Intestinal obstruction is a frequent surgical emergency and is responsible for about 15% of cases of acute abdomen [1]. It is of very high healthcare burden with 3–4% morbidity and mortality in uncomplicated cases and even 30% in strangulation cases [1]. In the UK, it is responsible for almost 51% of emergency laparotomies, reflecting its severity in surgical practice [2]. In India, no cumulative data of the healthcare burden of intestinal obstruction is available, and hence it is hard to estimate the overall morbidity and mortality contribution of intestinal obstruction in India.

The etiology of intestinal obstruction varies significantly among nations with a trend to correlate with the nation's level of development and the economic status of the country's healthcare system. Adhesions are reported to be the most frequent cause of intestinal obstruction in developed nations, but in developing nations and underdeveloped countries, it is unclear whether adhesions or herniated obstructions are the most frequent causes[3,4].

The variation emphasizes the need for region-

specific studies to determine the epidemiology and clinical presentation of intestinal obstruction more comprehensively. There are limited prospective studies from Eastern India evaluating the etiopathogenesis, clinical presentation, and outcome of intestinal obstruction. Results from other parts of India are available and have shown considerable heterogeneity, and it is hence likely that local studies will have to contribute more definitive data regarding the condition. The present study aims to bridge the gap by evaluating the sociodemographic profile, etiology, clinical presentation, and outcome of intestinal obstruction patients in a tertiary care facility in Eastern India. The study findings will be expected to add to the existing knowledge regarding the condition and facilitate the formulation of more specific and effective management algorithms.

Second, the study will identify the therapeutic and diagnostic use of Gastrografin in small bowel obstruction. Gastrografin, being a water-soluble contrast agent, has been used to accelerate the resolution of incomplete small bowel obstruction and thereby prevent surgery. Its efficacy in the local population will provide insight into its use in clinical practice. The study also aims to identify predictors of the outcome of intestinal obstruction that will enable early risk stratification and improved management of patients.

Understanding the etiopathogenesis and clinical patterns of intestinal obstruction in Eastern India will allow comparison across other populations and thus determine region-specific characteristics. It is vital in maximizing the treatment protocols and achieving individualized patient management, eventually reducing morbidity and mortality from this illness.

Study Design and Setting

This was a prospective observational study in the Department of General Surgery, All India Institute of Medical Sciences (AIIMS), Patna. The study was conducted from January 2021 to May 2022, following Institutional Ethics Committee approval (Ref. No. AIIMS/Pat/IEC/PGTh/Jan20/24 dated 01/03/2021). The study aimed to evaluate the clinical profile, etiopathogenesis, and outcomes of intestinal obstruction in patients presenting to the surgical emergency department of AIIMS Patna.

Study Participants

All the patients presenting clinically with intestinal obstruction were included in the study in the surgical emergency department. Duodenal obstruction cases and patients under 16 years of age were excluded. Consent was obtained from all the patients before they were included in the study.

Sampling Strategy

The study utilized the convenient sampling technique, including all the study-eligible patients with intestinal obstruction who were admitted during the study duration. The sample size was computed based on the 7.35% mortality rate utilized in the study by Adhikari et al. With a 7% mortality among intestinal obstruction patients and a 95% response rate assumption, the sample size was computed to be at least 106 in order to estimate the expected mortality with 5% absolute precision and 95% confidence.

Study and Data Collection Protocol All patients presenting symptoms of intestinal obstruction were evaluated according to institutional management guidelines. In-depth demographic information, such as age, sex, body mass index (BMI), comorbidities, smoking and alcohol history, and American Society of Anesthesiologists (ASA) grade, was documented. The patients were categorized into age groups, i.e., 15–30 years, 30–40 years, 40–50 years, 50–60 years, and >60 years. BMI categorization was done according to standard guidelines and categorized the patients into normal (18.5–24.9 kg/m²), overweight (25.0–29.9 kg/m²), and obese (≥30 kg/m²) groups.

