address were obtained on each child and entered into a proforma.

Clinical data including duration of illness, presenting symptoms

and signs, laboratory investigation results, operative findings and

histology reports (where applicable) were documented in the

proforma. The complications and outcome of operative intervention

were also documented. The author was at different times the

surgeon, assistant surgeon or participant in supervising patients’ pre-

operative and post-operative cares. All attempts were made to follow

patients up for a minimum of three months in the surgical out-patients

clinic.

Data Analysis

Data collected were analyzed on a personal computer using

Epi Info version 6.04 statistical soft ware and the SPSS software was

used to calculate regression, taking p-value to be 0.05. Simple

22

proportions i.e. mean, median, mode, standard deviation (SD) and

frequency tables were generated.

Limitations

The high cost and the lack of facility for some laboratory

investigations prevented the routine check of some parameters

before surgical intervention e.g. serum bicarbonate. Some tests are

not readily available during call hours e.g. serum creatinine,

microbiology plates and specimen transport medium for preservation

of specimen. These affected the predictive information that some of

these investigations would have provided for the outcome of

management of the patients.

Due to religious and socio-cultural beliefs, autopsy was not

possible in patients who died postoperatively, to confirm the cause of

death or those who died before surgical intervention, to ascertain the

diagnosis of the surgical abdomen. This would have assisted in

determining the accuracy of incidence of causal factors of PSAE and

the complications thereof.

23

CHAPTER FOUR

RESULTS

A total of six thousand, three hundred and fifty-nine (6,359) new

pediatric patients aged 12years and below presented to the University

of Ilorin Teaching Hospital Ilorin between 1st of October 2002, and

31st December 2003. Two thousand, nine hundred and forty-six

(46.3%) were surgical patients, the paediatric surgical unit operated

on two hundred and sixty-one patients during this period and

105(40.2%) were paediatric surgical abdominal emergencies (PSAE).

One hundred patients (3.4% of the total paediatic admission) who

were PSAE were consecutively selected for the purpose of this study.

The remaining five patients discharged were against medical advice

in the course of treatment and were therefore excluded from the

study.

Patients Disposition

Majority of the patients, 78(78%) came in through the

Emergency Paediatric Unit (EPU) of the hospital; 7(7%) were through

the neonatal intensive care unit (NICU), 5(5%) were from paediatric

in-patients (Ward 3), 7(7%) came in through the accident and

emergency room (A & E) and 3 (3%) through the out-patient service.

24

Age and Sex Distribution

The age group and sex distribution of the patients with surgical

abdominal emergency conditions is as shown in Table 1. The mean

age of patient with PSAE was 4.6yrs, standard error of mean (SEM)

is 0.469 and seventy-one (71%) patients were males and 29 (29%)

were female. (M: F = 2.5:1).

Surgical abdominal emergencies occurred most commonly

during school age (7yrs – 12yrs), followed by neonatal period (<1mth)

and infancy (1 month to 12 months)

Table 1: Age group and sex distribution among pediatric

surgical abdominal emergencies

Age MALES FEMALES TOTAL

Neonates<1mth 19 2 21

Infancy 1-12 mth 13 7 20

Early Childhood

13mth-6yrs

16 3 19

Late childhood

7yrs- 12yrs

23 17 40

Total 71 29 100

25

Causal factors in pediatric surgical abdominal Emergencies

The prevalence of the various causal factors are illustrated in

table 2 and figure 1. Intestinal obstruction occurred in 44% of the

cases, perforated intestine due to typhoid enteritis occurred in 22%,

Appendicitis in 15%, Blunt abdominal trauma was 7% (4 splenic

lacerations, 1 with combined hepatic laceration, 1 ileal laceration and

1 duodenal perforation, 1 polycystic kidney injury). Mesenteric

adenitis accounted for 2% of the cases. Other causal factors are 3

cases each of infantile hypertrophic pyloric stenosis (IHPS) and

abdominal abscess (among whom was a patient who was HIV

positive). Abscesses were found mainly in the pelvis and the

paracolic gutters. E. coli was cultured in one patient but the other two

were sterile aspirate. A single case each of left renal cross ectopia

that had acute spontaneous hemorrhage and a spontaneous gastric

perforation in a 34-week premature male patient.

The 44 cases of intestinal obstruction are illustrated in Table 3.

Intussusception (IT) occurred in 15 (34.1%) patients, Ano-Rectal

Malformation (ARM) in 11patients (25%), obstructed external hernia

in 5patients (11.4%), Jejuno-ileal atresia in 4 patients (9.1%), 3

(6.8%) cases of postoperative adhesive intestinal obstruction. Two

cases (4.5%) each of mesenteric cyst and Hirschsprung’s disease

and a single case each (2.3%) of mal-rotation of the gut and a midgut

volvulus.

26

Table 2: Distribution of age and causal factors in surgical

abdominal emergencies

Age Acute Appendicitis.

Mesenteric

adenitis.

Typhoid ileal perforation.

Intestinal Obstruction.

Abdominal Trauma

IHPS OTHERS TOTAL

< 1 month

18

1

2

21

1 -12mth

1

17

2

20

13mth-6yrs

1

8

7

1

2

19

7yrs-

12yrs

14

1

14

2

6

3

40

Total 15 2 22 44 7 3 7 100

# IHPS- infantile hypertrophic pyloric stenosis

27

Figure 1: proportions of PSAE causal factors.

15%

2%

22%

44%

7%3%

7%

Acute Appendicitis.

Mesentericadenitis

typhd ileal perforation

Intestinal Obstruction

Abdominal Trauma

IHPS

Others

keys: IHPS- infantile hypertrophic pyloric stenosis

Table 3: Distribution of age groups and causal factors in

mechanical intestinal obstruction (MIOB)

AGE External

hernia

Intus

suscepti

on

AnoRectal

Malformati

on

Jejuno-

Ileal

atresia

Malro-

tation

Mesen

teric

cyst

Post-op.

