Management Outcome and Associated Factors among Intestinal Obstruction Patients Treated Surgically, Eastern Ethiopia

Intestinal obstruction is a global problem consuming much in terms of surgical services. It is a common surgical emergency and a significant health problem in Ethiopia. Several factors contribute to poor management outcomes in the case of intestinal obstruction. Post-operative mortality rate ranges from 3% to 30%. Despite this high rate of mortality, there is no recently published literature that has explored Intestinal Obstruction and its associated factors at Chiro General Hospital. Methods Institution based cross-sectional study was conducted among 254 of patients admitted with Intestinal obstruction who treated surgically at Chiro General Hospital. Data were collected using checklists from individual patient cards by trained three BSc nurses from 13 to 18 July 2018 and completeness of data collection was checked every day by the principal Investigator. Data were entered to Epi-Data version 3.1 computer software and exported to SPSS statistical software version 22 for analysis. Bivariable binary logistic regression was used to saw the association between each independent variable and dependent variable. All variables with P-value < 0.2 during bi-variable analyses were considered for multivariable logistic regression analyses. Odds ratio along with 95%CI were estimated to measure the strength of the association. Level of statistical significance was declared at p value less or equal to 0.05.


Background
Intestinal obstruction is a global problem consuming much in terms of surgical services. It is a common surgical emergency and a significant health problem in Ethiopia. Several factors contribute to poor management outcomes in the case of intestinal obstruction. Post-operative mortality rate ranges from 3% to 30%. Despite this high rate of mortality, there is no recently published literature that has explored Intestinal Obstruction and its associated factors at Chiro General Hospital.

Methods
Institution based cross-sectional study was conducted among 254 of patients admitted with Intestinal obstruction who treated surgically at Chiro General Hospital. Data were collected using checklists from individual patient cards by trained three BSc nurses from 13 to 18 July 2018 and completeness of data collection was checked every day by the principal Investigator. Data were entered to Epi-Data version 3.1 computer software and exported to SPSS statistical software version 22 for analysis.
Bivariable binary logistic regression was used to saw the association between each independent variable and dependent variable. All variables with P-value < 0.2 during bi-variable analyses were considered for multivariable logistic regression analyses. Odds ratio along with 95%CI were estimated to measure the strength of the association. Level of statistical significance was declared at p value less or equal to 0.05.

Conclusions
The magnitude of unfavourable management outcome of patients with Intestinal obstruction who treated surgically in this study was high. Old age, late presentation of illness and gangrenous bowel obstruction were significantly associated with unfavourable management outcome. So that early detection prompt management of patients with Intestinal obstruction reduce the occurrence of unfavourable outcome of patients.

Background
Intestinal obstruction (IO) occurs when there is an interruption in the forward flow of intestinal contents. This interruption can occur at any point along the length of the gastrointestinal tract, and clinical symptoms often vary based on the level of obstruction. Intestinal obstruction may be of acute or chronic onset. It may be classified as dynamic obstruction (mechanical obstruction) or adynamic obstruction (paralytic ileus and pseudo-obstruction). It may also be classified as small bowel and large bowel obstruction[

1]
Intestinal Obstruction is a major cause of morbidity worldwide. Intestinal obstruction is one of the commonest abdominal surgical emergencies. When intestinal obstruction is not relieved in time, the patient may die. Early diagnosis and prompt management are therefore mandatory. Intestinal obstruction is a global problem consuming much in terms of surgical services. It is a common surgical emergency and a significant health problem in Ethiopia [ 2,3]. IO has been the leading cause of acute abdomen in several African countries whereas acute appendicitis is the most frequently seen cause in the developed world.
Most of the gas that accumulates originates from swallowed air, although some is produced within the intestine. The fluid consists of swallowed liquids and gastrointestinal secretions (obstruction stimulates intestinal epithelial water secretion). With ongoing gas and fluid accumulation, the bowel distends and intraluminal and intramural pressures rise. If the intramural pressure becomes high enough, micro vascular perfusion to the intestine is impaired, leading to intestinal ischemia, and, ultimately, necrosis. This condition is termed strangulating bowel obstruction [ 4 ].
Intestinal obstruction continues to remain a challenge to surgeon despite advances in field of medicine, path physiology, surgical technique and conservative management and accounts for a large percentage of surgical admissions for acute abdominal pain and high mortality ranges from 3% to 30% all over the world. Universally, intestinal obstruction varies from country to country or regions in terms of its incidence, causes and management outcomes depending on ethnicity, age group, dietary habits, and geographic location, among other factors as well as living condition of the community[ With only a few studies conducted in north and central Ethiopia [ 5,7] there is a paucity of research about management outcome of IO in Ethiopia, particularly in the West Hararge. Furthermore, there is no recently published literature that has explored IO in rural and regional hospitals. Thus, this study was conducted to fill this information gap and generate base line information about management outcome of IO in CGH, Eastern Ethiopia.