Clinical presentation, such as duration of symptoms at presentation, history of previous abdominal surgery, and initial vital parameters like pulse rate, respiratory rate, blood pressure, and clinical signs of peritonitis, were recorded. Metabolic derangements, as identified by arterial blood gas (ABG) analysis, were recorded in terms of pH and lactate levels. Radiological features were evaluated by abdominal X-rays, noting parameters such as multiple air-fluid levels, dilated loops of bowel, gasless abdomen, and lack of rectal gas shadow. The location of the obstruction, either small bowel or large bowel, was identified based on radiographic features.

In patients who were given Gastrografin as a therapeutic and diagnostic measure, serial X-rays at 8, 16, and 24 hours after administration were obtained to assess passage of contrast into the colon. In surgical patients, time from admission to surgery, operative time, and need for stoma formation were assessed. Diagnosis was established on intraoperative findings and histopathological examination.

Outcome Variables and Follow-Up

Postoperative morbidity was meticulously recorded, such as surgical site infection (SSI), anastomotic leak, enterocutaneous fistula, pleural effusion, pneumonia, electrolyte imbalance, metabolic derangement, sepsis, acute respiratory distress syndrome (ARDS), and death. Hospital stay was recorded in all patients.

Follow-up examinations were performed six months post-discharge. Initial follow-up was completed one week post-discharge and monthly for six months. Patients were assessed for recurrence of intestinal obstruction, change in bowel habits, and complications of stoma, including necrosis, prolapse, or retraction. Where physical visits were not possible, follow-up data were collected by telephonic interviews through a validated questionnaire. Recurrence was confirmed by clinical assessment and, where necessary, by CT scans. Deaths during follow-up unrelated to intestinal obstruction were excluded from mortality rates. Patients with three or more missed follow-up visits or telephonic interviews within six months were regarded as lost to follow-up.

Statistical Analysis Statistical Package for the Social Sciences (SPSS) Statistics v26 software (IBM, Armonk, NY) was utilized to analyze the data. Demographic profile, clinical presentation, radiological report, and postoperative outcomes were described in terms of descriptive statistics. Continuous data were presented as mean with SD and categorical data were presented as counts with percentages. Continuous variables were contrasted with two study groups by means of an independent t-test with normality distribution before use. Preoperative variables like vital signs, comorbidities, and metabolic derangements were contrasted with hospital length of stay through use of the independent t-test. For categorical variables like preoperative factors and other outcomes, the chi-square test was applied. Statistical significance was at a two-tailed p-value of less than 0.05 for t-tests and chi-square.

Demographic and Clinical Characteristics

There were 106 patients with intestinal obstruction (IO) who participated in the study. The mean age of the participants was 42.84 years (±17.4), most of whom were 15–30 years old (29.2%). Females comprised 58.5% of the population, and 76.4% had a normal BMI (mean: 21.5 ±2.97 kg/m²). There were no comorbidities for most patients (70.8%), while hypertension (7.5%) and pulmonary diseases (12.2%) were the most frequent pre-existing conditions. More than half (55.7%) were ASA grade I, which represents low risk for surgery (Table 1, Figure 1).

Etiology and Clinical Presentation

Adhesive small bowel obstruction (ASBO, 34.9%) and large bowel cancers (25.6%) were the most common causes of IO (Table 2). Abdominal pain was seen in all the patients, whereas 81.1% had nausea/vomiting, 83% distension, and 78.3% obstipation. Importantly, 23.6% of the patients delayed seeking care for >14 days. Radiographs indicated small bowel obstruction (SBO) in 78.3% of presentations, with dilated loops of bowel in all cases (Table 3).

Interventions and Outcomes

Conservative management resolved 9.4% of symptoms. In 30 patients given gastrografin, 70% (n=21) were successful with contrast arriving in the colon in 8–24 hours (Table 4, Figure 2). Operations were needed for 70.8% (n=75), most commonly resection and anastomosis (33.3%) or ileostomy (22.7%). Postoperative complications were superficial surgical site infections (SSI, 60%), electrolyte disturbances (42.6%), and sepsis (9.3%). Mortality was 6.6% (Table 5).

Predictors of Adverse Outcomes

Tachycardia (p=0.007), tachypnea (p=0.016), and metabolic derangements (p<0.001) on presentation correlated with long hospital stay (mean LOS: 12.85 days in surgical cases vs. 7 days in conservative management; Table 8). Failure to pass Gastrografin was linked with tachypnea (p=0.005) and metabolic derangement (p=0.025) (Table 6).