Adhesion

Hirschsprung’

s disease

Midgut

Volvulus

Total

< 1mth 2 11 4 1 1 19

1-12mth 1 13 1 1 16

13mth-

6yr

2 1 1 2 1 7

7yr-12yr 1 1 2

Total 5 15 11 4 1 2 3 2 1 44

28

Causal factors and duration of illness before presentation

Fourteen patients (14%) presented for surgical interventions

within 24hours of onset of symptoms as shown in Table 4. Of this

only 5 patients (35.7%) presented within 6hours. Five of the 14

patients had intestinal obstruction (ARM - 2, postoperative adhesion -

1, intussusception - 1, umbilical Hernia - 1) Four had appendicitis,

Four had blunt abdominal trauma from either a fall or motor vehicular

accident (MVA). One patient had omphalocele (exomphalus)?

Rupture.

Majority of the patients (64%) presented within the first 5days of

onset of symptoms, while 10% presented after 2 weeks. Fourteen of

the patients (63.7%) with perforated typhoid ileitis presented after a

week from onset of symptoms.

Table 4: Distribution of causal factors and interval before

presentation

Time Acute

appendicitis

Mesenteric

adenitis

Typhoid

perforation

Gastro-

intestinal

obstruction

Abdominal

trauma

Others

Total

<24hours 4 5 4 1 14

24-48hrs 5 2 11 1 19

3-5days 2 1 5 19 2 2 31

6-14days 2 15 8 1 26

>14days 2 1 4 3 10

Total 15 2 22 47 7 7 100

29

Time interval between admission and surgery.

Fifty-four (54%) of the patients had surgical intervention within

24 hours of presentation to the paediatric surgical unit. The median

surgical intervention period was 24.00 hours, Standard error of mean

(SEM) of 9.53hrs. Twenty-four (24%) of the patients had surgical

intervention after 48 hours.

Seventy-eight patients (78% of total) had delay of more than

6hours before surgical intervention. This was due to hospital logistic

(lack of theatre space and laboratory back up) in 43 (55.1%) patients,

need for resuscitation and stabilization of patient in 15 (19.2%)

patients. In 9(11.5%) patients, parents were unable to procure drugs

and consumables for the initial management of their wards, despite

provisions of operation packed items by the hospital on deferment of

payment basis. This was due to exhaustion of their funds at the

referring center before coming to UITH, Ilorin. Others were delayed

because of initial conservative approach in 7 (8.9 %) of the patients,

refusal of parents to consent to operation in 2 (2.6 %) and transfer of

patients from the pediatrician to the pediatric surgical unit in 2 (2.6 %)

of the patients.

Specific causal factors in Pediatric Surgical Abdominal Emergencies.

1. Appendicitis

Table 5 shows that appendicitis accounted for 15% of all

causes of PSAE in this study. The youngest among the patients was

4yrs old and the oldest was 12yrs old. The mean age at presentation

30

was 10.6yrs, SD = 1.03, median age was 11years. M: F is 1.1:1.

Duration of symptoms ranged from 6hours to 14days with a

All patients had histological confirmation of appendicitis, there was no

negative appendicectomy. Hospital stay median of 36hrs.

Simple acute appendicitis accounted for 8(53.3%) cases, a

case (6.7%) of appendiceal abscess and 6 (40%) cases of ruptured

inflamed appendix.ranged between 3 and 8days for simple

appendicitis with a median of 4 days while complicated appendicitis

cases stayed between 5 and 14days in the hospital with median stay

of 9 days. Two patients among the ruptured appendix cases had

wound infection with partial wound dehiscence. All patients were

discharged home alive.

31

Table 5: Pattern of presentation and management of

Appendicitis

Cases no

Age (years)

Sex Symptom duration

Admission Duration (days)

diagnosis treatment Histology

outcome

Complication

1 12 M 36hrs 3 acute appendicitis

appendectomy + alive Nil

2 12 M 10days 8 “ “

+ “ Nil

3 10 M 6days 9 “ “

+ “ “

4 12 M 23hrs 4 “ appendectomy + “ “ 5 12 F 7hrs 5 “

“ + “ “

6 11 M 2mth 3 acute appendicitis

“

+ “ “

7 12 M 24hrs 3 Ruptured app.

Exploratory laparotomy & appendectomy.

+ ascaris ball

“ Wound infection

8 10 F 4hrs acute appendectomy

+ “ Nil

9 4 M 24hrs 5 ruptured “

+ “ “

10 11 F 14 days 8 acute “

+ “ “

11 11 F 4days 9 ruptured “

+ “ “

12 11 M 48hrs 5 ruptured Exploratory Laparotomy & appendectomy

+ “ “

13 12 F 12hrs 5 Appendix abscess

“

+ “ “

14 11 F 24hrs 14 ruptured “

+ “ Wound infection

15 12 M 5days 8 ruptured “

+ “ Nil

+ confirmed inflamed appendix

32

Perforated Typhoid Enteritis

Table 6 shows the distribution of cases of perforated typhoid

enteritis, the second commonest cause of PSAE in this study. There

were 22 patients with a male: female ratio of 1.6:1. The youngest

patient was 2years old and the oldest was 12years with a mean age

of 7.7years, SD = 1.19. Sixteen (72.7%) of the patients were above

7years of age. Eleven of the patients (50%) had associated severe

anaemia and needed blood transfusion before surgical intervention.

Seventeen (77.3%) of the patients had single terminal ileal perforation

while 3 (13.6%) patients had 2 perforations; (see fig 1) one of these

patients also had gallbladder empyema. Two (9.1%) patients had 3

perforations on the terminal ileum. All patients had emergency

exploratory laparotomy. Majority of the patients (95.5%) had simple

two-layer closure of the perforations while 1 patient had a right

hemicolectomy due to location of one his 3 bowel perforations 2cm

from the ileocecal valve that made simple closure difficult. The patient

with gallbladder empyema also had a cholecystectomy in addition to

simple ileal perforation closure.