Methods
Study design, period, setting, and population Institutional based cross sectional study was conducted from June 13-18 2018 at Chiro General Hospital, Eastern Ethiopia. Chiro town is found at 328 km to the east of Addis Ababa. The hospital has been provided health care service for more than 1,441, 008 populations in its catchment area in the eastern part of Ethiopia with a total of 166 beds. All medical records of patients surgically treated for intestinal obstruction from from 1 January 2014 to 31 December 2017 were the study populations.
254 patient cards were included in the study.

Data Collection Methods
Data were collected based on structured data abstraction sheet from medical records and registers.
The abstraction sheet includes sociodemographic, type of procedure, and duration of illness variables.

Data Quality Control
Pretest was done on 5% of the sample size. Training was given for data collectors and supervisors on data collection tools and data collection procedure for one day. Data collectors had been supervised closely by the supervisors and the principal investigator. Completeness of each abstraction sheet had been checked by the principal investigator and the supervisors in a daily base. Double data entry was done by two data clerks and consistency of the entered data was cross-checked by SPSS software.
Data processing and analysis Data were entered, coded, cleaned and checked by EpiData statistical software version 4.2.0.0 and analysis was done by using SPSS Version 14 statistical software. Descriptive statistics of different variables had been presented by frequency, percentage tables, and pie chart. Binary logistic regression was used to saw the association between each independent variable with dependent Variable. Descriptive statistics such as proportions, percentages, ratios, frequency distributions and appropriate graphic presentations were used for describing the data. During bi-variable analysis Pvalue < 0.3, seven variables were considered for multivariable logistic regression analysis. All variable during bi-variable analysis, standard of error was below 2.0, hence multi-colliniarity was not present between variables. On multivariable logistic regression analysis, the value of Hosmer lemeshow fit model test was 0.58. Odds ratio along with 95% CI was estimated to identify factors associated with the outcome variable. Level of significance was declared at P-value ≤ 0.05.

Ethical Considerations
Ethical clearance was obtained from Haramaya University, College of Health and Medical Sciences, Institutional Health Research Ethics Review Committee (IHRERC).Then Official letter had been written to Chiro General Hospital for permission and support. The medical record identification information (name and card number) had not been collected and confidentiality maintained. All data collected from the chart kept strictly confidential and used only for the study purpose.

Results
Socio-demographic characteristics of study participants Among 274 patients who were treated surgically for IO during the study periods, 20(7.3%) patients' cards were incomplete files. Therefore, the remaining 254 patients cards treated surgically for intestinal obstruction during the study period were retrieved. The age ranged from 1 to 90 years with a mean age of 34 years and SD of 16.24 years. Thirty two (12%) patients were in age group 55 years or above while the remaining 222 (87%) were in the age group below 55 years. There were 226(89%) males' and 28(11%) females' patients and M: F ratio was 8:1. There were 198(78%) patients from out of Chiro resident and 56(22%) patients from Chiro (Table 1) (Table   3).