Follow-up and Recurrence

During a 6-month follow-up, 10.4% experienced recurrence. Stoma complications (prolapse: 6.3%, retraction: 18.8%) were observed in 25% of surgical patients (Table 7).

Tables and Figures

Table 1: Demographic characteristics of the study cohort

Table 2: Etiological distribution of intestinal obstruction Aetiology of IO (N = 106)

Table 3: X-ray Findings at Presentation (N = 106)

Table 4: Results of Administration of Gastrografin Contrast (n = 30)

Table 5:  Outcome of IO in Patients Who Underwent Surgical Intervention (n = 75)

Table 6: Association between Preoperative Characteristics and Gastrografin Challenge Result (n = 30)

*P value by chi-square test; P value <0.05 is statistically significant

Table 7: Follow-up Data of Patients (N=106)

Table 8: Association Between Preoperative Characteristics and Mean Length of Stay (LOS) in Patients with IO (N = 106)

*P-value by independent t-test; ** p-value < 0.05 is statistically significan

Figure 1: Comorbidity status of patients (pie chart)

Figure 2: Time to contrast passage in gastrografin challenge (pie chart).

The work offers important observations regarding the etiologies, clinicopathological patterns, biochemical presentations, morbidity, and mortality of intestinal obstruction in an Eastern Indian tertiary care center. Intestinal obstruction is a leading surgical emergency with high morbidity and mortality rates, even after advances in surgery and critical care management. The diagnosis at early stages and proper intervention are instrumental in better outcomes for patients, especially in developing countries where cases present late.

The age distribution of patients in the study showed that most cases were in the young age group with a mean age of 42.8 years and higher frequency in females (59%). This is in contrast to some studies where male predominance has been noted. The incidence of comorbidities was low, as would be expected in the younger age group, but the incidence of tuberculosis and obstructive pulmonary diseases in a subgroup of patients underlines the

importance of proper assessment of underlying health conditions in patients presenting with intestinal obstruction. The history of previous abdominal surgery was notable, with 43% of patients having had at least one previous operation, most often appendectomy or hysterectomy. This is consistent with international literature that indicates adhesions continue to be a leading cause of intestinal obstruction, especially in developed countries where elective hernia repair and enhanced cancer screening have decreased the number of obstructed hernias[5,6,7,8].

Delayed patient presentation to the emergency department was one of the worrying findings in this study. The mean duration of the symptoms was five days, with 37% of the patients coming in eight days after symptom onset. Delays in seeking care are an important cause for bowel ischemia, peritonitis, and higher morbidity. Inequitable access to healthcare, low awareness, and economic factors must be contributing reasons for delay in Bihar. Effective healthcare-seeking behavior needs to be promoted through better community awareness schemes. The research revealed that 35% of the patients presented with tachycardia, 18% with tachypnea, 2% with hypotension, and 14% with moderate dehydration on presentation. These results indicate that a significant percentage of patients already presented with evidence of bowel ischemia or sepsis, and thus early surgery is required.

The research noted that small bowel obstruction (78%) was significantly more prevalent compared to large bowel obstruction (22%), which is consistent with international trends. Among the etiological factors, adhesions were the most frequent (35%), followed by malignancies of the large bowel (26%) and abdominal tuberculosis (20%). These results reflect the trends observed in other Indian studies, with obstructed hernias being more frequent in low-resource environments in which elective hernia repair is not common[3,9-11]. The relatively high incidence of tuberculosis obstruction in this study serves to remind of the continuing burden of tuberculosis in India, much of which presents in the form of adhesions or strictures producing obstruction. Carcinoma of the rectum and ascending colon, the second most frequent cause of large bowel malignancies, highlights the imperative for intensified screening measures and early intervention.