Fifteen patients (68.2%) had post-operative complications.

These were wound infection in 8(53.3%) patients, wound dehiscence

and septicaemia in 2(13.3%) patients each and a case each of burst

abdomen, disseminated intravascular coagulation and

enterocutaneous fistula in 1(6.7%) patient each.

33

Two patients (9.1%) died due to severe septicaemia. The other

patients were discharged home after seven to thirty-five days on

admission. Median hospital stay was 12 days.

Figure 2: single perforation on terminal ileum in typhoid enteritis

caecum

appendix

perforation

34

Table 6: Pattern and management of perforated typhoid enteritis

Cases no

Age Sex Symptoms duration (days)

Admission duration (days)

Features Treatment No of perforations

outcome Complication

1 9 M 10 22 Fever, abd. Pain

Ex.lap+ closure

1 Alive Wound infection

2 4 M 10 18 “ +anemia

“ 1 Alive “

3 10 M 14 22 “ “ 3 “ “ 4 10 M 14 10 Fever,

abd. Pain

“ 2 Alive NIL

5 5 M 10 25 " “ 1 “ Enterocutaneous fistula

6 7 M 14 5 “ “ 1 Alive Septicemia 7 8 F 15 8 “ “ 1 “ nil 8 4 M 7 28 +anemia “ 1 “ Wound

infection 9 4 M 14 5 +Anemia

melaena “ 1 Died DIC

10 12 F 6 28 anemia “ 1 Alive Burst abdomen.

11 7 F 7 22 marasmus Ex.lap+ closure

1 “ Wound infection

12 11 F 2 21 “ “ 2 “ “ 13 4 M 7 14 +Anemia Hemico

lectomy 3 “ “

14 12 M 5 12 +Anemia “ 1 Alive “ 15 7 F 28 35 “

hypokalemia, marasmus.

Ex. Lap.+ closure +cholescystectomy

2 gallbladder empyema

“ Wound dehiscence

16 5 F 6 8 +anemia Ex. Lap+

1 “ Nil

17 7 F 5 9 +anemia “ “ “ “ 18 7 F 5 Fever

pain “ “ “ “

19 6 M 2 10 “ “ 1 “ “ 20 12 M 10 9 “ “ 1 “ “

21 12 F 10 12 Anemia Ex. Lap. + closure

1 “ Wound dehiscence

22 2 M 7 2 “ “ 1 Died septicaemia

Ex. Lap. = exploratory laparotomy

Abd.=Abdominal

35

.

3. Mesenteric Adenitis

Two patients had mesenteric adenitis, one of them was 8

months old male patient, 1st of a set of twin who also had severe

perinatal asphyxia and neurologic deficit. He was suspected to have

an intussusception clinically and on ultrasound suggestion, but

discovered to have huge inflamed mesenteric lymph nodes and

descending colon fecal impaction. He was subsequently managed as

a case of viral septicaemia.

The second patient was 7years old male with suspected

perforated typhoid enteritis. At laparotomy there were large

mesenteric lymph nodes and hyperaemic terminal ileum without

perforation, mesenteric node biopsy showed inflammatory cells.

4. Abdominal trauma

Seven (7%) patients sustained blunt abdominal injury in this

study (table 7). The ages ranged between 4 and 11yrs with mean age

of 8.86yrs, SD = 0.53. Blunt abdominal injury followed motor vehicular

injury (MVI) in 5(71.4%) cases of which 4(66.6%) of patients were

pedestrians. One patient (14.3%) fell on his tummy following a push

by a peer at school and one patient fell from a tree. Four patients

(57.1%) sustained splenic injury with one of them having an additional

hepatic laceration. One patient each (14.3%) sustained duodenal

perforations, ileal perforation and a right polycystic kidney

36

hemorrhage. The patient with duodenal perforation also sustained

multiple fractures of the ribs and right femur. Two patients (28.6%)

died despite operative intervention. One death was due to

septicaemia and fluid and electrolyte imbalance from

enterocutaneous fistula in the patient with duodenal fistula and the

other death was due to severe hemorrhage in the patient with hepatic

injury.

Table 7: Pattern and management of abdominal trauma

Case no

Age Sex Mechanism Investigations Organ injured

Treatment Outcome Complication

Associated injury

1 10 M MVI USS, CxR Spleen Conservative

Alive Nil nil

2 11 M MVI “ Spleen, liver

Laparotomy & splenorrhaphy & hepatorrhaphy

Died Hemorrhage

Hepatic Artery avulsion

3 10 M Fall USS, CxR, AbdxR

Duoden-um

Laparotomy & closure & gastrojejunostomy

Died Enterocutaneous fistula

# femur and ribs

4 4 M MVI* USS Spleen Splenectomy

Alive Hemorrhage

nil

5 7 F MVI* USS Spleen Splenorrhaphy

Alive Nil nil

6 8 M Fall AbdxR, USS Ileum Laparotomy & closure of perforation

Alive nil nil

7 11 M MVI* USS Right polycystic kidney hemorrhage

Rt nephrectomy

Alive nil nil

*Pedestrian, MVI= motor vehicle injury USS-abdominal ultrasound.

AbdxR- abdominal x-ray, CxR- chest X-ray

37

5. Anorectal malformation (ARM)

There were eleven patients with anorectal malformation (see

illustration in figure 3). Ten (90.9%) patients were male and one

(9.1%) was a female. Their ages ranged between 12hours and 1

month at presentation. The mean age was 5.23days. Table 8 shows

that 7 (63.7%) male patients had ARM with recto-urethral fistula,

while 3(27.2%) male patients had covered anus with associated

anocutaneous fistula, which were stenosed. The single female had

absent anus with rectovestibular fistula. A male (10%) had associated

coronal hypospadias and choanal atresia while another one had a left

sacral hemi-vertebral. All patients had invertogram done which

showed four (36.4%) patients with radiological characteristic of high

ARM and were given temporary transverse loop colostomy. Four

(36.4%) male patients had single stage posterior sagittal

anorectoplasty (1-PSARP) without colostomy as shown in figure 4.

