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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 18  |  Issue : 1  |  Page : 1-4

Changing pattern of adult intestinal obstruction in Nigeria: A narrative review


1 Department of Surgery, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi State, Nigeria
2 Department of Surgery, Aminu Kano Teaching Hospital, Kano State, Nigeria

Date of Submission15-May-2020
Date of Decision06-Dec-2020
Date of Acceptance27-Jan-2021
Date of Web Publication4-May-2021

Correspondence Address:
Dr. Ibrahim Umar Garzali
Department of Surgery, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_14_20

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  Abstract 


Intestinal obstruction is a failure of craniocaudal propagation of intestinal contents and may be due to a mechanical or functional pathology. Acute mechanical intestinal obstruction is one of the leading causes of surgical admissions in most emergency departments worldwide and is a significant cause of morbidity and mortality, especially when associated with bowel gangrene or perforation. It accounts for 15% of all emergency visits from acute abdominal pain. In Nigeria and most of Africa, external hernias were the main causes of intestinal obstruction throughout the 20th century; however, at the onset of the 21st century, some reports have shown a rising frequency of adhesive obstruction in our environment. We conduct this narrative review to determine if there is a changing pattern of adult intestinal obstruction in Nigeria. Literature search was conducted by two independent reviewers. The keywords used were “adult,” “intestinal obstruction,” “cause,” and “Nigeria.” The keywords were combined using the Boolean logic. The keywords were searched in PubMed and Google Scholar. The overall mean age of the study population is 44.3 years, with a male-to-female ratio of 3.6:1. Of the 1435 cases of intestinal obstruction reported in the studies selected, post-operative adhesive intestinal obstruction was responsible for 590 of them, which is equivalent to 41.1% of all the obstruction. Obstructed external hernias were responsible for 357 cases of obstruction, which is equivalent to 25.9%. The most common cause of intestinal obstruction in Nigeria is post-operative adhesion.

Keywords: Adult, intestinal obstruction, Nigeria, pattern


How to cite this article:
Garzali IU, El-Yakub AI. Changing pattern of adult intestinal obstruction in Nigeria: A narrative review. Niger J Basic Clin Sci 2021;18:1-4

How to cite this URL:
Garzali IU, El-Yakub AI. Changing pattern of adult intestinal obstruction in Nigeria: A narrative review. Niger J Basic Clin Sci [serial online] 2021 [cited 2021 Nov 28];18:1-4. Available from: https://www.njbcs.net/text.asp?2021/18/1/1/315406




  Background Top


Intestinal obstruction is a failure of craniocaudal propagation of intestinal contents and may be due to a mechanical or functional pathology.[1] Acute mechanical intestinal obstruction is one of the leading causes of surgical admissions in most emergency departments worldwide and is a significant cause of morbidity and mortality, especially when associated with bowel gangrene or perforation.[1],[2] It accounts for 15% of all emergency visits from acute abdominal pain.[3],[4] The mortality of intestinal obstruction has reduced with better understanding of pathophysiology, improvement in diagnosis, fluid and electrolyte resuscitation, potent antibiotics, nasogastric tube decompression and improvement of surgical techniques and anaesthesia; still, mortality ranges from 3% for simple obstruction to 30% when there is perforation or vascular compromise.[4],[5],[6]

The aetiology of intestinal obstruction varies remarkably from country to country.[7],[8],[9] At the turn of the 20th century, external hernia accounts for more than half of the causes of intestinal obstruction worldwide; however, by mid-century, there was an increased elective hernia repair which was responsible for the drop of hernia from the most common cause to the third most common cause of obstruction.[3] With increasing elective hernioraphies and other abdominal surgeries in the industrialised nation, hernia was replaced by post-operative adhesion as the most common cause of intestinal obstruction.[10],[11],[12]

In Nigeria and most of Africa, external hernias were the main cause of intestinal obstruction throughout the 20th century;[11],[13],[14],[15],[16] however, at the onset of the 21st century, some reports have shown a rising frequency of adhesive obstruction in our environment.[17],[18],[19]

We conduct this narrative review to determine if there is a changing pattern of adult intestinal obstruction in Nigeria.


  Methods Top


This is a narrative review of studies that assessed the aetiology of intestinal obstruction across Nigeria.

Search strategy

Literature search was conducted by two independent reviewers from 3rd April through 30th April 2020. The keywords used were “adult,” “intestinal obstruction,” “cause” and “Nigeria.” The keywords were combined using the Boolean logic. The keywords were searched in PubMed and Google Scholar. Only studies published in English language were included. Related articles and reference list were also searched manually to avoid omission. The titles of the studies were screened and abstracts were evaluated for inclusion or exclusion.

Study selection

Inclusion criteria

  1. Studies conducted in Nigeria
  2. Retrospective and prospective studies that reported the most common causes of intestinal obstruction in the study
  3. Studies published from 1st January 2005 onward
  4. Mean age of the study population greater than 18 years.


Exclusion criteria

  1. Study population less than 18 years of age
  2. Studies outside the Nigeria.


Data extraction

Data were extracted by two independent researchers. The extracted data included the following:

  1. State in which the study was conducted
  2. Lead author
  3. City in which the study was conducted
  4. The mean age of the study population
  5. The male-to-female ratio of the study population
  6. Sample size
  7. Year of publication
  8. The most common causes of intestinal obstruction in the selected study
  9. The number of obstruction caused by obstructed external hernia in the selected study
  10. The number of obstruction caused by post-operative adhesion in the selected study.


