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)…………………………………………………………..
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