Three patients (27.3%) with stenosed anocutaneous fistula had

cutback anoplasty.

Two (18.2%) patients had post-operative superficial wound

dehiscence, 1(9.1%) patient had wound infection, while 2(18.2%) died

from postoperative apnea and electrolyte imbalance. These were the

patients with associated congenital anomalies (hypospadias, choanal

atresia, sacral agenesis).

38

Figure 3: Anorectal malformation in a male child

Figure 4: Anal vent in one stage posterior sagittal anorectoplasty

Imperforate

anus

Posterior

sagittal wound

Syringe vent

39

Table 8: Summary of anorectal malformation(ARM)

Case no

Age

Sex DOS DOA features Type Treatment Outcome Complication

1 38hrs M 38hrs 14 Anorectal RUF

Interned iate

1-PSARP Alive Wound dehiscence

2 5/7 M 5/7 18 Anorectal RUF

Inter-mediate

1-PSARP Alive Nil

3 3/7 M 3/7 7 Anorectal RUF

High Colostomy Alive Nil

4 3/7 M 3/7 3 Anal stenosis,covered anus

Low Anoplasty Alive Nil

5 24hrs M 24hrs 13 ARM+RUF,jaundice

High Colostomy Alive Nil

6 4/7 M 4/7 10 ARM+RUF Inter-mediate

1-PSARP Alive Wound infection

7 ***30/7hrs

M 28hrs 15 Anal stenosis,covered anus

Low Anoplasty Alive Nil

8 57hrs M 57hrs 4 Covered anus

Low Anoplasty Alive Nil

9 4/7 F 4/7 12 RVF Interned iate

1-PSARP Alive Wound dehiscence

10 12hrs M 12hrs 1 ARM,Hypospadias,choanal atresia

High Colostomy Died Apnea

11 39hrs M 39hrs 5 ARM,RUF Sacral agenesis

Gangrenous bowel High

Colostomy Died Electrolyte imbalance,Necrotizing fascitis

Keys: 1 – PSARP = One stage posterior sagittal Anorectoplasty RUF = rectourethral fistula DOS= duration of symptoms DOA= duration of admission RVF= recto vestibular fistula

40

Intussusception (IT)

There were 15 patients with intussusception (see figure 5). This

constituted the highest cause of intestinal obstruction in the study.

There were 9 males and 6 females with a M:F of 1.5:1. The ages

ranged from 2 months to 12 years with a median age of 5 months.

The mean duration of symptoms before presentation was 5.6

days with 6 (40%) of the patients presenting by 3 days. All the

patients presented with abdominal pain and vomiting. Six (40%)

patients presented with red currant jelly stool. A patient each had

hematochexia and protrusion of intussusceptum through the anus.

Table 9 shows that 2 (13.3%) of the patients (cases 9 and 11)

had pathological lead points. Eleven (73.3%) of IT were ileocolic, 2

(13.3%) were caecocolic, and 1 (6.6%) each was ileocaecal and

colocolic. Four (26.6%) had bowel gangrene at laparotomy and right

hemicolectomy was done in these cases. One (6.6%) patient with

transverse colo-colic IT had lead point resected and a defunctioned

colostomy constructed. Lead point histology confirmed a non-

Hodgkins lymphoma. Five patients had complications giving a

complication rate of 33%, with a case each of wound infection,

prolonged ileus of more than 5 days, septicaemia, enterocutaneous

fistula and postoperative seizure and hyperthermia. Three patients

died accounting for a mortality rate of 20%.

41

Table 9: Pattern and management of intussusception

Case no

Age (month)

Sex DOS (days)

DOA (days)

Clinical features

Investigations

Operation finding

Treatment Outcome Complication

1 12 F 3 4 Red currant stool

USS+ve Ileo-cecal Reduction Died Post operative Convulsion,Hyperthermia

2 4 M 5 16 Abdominal

distension USS+ve, Hypokalaemia

Ileo-colic,Gangrenous bowel

Right Hemicolectomy

Alive Nil

3 3 F 7 12 Abdominal

distension USS+ve, Hypokalaemia

Ileo-colic,Bowel perforation

“ Alive Wound infection

4 8 M 7 8 Anal protrusion

USS—ve ileocolic Reduction Alive Nil

5 5 M 4 8 “ “ “ “ “ “ 6 5 M 3 30hrs Red currant

stool No USS “ Reduction died “

7 4 F 3 8 Anemia, red currant stool

USS +ve. “ Reduction alive “

8 4 M 5 21 “ USS, hypokalaemia

“ “ “ Prolong ileus, bronchopneumonia

9 36 M 14 10 Diarrhea, hematochexia

USS +ve Colocolic, non- Hodgkins

Resection + colostomy

Alive nil

10 12 M 3 8 Diarrhea USS +ve, hypokalaemia

Ileocolic, gangrenous bowel

Right hemicolectomy

Alive nil

11 144 M 14 21 Bilious vomiting

USS +ve Ileocolic, abdominal Tuberculosis

Reduction + anti-Kochs

alive nil

12 5 M 6 8 Red currant stool

USS +ve cecocolic reduction alive “

13 5 F 3 8 USS +ve ileocolic “ “ 14 12 F 3 3 Red currant

stool USS +ve “ “ died Septicemia,

renal failure 15 2 F 4 22 Vomiting

excessive cry

USS +ve, Cecocolic, gangrenous cecum

Right hemicolectomy

alive Enterocutaneous fistula

DOS-duration of symptoms, DOA- duration of admission

42

Fig. 5 : Ileocolic Intussusception brought out of laparotomy incision

intussusception

43

Table 10: Summary of other mechanical intestinal obstruction(MIOB)