Data synthesis and analysis

The pooled sample size (Np) was calculated as the summation of individual sample size of the studies selected.

In each study selected, the most common cause of obstruction was identified. The number of patients affected by that external hernia and post-operative adhesion in each study was noted and identifies as n with the abbreviation of the disease as subscript. For hernia in the first study, the number of patients will be “n1hern,” and for adhesion, the number of patients will be “n1adh.” The same applies for the second study with 1 replaced with 2, i.e., “n2hern” and “n2adh” and so on.

The pooled number of patients affected by the diseases after the review is calculated as a summation of number affected by the disease in each study.

For example, pooled number of patients affected by hernia after the review is Nphern:

Nphern = n1hern + n2hern + n3hern +… + nXhern.

The pooled number of patients affected by adhesive intestinal obstruction after the review is Npadh:

Npadh = n1adh + n2adh + n3adh +… + nXadh.

The percentage of patients affected by the disease is achieved by dividing the pooled number of patients affected by the disease to the pooled sample size multiplied by a 100.

Percentage of obstruction caused by hernia = Nphern/Np × 100

Percentage of obstruction caused by adhesion = Npadh/Np × 100

The disease with the highest percentage will be the most common cause of obstruction in Nigeria.


  Results Top


The study selection process is presented in [Figure 1]. The literature search yielded 53 potentially relevant publications. We removed three duplicate studies after screening the titles. After evaluating the abstract of each study, 40 studies were excluded because they did not meet the inclusion criteria.
Figure 1: Study selection process

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Subsequently, we carefully read the full text of each of the remaining 10 studies.

As shown in [Table 1], the eligible studies were conducted from 2005 through 2018 with a total number of 1435 patients, and the sample size ranged from 38 to 372. Among them, three studies were conducted in Northern Nigeria and seven were conducted in southern part of Nigeria.
Table 1: Key parameters extracted from the included studies

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Six of the studies were of the retrospective study design while four were of the prospective study design.

The overall mean age of the study population is 44.3 years, with a male-to-female ratio of 3.6:1. Of the 1435 cases of intestinal obstruction reported in the studies selected, post-operative adhesive intestinal obstruction was responsible for 590 of them, which is equivalent to 41.1% of all the obstruction. Obstructed external hernias were responsible for 357 cases of obstruction, which is equivalent to 25.9%.


  Discussion Top


Adult intestinal obstruction accounts for 15% of all emergency visits from acute abdominal pain.[3],[4] The mortality of intestinal obstruction has reduced with better understanding of pathophysiology, improvement in diagnosis, fluid and electrolyte resuscitation, potent antibiotics, nasogastric tube decompression and improvement of surgical techniques and anaesthesia; still, mortality ranges from 3% for simple obstruction to 30% when there are perforation and/or vascular compromise.[4],[5],[6]

The cause of intestinal obstruction varies from country to country, with post-operative adhesive obstruction being the most common in industrialised nation.[10],[11],[12] In most developing Nations of Africa, hernia was the most common cause of obstruction and this was attributed to poor health-seeking behaviour of the population.[11],[13],[14],[15],[16] Our study however revealed that the most common cause of obstruction in Nigeria was post-operative adhesion, accounting for 41.1% of all intestinal obstruction. This is similar to studies by Malik et al. in Pakistan and Catena et al. in Italy.[2],[26] The rise may be attributed to improved access to healthcare in Nigeria with Increased elective abdominal surgeries.

Obstructed external hernia accounted for 25.9% of all obstructions in the study. This is less than former reports of intestinal obstruction where hernia constitutes about 38% of all obstructions in Ibadan as reported by Irabor et al.[15] in 2002 or reported by Adisa and Mbanaso[13] in which intestinal obstructed hernia constitutes 56.9% of all obstruction in Aba, Abia State. The fall of hernia as a cause of intestinal obstruction may be attributed to increased utilisation of community-based elective hernia repair during community surgical outreaches as well as quality day-case hernia surgery in most tertiary institutions.[22]


  Conclusion Top


The most common cause of intestinal obstruction in Nigeria is post-operative adhesion. This indicates a change in the pattern of the aetiology of the obstruction to mirror that of the developed world.

Acknowledgement

The authors will want to acknowledge Dr Rabiu Ibrahim Jalo for his contribution in the data extraction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Irabor DO, Ladipo JK, Aghahowa M, Ogunmodede IA, Aisudionoe-Shadrack OI. The “Ibadan intussusception”; now a myth? A 10 year review of adult intestinal obstruction in Ibadan, Nigeria. West Afr J Med 2002;21:305-6.  Back to cited text no. 15
    
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Dodiyi-Manuel A. Adult intestinal obstruction in Braithwaite Memorial Specialist Hospital, Port Harcourt, Nigeria: A 3-year review. Port Harcourt Med J 2012;6: 34-7  Back to cited text no. 21
    
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Ojo EO, Ihezue CH, Sule AZ, Ismaila OB, Dauda AM, Adejumo AA. Aetiology, clinical pattern and outcome of adult intestinal obstruction in Jos, North Central Nigeria. Afr J Med Med Sci 2015;43:29-36.  Back to cited text no. 22
    
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