Discussion
The magnitude of unfavourable management outcome of IO at Chiro General Hospital was 21.3%. The most unfavourable management outcome of IO was wound site Infection. In current study Old age, late presentation of illness and pre-operative diagnosis of gangrenous bowel were significantly associated with the occurrence of unfavorable management outcome of Intestinal Obstruction. This is in line with the study done Adama(24.6%) [ 10 ] and India (25.89%) [ 11 ]. But the magnitude of unfavourable management outcome of IO in this study was low compared with the reported studies done at Canada (64%)[ ] . This difference may be the cause of IO and type of procedure done (intussusception was the most cause of IO by which highest R&A was done while R&A was significantly associated with management outcome) a study done at Nigeria. This difference may be different studying population and different mean age a study done in both studies. On the contrary, this magnitude was higher than the study done in Kenya (13.6%) [ 14 ]. The possible difference may be residence of a patient in which there were lower proportion of patient came from rural dweller (58.7%) [ 14 ] than this study (78%). Patient who came from urban area or area near to hospital have good awareness on the importance of getting health service early, hence early intervention had lower unfavourable outcome. The other possible reason for the difference SOP (Standard of Procedure) may be applied more properly in the study area of Kenya. Following SOP for every procedure decrease the acquisition of microorganism into surgical wound, hence the lower the infectious organism, the lower the magnitude of unfavourable outcome.
The most post-operative complication was wound site infection (hematoma& incisional SSI) 30(55.5%) followed by post-operative pneumonia 08(14.8%), Anastomotic leak 06(11.1%), 05(9.3%) respectively. The most post-operative complication was similar a study done at Adama, Kenya and Nigeria which accounts 39.3%, 33% and 31.4% respectively among patient develop complication [ 14 ]. But a study done at Canada the most post-operative complication was respiratory complication like pneumonia [ 12 ] which is second complication in this study. This difference may be the lower proportion of malnutrition patient & poor health-seeking behavior and higher standard of life modification style including hygiene in developed nation such as Canada than developing nation such as Ethiopia and other African countries.
Unfavorable outcome of patients with IO was affected by the cause of obstruction, duration of illness, age and complication detection time. [ 15].
In this study, being old age (age ≥55 years) was nearly 3 times more likely to develop unfavorable management outcome of IO, compared with those patients whose ages less than 55 years. This was in line with a study done Gondar [ 5]. This study was contradict with a study done in Adama [ 10 ],in which age of patients were not significant predictor of unfavourable outcome. This may be due to old age group in study area may came early, hence high proportion of favourable outcome.
Generally outcome of patient with surgically treated for IO might be affected by different factors, such as age of patient, residence of patient, duration of illness, cause of obstruction, viability of bowel, type of procedure done and length of hospital stays.
Duration of illness before surgical intervention has significant statistical association with unfavorable management outcome of patients with IO. Patient who came late were about three times more likely to develop unfavorable management outcome, compared patients who came early. This study was similar a studies done in Adama [ 10 ] and Gondar [ 5], in which patients who came late had higher propotion of poor outcome. This was possibly due to poor health-seeking behavior and poor transportation system in this sub-region. Late presentation in case of intestinal obstruction accounts for disastrous outcomes, notably high rate of complications, long hospital stay and high mortality rates [ 2].
In this study unfavorable management outcome of patient with IO were significantly affected by intraoperative finding of gangrenous bowel. Patients with gangrenous SBO and gangrenous LBO were more likely to develop unfavorable management outcome of patient with IO, compared with patients with simple SBO. This study was in line with a study done at Adama [ 10 ].
In this study gender of the patients did not influence the outcome of treatment in terms of morbidity and mortality. This also same in study done at Adama, Nigeria, Ruanda [ 10, 13,16].
In this study unfavorable management outcome were not significantly affected by Intra-operative procedures of bowel resection and anastomosis. This was in contrary with a studies done at Nigeria, Kenya and Adama [ , 13 13 ],in which RA were significantly increase the outcome of unfavourable management outcome.

Limitation of the study
In this study since it was a document review ,some data's were incomplete, as well poor hand writing in some cards and even few cards were missed.
It was impossible to measure some essential parameters, which may significantly contribute for Unfavorable outcome of IO like Educational status of the patients, Occupational status, and House hold income per month since, secondary data was utilized in this study.
There was scarcity of data available in the country, and no similar published data from the region which makes difficult in comparisons of the study.
The results of the study may not show the actual picture of the problem in the community since this study was a facility based study.

Conclusion
In conclusion, the magnitude of unfavourable management outcome of patients with IO who treated surgically at Chiro General Hospital was high; this can result in significant morbidity and mortality.
The common factors associated with unfavourable management outcome of patients with IO who treated surgically were old age, late presentation of illness and gangrenous bowel obstruction. But still magnitude of unfavourable management outcome can be reduced largely through: early detection, fluid resuscitation and electrolyte balance, administration of prophylactic antibiotics prior to operation and properly applying infection prevention protocol and SOP.
Even though, the occurrence of unfavourable management outcome is not preventable but still it can be decreased largely through assessing the risk factors, early recognition and following the standardized management protocol Declarations Ethics approval and consent to participate: Ethical clearance was obtained from Haramaya University, College of Health and Medical Sciences, Institutional Health Research Ethics Review Committee (IHRERC).

Consent to publication: Not applicable
Availability of data and materials: Data will be available upon request from the corresponding author.
Competing interests: The authors declare that they have no competing interests.

Funding: Not applicable
Authors' Contribution: TD1 worked on designing the study, training the data collectors, supervising the data collectors, interpreting the result, preparing the manuscript. TD1, TD,BM, MY analyzed and interpreted the result . BM wrote the manuscript. All authors involved starting from design, data interpretation, to critically review the manuscript.

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