Case no

Age Sex DOS

DOA

Features Investigation

Diagnosis Treatment Outcome complication

1 1mth M 1day 4days Right scrotal swelling

PCV Obstructed RISH, non-viable testis

Herniotomy Alive nil

2

6yrs M 1day 8day “ “ Strangulated small bowel

Herniotomy + resection and anastomosis

“ Wound infection

3 18days

M 4hrs 5days Right Groin swelling

Strangulated right testis

Herniotomy “ Nil

4 1yr M 3days 8 days Left. Groin swelling

Obstructed LISH

Herniotomy Alive “

5 4yrs M 9hrs Umbilical swelling

Incarcerated small bowel

Mayo’s repair

“ “

6 2 days

F 36hrs 20days

Bilious vomiting, HIV +ve

USS, AbdXR, barium meal

Jejunal atresia type I

Laparotomy +gastrojejunostomy

“ Prolong ileus wound infection

7 3 days

M 3days 18 days

Bilious vomiting

AbdxR, USS

Ileal atresia type IV

Laparotomy + resection + anastomosis

Alive nil

8 7 days

M 7 days 2 days “ “ “ “ Died Respiratory failure

9 1 day M 14hrs 25 days

“ “ Ileal atresia type IIIA

“ Alive Wound infection

10 11 days

M 10 days

12 days

Bilous vomiting

USS, abdxR

Jejunal mesenteric cyst

Laparotomy +resection + anastomosis

“ Wound infection

11 2yrs F 3 days 13 days

“ “ Multiple jejunal mesenteric cysts

“ “ nil

12 2mth M 2days 13days

“ “ Midgut volvulus,Gangrenous bowel

“ Died Anastomotic leak

13 2mth M 1 day 9days “ “ Malrotation Laparotomy + Ladd procedure

Alive Prolonged ileus

14 12yrs M 6hr 2weeks

Previous lap. Abd. Pain, vomiting

AbdxR Post operative Adhesive band

Laparotomy + adhesiolysis

“ nil

15 3yrs F 3days 8days “ “ “ “ Alive “

16 3yrs M 2days 12 days

“ “ “ “ “

17 5mth M 14days Constipation, abd. distention

Abd. XR, rectal biopsy

Hirschsprung’s disease

Colostomy “ “

18 1.5yrs M Marasmic-kwarsiokor, constipation

“

“

“

Alive

Burst abdomen

DOS- duration of symptoms DOA- duration of admission,

RISH-:Right inguinoscrotal hernia. USS : Ultrasound.

Abd.xR- Abdominal X- Rays

44

Table 11:

Morbidity and mortality pattern among the causal factors of PSAE

Causal factors No of

patients

Morbidity

rate

duration of

hospital stay

(days)

Median

duration of

hospital stay

Case fatality

Simple

appendicitis

8 (0%) 3-8 4days 0

Complicated

appendicitis

7 2(28.6%) 5-14 9days 0

Typhoid

perforation

22 10(42%) 5-35 12days 2(9.1%)

Intussusception 15 5 (33.3%) 1-22 11days 3(20%)

Abdominal

trauma

7 2(28.6%) 2-17 9.5days 2(28.6%)

Anorectal

malformation

11 4(36.4%) 1-23 10days 2(18.2%)

Intestinal

atresia

4 3 2-25 16.5days 1(25%)

Midgut volvulus 1 - 13 1(100%)

Post-operative

adhesion

3 0- 8- 14 12 days 0

Table 11 shows the morbidity and mortality pattern among the

various causal factors of PSAE. The overall median hospital stay is

10days. Eighty-nine (89%) patients were discharged home, while

11(11%) died.

The mortality was significantly affected by a younger age of

patients (p= 0.016) and presence of guarding (p= 0.008) signifying

peritonitis. There were 4(4%) patients out of those discharged who

45

were awaiting definitive procedures. These were the patients on

colostomy. All patients were followed up for a minimum of 3 months

46

CHAPTER FIVE

DISCUSSION

Surgical abdominal emergency operations form a substantial

part of the total number of surgical operations conducted yearly by

the paediatric surgical unit of the University of Ilorin Teaching

Hospital, Ilorin. During the period of the present study, 40.2% of

cases managed by the paediatric surgical unit were emergency

abdominal operations. This study showed that of all pediatric patients

aged 12 years and below admitted at the UITH, Ilorin between 1st of

Oct. 2002 and 31st of Dec., 2003, 3.4% had confirmed emergency

surgical abdominal conditions. Various reports put the incidence of

pediatric surgical abdominal emergencies at between 2.4 – 3.1% of

all pediatric admission.4,5.

Paediatric Surgical Abdominal Emergencies (PSAE) occurred

most commonly during late childhood (7-12yrs) in 40% of cases

followed by the neonatal period (<1mth) in 21% of cases and infancy

(1mth to 12months) in 20% of cases. Mechanical Intestinal

obstruction (MIOB) was the commonest PSAE in this study

accounting for 44% cases. This is in agreement with findings in

previous reports, which showed that acute intestinal obstruction is the

most common abdominal emergency encountered in the general

population 6,7,8 and specifically in the paediatric age group 10,21.

47

The neonatal period (<1month) recorded the highest cases of

MIOB with congenital bowel atresiae (ARM and IA) being the

commonest causal factors. This accords with reports of previous

works10, 29, 44. During infancy (1-12months) intussusception (IT)

accounted for the highest causal factor of intestinal obstruction

(MIOB). This confirms IT as the commonest acquired cause of MIOB

in children 21, 45, unlike in adult series where external hernias were

prime causes of MIOB, 6, 7, 12.

In late childhood (7yrs-12yrs), peritonitis due to perforated

typhoid enteritis is the second commonest cause of PSAE in this

study and accounted for 22% of cases. This study showed a slight

male preponderance of 1.4:1 which is in agreement with most series

involving only children 20, 43, 45, in which the ratio were between 1.1-

1.7:1. This was followed by acute appendicitis in 15% of cases. The

general population series (children included) had shown that acute

appendicitis accounted for the second largest cause of surgical

abdominal emergencies 7,12 or even the commonest cause of

abdominal emergencies in some other series9,46.