With respect to management, conservative management succeeded in only 10% of patients, considering the severity of cases in this study. Gastrografin challenge was utilized in 30 adhesive small bowel obstruction (ASBO) patients, with success in 70%. The predictive role of gastrografin for surgical need has been documented well, and in the present study, gastrografin failure to pass within 24 hours was found to be highly correlated with tachypnea and metabolic disturbances. This confirms the role of gastrografin not only in therapeutic management but also in the early detection of patients needing surgery. Evidence is available from literature to confirm high sensitivity and specificity of gastrografin for prediction of resolution of ASBO without surgery with area under ROC curve 0.98 [12]. Moreover, the decreased length of stay found in conservatively treated patients by gastrografin, as substantiated by systematic reviews, forms a key aspect to maximize utilization of resources [13].

70.8% of patients needed surgical intervention, which was most frequently for failed conservative management, bowel ischemia, or total obstruction. Bowel resection was done in 33% of surgical patients for reasons like gangrenous bowel, strictures, malignancy, intussusception, or volvulus. Anastomotic leak was seen in 4 patients, which required diversion stomas. The research also identified a comparatively high incidence of emergency hernia repair with mesh insertion in six patients, none of whom developed recurrence or mesh-related complications during follow-up. While mesh insertion in contaminated fields is still controversial, this observation concurs with growing evidence that well-selected cases can be safely treated with mesh insertion in emergency situations without added postoperative morbidity.

The overall mortality in the study was 6.6%, which compares well with other Indian and international studies[3,9-11]. The conditions related to higher morbidity were high duration of symptoms, tachycardia, tachypnea, hypotension, dehydration, metabolic derangements, and high lactate levels (>2 mmol/L) on presentation. The results reinforce the need for early identification of high-risk patients and aggressive resuscitation followed by early surgical intervention. Postoperative complications were prevalent, with 76% of the patients having surgical site infections (SSI), such as superficial (60%) and deep (16%) infections. Other significant complications included postoperative pleural effusion (21%) and electrolyte imbalance (43%). Poor preoperative factors like hypoalbuminemia and anemia were key to causing these complications. The average length of stay in hospital was 12.85 days for operative patients, while conservatively managed or gastrografin challenge patients spent roughly seven days in the hospital. This highlights the importance of the implementation of measures to minimize preoperative delay in order to enhance outcomes and reduce hospital load.

Stoma creation was necessary in 32 patients, and stoma complications like retraction (6 patients) and prolapse (2 patients) were noted on follow-up. The high rate of stoma creation in this study can be explained by delayed presentations, higher rates of bowel ischemia, and poor preoperative biochemical status. These observations underscore the need for early surgical decision-making to prevent the necessity for large resections and stomas.

The results of the study concur with the current literature that states delayed presentation, metabolic derangement, and hemodynamic instability are predictors of bad outcomes in intestinal obstruction. Though no predictors for mortality were seen, sepsis, dehydration, and electrolyte imbalance were significant causes for increased morbidity. Bankole et al.'s study also pointed out in a similar fashion that tachycardia, pyrexia, and electrolyte imbalances were predictors of bad outcomes [4]. Future work must concentrate on predictive models with clinical, biochemical, and radiological parameters to inform early intervention practices.

Notwithstanding its important findings, this work was subject to some limitations. The follow-up period was only six months, limiting the capacity to evaluate long-term recurrence of ASBO or complications from mesh placement in obstructed hernia repairs. Moreover, being an observational study, it did not have a comparative control group, which would have been more convincing evidence for the efficacy of gastrografin challenge in management. More prospective controlled trials are required to confirm these results and tailor management protocols for intestinal obstruction in resource-poor settings.

Finally, our research confirms that adhesions continue to be the most frequent etiology of intestinal obstruction in Eastern India, with significant abdominal tuberculosis burden for obstruction, and evidence of regional etiologic variations. Delayed presentation with evidence of bowel ischemia was a key predictor of increased morbidity, which underscores the necessity for better healthcare awareness and accessibility. The use of gastrografin in the resolution of adhesive small bowel obstruction is promising, but larger randomized controlled trials are needed to confirm its therapeutic value. Our results also indicate that in obstructed hernias without strangulation, mesh repair is associated with good outcomes without postoperative mesh-related complications. Preoperative patient vitals and metabolic state are key to predicting prognosis, underscoring the need for prompt diagnosis, optimal preoperative optimization, and prompt surgical intervention in order to enhance overall results.

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