The high rate of perforated typhoid enteritis in this study may

be accounted for by the high referral from private clinics in the city

and rural public health centres by medical and health workers who

are aware of the high morbidity and mortality rate associated with this

48

pathology but unfortunately delayed the transfer of these patients to

this tertiary facility. The high occurrence of typhoid perforation in this

study and others 20, 43, could also be due to late presentation caused

by ignorance and poverty. Acute appendicitis cases might have been

operated on by general practitioners outside this facility, leading to

affectation of proportion of incidence among causal of PSAE.

The time lapse between onset of illness and when patients

were presented to the hospital depended on the cause of PSAE, the

symptoms at onset and the age of the patient. Delay in seeking

medical treatment is generally accepted as the major factor

responsible for the high morbidity in many centers3-7, 21, 44, 47. Only 14

patients (14%) presented within 24hours of onset of symptoms.

Thirty-three percent of total patients presented within 48hours due to

unrelenting abdominal pains and vomiting or progressive abdominal

distension, which did not respond to local herbs, or over the counter

(OTC) drugs and onset of super-imposed fever.

Patients who presented within 6-10 days of onset or thereafter

were 15 cases of perforated typhoid enteritis (or 44% of all

presentation after 6 days) that had initial fever and some

constitutional symptoms and were receiving treatment for resistant

malaria before onset of sudden severe abdominal pains and

49

abdominal distention. All together 64% of the entire patients

presented within the first 5days of onset of symptoms.

The time lapse from paediatric surgical consultation to surgical

intervention depended on patients’ clinical status, hospital logistics

and co-operation of parents or guardians in making funds available

for procurement of drugs, investigations and consent to surgical

intervention. The hospital management made provision for deferment

of payment for operation packs and anaesthetic materials only. The

hospital management should make available at least a theatre suite

with dedicated staff and facilities to facilitate prompt attention to

emergencies.

Typhoid enteritis is endemic in many developing communities

20,43,45,48 and it is reported to be as common in children as in adults

though rare in infancy and early childhood43, 45. In this study one of the

patients was 2 years old. This patient died due to multiple organ

failure superimposed on septicaemia. The other death was in a 4-

year-old who had associated gastrointestinal bleeding, which is a

poor prognostic factor. Mortality rate was 9.1% which supports

reports in some series 49, 50.

Majority of the patients with TP in this series presented with

fever, abdominal pain and generalized abdominal tenderness. 22.7%

of all patients with TP had multiple perforations. This is higher than in

50

other series45, 48. One of the patients had multiple perforations of the

gall bladder, which were sealed off by the omentum in addition to 2

perforations of the terminal ileum. There were no calculi either in the

gall bladder or the bile duct. Acalculus cholecystitis is known to be

associated with typhoid fever. All perforations were within 30cm of the

ileocecal valve which is in accord with many reported series 20, 43, 45, 48.

The treatment of TP is surgery, which is aimed at eliminating the

source of continuing contamination of the peritoneal cavity, control of

and the termination of progression of sepsis20,43,45,48. Simple two-layer

closure 43 following debridement of ulcer was done in all patients

except one patient who had a right hemicolectomy and ileo-

transverse colon anastomosis. Copious warm saline lavage of the

peritoneal cavity was done and drains were used in all cases. This

appeared to minimize intra-peritoneal post-operative abscess

collection 45,48.

The post-operative complication rate in TP was 63.6%, the

commonest complication was wound infection (71%) which was

responsible for prolonged hospitalization rate. The mean duration of

hospital stay was 12 days (range 5-35 days). The mortality in children

less than 5 years old in this series was 28.6%. Bell et al 51 found that

extremes of age have an adverse effect on the mortality of TP. All

51

patients after operation received treatment for typhoid fever but none

was immunized with typhim V vaccine.

Appendicitis, the third commonest cause of PSAE in this study

accounts for 15% of all cases, which was within the reported range of

11.2- 18% of other workers 4.5. However, this is in contrast to

situations in Caucasian communities where acute appendicitis has

remained the commonest cause of childhood acute abdomen2. The

small number in this study despite increasing incidence in African

series 3-5,9 may be due to spontaneous resolution of disease,

resolution after self-medication or intervention by general medical

practitioners who fail to refer patients for pediatric specialist care.

Therefore this report may not be the true incidence of the disease in

the community.

The peak age incidence among patients with appendicitis was

between 10 and 12 years. Only one patient was 4years old. This

agrees with the series of Adejuyigbe et al 4, Taiwo et al5 and

Abubakar and Ofoegbu 10 where appendicitis is said to be uncommon

in neonatal period and early childhood. This may be due to paucity of

lymphoid follicles in the submucosa of the appendix in this age group

and concomitant wide base of the appendix with relative larger lumen

of the organ which predispose to less obstruction and subsequent

rise in its intraluminal pressure.15,32-34. However, acute appendicitis

52

has been reported in children as young as 18 month old 28, 30, 51, and

even in a neonate52. There was a slight male preponderance (1.1:1)

which agrees with most reports from Africa and the rest of the world 4,

15, 32- 34, 53.

All patients with appendicitis presented with abdominal pain,

which was accompanied by or preceded by vomiting. Seven

(46.7%) patients had complicated appendicitis at presentation. This

agrees with the findings of Adejuyigbe et al.4 and Taiwo et al.5 in

which complicated appendicitis accounted for 42.5% and 54.2%

respectively. Ten (66%) patients had exploratory laparotomy via a

right paramedian incision and appendectomy instead of

appendectomy via a Lanz incision due to presence of generalized

peritonitis on physical examination, which connotes an advanced

appendicitis. However, only 40% of these patients had a truly

ruptured appendix. This form of presentation may be explained by the

poorly developed omentum, which failed to localize inflammation in

these children. All patients with straightforward appendicitis had an

uneventful course with short hospital stay while those with ruptured

appendix who developed wound infection or post-operative pyrexia

stayed longer on admission.

Mechanical intestinal 0bstuction (MIOB) was responsible for the

highest cause (44%) of PSAE in this study. Mechanical intestinal

53

obstruction which was defined as inhibition of antegrade propulsion of

the contents of the small and large bowel starting from the duodenum

to the rectum excluding cases of esophagus atresia, gastric outlet

obstruction and paralytic ileus.

The rate of MIOB was in concordance with other studies in

children. 10, 21, 45 Neonatal intestinal obstruction accounts for 40.9% of

all MIOB, which is the period in which MIOB occurred the most. Of

this, anorectal malformation (ARM) and intestinal atresia (IA) together

accounted for 83.3% of the lesions. This is higher than in the series

by Adejuyigbe et al (71.8%) 44, Adeyemi (70.6%) 54, and Momoh

(70.9%) 55. The low incidence of Hirschsprung’s disease in this study

is remarkable. This may be due to the deletion of unconfirmed cases

of suspected Hirschsprung’s disease from this study due to parents

refusal of diagnostic rectal biopsy on their children at presentation

following relief of obstruction by digital rectal examination or warm

saline enema.

Vomiting, delayed or non-passage of meconium and

progressive abdominal distension were the classical triad of clinical

presentation in this study, which conforms with reports from other

series 44, 54, 55. These features however, vary according to the level of

obstruction.

54

One-stage correction of anorectal malformation has been found

to be simple and safe even when performed on neonates56- 58. It has

reduced the risk of repeated exposure to anaesthesia, high cost of

three-stage operation, parental stress in caring for their wards and the

complications of colostomy59.

Late presentation of these patients to the hospital and

presence of associated congenital anomalies contributed to the

morbidity and mortality noted in this as well as in previous studies 44,

54, 55. Two patients with ARM who had associated congenital

anomalies died while a patient with type IV ileal atresia who

presented late died from multiple organ failure precipitated by a

respiratory failure.

The single patient who had ‘idiopathic’ midgut volvulus with

extensive bowel gangrene, died from anastomotic leak due to poor

wound healing. This was due to malnutrition, which could have been

corrected by parenteral nutritional support. The male patient with

mal-rotation of the gut presented to the surgical unit at two months of

age. He had earlier presented at the NICU at 1 week of age following

persistent non-bilious vomiting that resolved following 2 weeks of

naso-gastric aspiration and antibiotics. Plain abdominal X-ray done

then was not specific. Patients would benefit from detailed and

appropriate investigation to confirm diagnosis. Radiological

55

investigations play a central role in the diagnosis of intestinal mal-

rotation but plain abdominal x-ray is of value only when volvulus has

occurred 60.

Intussusception constitutes the highest acquired cause of

MIOB in children accounting for 34.2% in this study. The incidence of

intussusception varies from one part of the world to the other and

even in different regions of the same country 47, 61. The male female

ratio was 1.5:1. This male preponderance is in keeping with those of

other workers21, 47, 61, 62. The peak age incidence is between 3-5

months. No patient was found to have intussusception in neonatal

period and 13 (86.7%) patients were 1year and below. This confirms

previous reports of the age incidence of intussusception47, 62.

Patients above 2years usually have a pathologic lead point.

This was seen in 2 of our patients aged 3years and 12 years who had

Non-Hodgkin’s lymphoma and bowel tuberculosis respectively.

None of the patients in this study presented within 24hrs of

onset of symptoms. Majority presented after 3 days of onset with

features of progressive pathology, such as dehydration, lethargy,

fever and red currant jelly stool. All patients had surgical intervention

and none had a hydrostatic reduction due to their late presentation,

though hydrostatic reduction is not readily available in this center due

56

to the scarcity of radio-diagnostic facilities as in many other centers in

the country 21.

The 20% mortality reported in this study is mainly due to

septicaemia in two patients and a patient who developed severe

hyperthermia and convulsion. This mortality rate agree with reports of

Adejuyigbe et al 21, but was lower than the reports of Rahman and

Mungadi61 and Ojuawo and colleagues62 who put mortality rate at

47% and 29.2% respectively.

Post-operative adhesion and bands occurred in 3(6.8%)

patients in this study. This followed appendectomy in two patients and

intussusception reduction in one patient. All had laparotomy and

adhesiolysis due to failed conservative management.

Obstructed hernias accounted for 5(11.4%) of cases in this

series. Two patients were neonates. One patient had obstructed

umbilical hernia. One neonate had gangrene of the right testis at

exploration despite early presentation within 4 hours and early

intervention. One patient also had small bowel gangrene that

necessitated resection and anastomosis. All patients survived.

The presence of a visible non-reducible swelling and excessive

cry alarmed the mothers and prompted early presentation to the

hospital. These may be responsible for the good results obtained in

these patients. Management of children with intestinal obstruction

57

demands aggressive diagnostic and resuscitative measures to

prevent or reduce biochemical derangement, intestinal strangulation

and sepsis. Increasing the awareness of parents to appreciate

possible deleterious effects of these pathologies and to know that

facilities are available for their correction will encourage early

presentation to the hospital. Making medical care centers accessible

and the cost of care affordable would also go a long way to reduce

morbidity and mortality.

Traumatic injuries is fast becoming a major cause of morbidity

and mortality in children in the developing countries11, 63. Abdominal

trauma constitutes 7% of the total causes of PSAE in this study. This

is lower than in the series involving adults in which the incidence is

between 9.64- 16.4%8, 9, 12, 46. In accordance with previous reports 63,

64 motor vehicle accident with majority of the patients (66.6%) being

pedestrians was responsible for most cases of blunt abdominal

trauma in this study. There were 8 visceral injuries in 7 patients. The

spleen was the most commonly injured organ in 57.1% of cases. This

is in agreement with blunt abdominal organ injury in adults2, 9, 12, 46

and children series3, 10, 63, 64. There was an associated hepatic

laceration in one patient with splenic injury. This patient died due to

secondary hemorrhage post- operation. Two patients sustained bowel

injury. One of them was a duodenal perforation and the other was an

58

ileal perforation. The patient with duodenal perforation also had

multiple fractures of the long bones that diverted attention of the

caregivers and delayed the diagnosis of the duodenal perforation. A

high index of suspicion of possible abdominal viscera injury in poly-

traumatized patient, which will neccesitate, repeated clinical

examination preferably by the same surgeon at interval of 2-4hrs

provides the most reliable indicator of significant intra-abdominal

pathology65. One patient sustained injury to a right polycystic kidney,

which bled into the cyst. A right nephrectomy was done in this patient.

The two (28.6%) deaths recorded were in patients with multiple

injuries. Duodenal injuries are known to be associated with a high

mortality due partly to injuries to nearby organs and vascular supply.66

Only one patient with splenic injury had a splenectomy due to severe

intra-abdominal hemorrhage and ultrasound suggestion of grade IV

splenic injury which was confirmed at laparotomy. Most patients with

blunt abdominal trauma and splenic injury could be managed

conservatively67 or preferably with a splenorrhaply to avoid

overwhelming post-splenectomy infection (OPSI) in splenectomized

patients 63.

Idiopathic intra-abdominal abscess and peritonitis were found in

three patients, two boys and one girl. There was inflammation of the

terminal ileum in two of them but no perforation and the female

59

patient was HIV positive. No other pathology was seen in any other

organs. In Ajao’s9 series there were eleven patients with ‘idiopathic’

intra-abdominal abscess.

60

CHAPTER SIX

CONCLUSION AND RECOMMENDATIONS

Conclusion

Paediatric surgical abdominal emergency constituted a large

proportion of the patients managed by the paediatric surgery unit in

this study. Majority of these patients presented in a debilitated state

after having been delayed at home or referring centres. This

contributed to the high morbidity and mortality recorded in this study.

The occurrence of paediatric surgical abdominal emergency

cuts across all children age groups; Neonatal, Infancy and childhood.

The pattern of causal factors in paediatric surgical abdominal

emergencies still placed intestinal obstruction in the lead but there is

displacement of appendicitis to the third position having been taken

over by perforated typhoid enteritis.

Management of children with abdominal emergency demands

aggressive resuscitation, diagnosis and prompt surgical intervention.

Recommendations

1. Health care providers should recognize their limitations and

refer cases beyond their competence to the nearest referral

centre promptly. Only qualified personnel who have received a

formal training should operate on children.

61

2. The Hospital policy on deferment of payment for operation

packs is commendable but should be extended to cover drugs

and other investigations relating to the disease to forestall delay

in intervention.

3. The Hospital Management should ensure that emergency

theatre suite is covered adequately with manpower (scrub

nurse, anaesthetist etc) and equipment at all times to reduce

incidence of non-availability of theatre space. Meanwhile, under

the present situation, paediatric emergencies should be given

priority above other emergencies in contesting for theatre

space.

4. Surgical neonatal and paediatric intensive care unit should be

established and adequately equipped with paediatric ventilators,

and electronic monitors among others to cater for these children

who are usually in a debilitated state.

5. Parenteral nutritional supplements should be provided to assist

in early recovery of these children and good wound healing.

62

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71

PROFORMA

Serial no:- ……………………………………………………………

Name…………………………………………………………………..

Hospital No…………………………………………………………….

Age /date of birth……………………………………………………….

Sex …………………………M/F

Weight at presentation………………………………………………….

Address……………………………………………………………………

Date of admission:- ………………………………………………………

Time interval between onset and presentation……hrs…..days………

Referred from:- a) home b) private clinic c) herbal home

d) govt. clinic/hosp

Symptoms

Abdominal pain Yes/No

Nausea Yes /No

Vomiting Yes/No

Anorexia Yes /No

Constipation Yes/ No

Fever Yes /no

Others………………………………………………………….……

72

Signs

Acidotic breathing Yes /no

Toxic look Yes /No

Pyrexia Yes / no

Dehydration Yes / no

Palor Yes /No

Dyspnea Yes /No

Jaundice Yes /No

Vital signs:

PR……….. BP…………. RR………. TEMP. …………

Abdomen: indicate if the following signs are Present (P) or Absent (A)

1. distention

2. tenderness

3. rebound tenderness………. Localised or

generalised

4. palpable mass(es)

5. guarding

6. bowel sound………. Normal, hyperactive or

hypoactive

73

Rectal examination:

inspection ……………………………………..…………….

Digital rectal examination:

Sphincter- lax/ normal / tight

Empty Yes /No

Tenderness Yes /No

Bulging pouch Yes /No

Palpable mass Yes /No

Investigations: 1. Pre-op. 2. Post-op.

1. PCV

2. WBC (T& DIFF.)

3. SERUM Na+ mmol/L

K+ “

Urea “

Creatinine “

4. X-rays-

Chest………………………………………………………..

Abdomen……………………………………………………

Abdomen/pelvic ultrasound…………….………..………..

5. Others …………………………………………………….………..

6. Blood transfusion ( vol. If used )………………..…………………

pre-operative diagnosis……………………………………..……………..

74

average urine output pre-op…………………………….………….mls/hr

America soc. Anaesthe. (ASA) score : - …………………….………….

time interval between admission and surgery……………………….hrs

cause of delay (if any )………………………………………….………….

Operative findings……………………………………………………...……

Final diagnosis………………………………………………………………

Histology report (if any)…………………………………………………….

Outcome……………………..alive or dead

Cause of death………………………………………………………………

Duration of hospital admission…………………………………………….

Post-operative complications (list) (I) wound infection, (ii) wound

dehiscence (iii) abdominal abscess (iv) intestinal obstruction

(v) others (specify)…………………………………………………………..