Mattu University

College of Health Sciences

Department of Public Health

By December, 2023

04/04/2024
Ferhan Abdella. [BSc Candidate]
By Ferhan A.[BSc Candidate]
Mattu, Ethiopia
1
Surgical management outcome of bowel obstruction and its associated
factors at Mettu Karl comprehensive specialized hospital, Mettu town, Ilu
aba bora zone, Oromia region, South west ethiopia,2023

ADVISORS:
1. Mr Gebisa Roba (BSc/PHO, MPH/Biost.)
2. Mr Usman Said (MPH in H. nutrition)

2
04/04/2024 By Ferhan A.[BSc Candidate]
 PRESENTATION OUTLINE

INTRODUCTION
Background
Statement of the problem
Significance of the study
Objective
Methods and Materials
Results
Discussion
Strength and Limitation
Conclusion and Recommendation
Acknowledgment

04/04/2024 By Ferhan A.[BSc Candidate] 3

 1. INTRODUCTION
1.1. Background

• Intestinal (bowel) obstruction (IO) is defined as a blockage or partial

blockage of the passage of the intestinal contents. It is a potentially risky
surgical emergency associated with high morbidity and mortality[Ullah, S.,
Khan, M., Mumtaz, N. and Naseer, A., 2009].

• Based on the anatomical location, IO is mainly classified as small bowel

obstruction (SBO) and large bowel obstruction (LBO).[Tiwari, S.J.,

Mulmule, R. and Bijwe, V.N., 2017].

04/04/2024 By Ferhan A.[BSc Candidate] 4
 Cont…

• Intestinal Obstruction was recognized, described, and treated by

Hippocrates (460-370 Before Christ.). At that time, it was believed that
living for God than for man is better if patients with Intestinal obstruction
have reached stage of bowel perforation. Both surgical and conservative
treatment options were tried since 350 Before Christ, but success rate of
both treatments was minimal until the 20th century [Zinner MJ, Ashley SW
2018].
04/04/2024 By Ferhan A.[BSc Candidate] 5
 Cont…

• Regardless of the underlying cause, IO surgery can result in a variety of

postoperative complications such as incisional site infections, wound dehiscence,

pneumonia, and sepsis, which are not uncommon, especially after an emergency

IO surgery, and even death as a result of poor surgical management[Girma, H.,

Negesso, M., Tadese, J., Hussen, R. and Aweke, Z., 2021].

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 Cont…

• Several patient-related and clinical-related factors can influence the

success of surgical therapy [Girma, H., Negesso, M., Tadese, J., Hussen,
R. and Aweke, Z., 2021].

• Little is known about this issue in Ethiopia, and there are no data
available on our specific study location; so, the purpose of this study was
to evaluate the surgical management outcome of IO and its associated
factors at Mettu Karl Comprehensive Specialized Hospital.
04/04/2024 By Ferhan A.[BSc Candidate] 7
 1.2. Statement of the problem

• Intestinal obstruction is a global problem consuming much in terms of

surgical services even in Eastern Europe and North America which is the
leading cause of acute abdomen especially for countries found in the
‘volvulus belt’ regions including Africa, India, Iran, Russia, and
Brazil[Townsend, C.M., Beauchamp, R.D., Evers, B.M. and Mattox, K.L.
eds., 2016].

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 Cont.…

• Globally, 2.1 deaths occur per 100,000 patients due to bowel obstruction,
3.5 deaths per 100,000 in developed countries, and 1.8 deaths in developing
countries [Walker, A.R., Richardson, B.D., Walker, B.F. and Woolford, A.,
1973].

• In rural Africa, acute intestinal obstruction accounts for a great proportion

of morbidity and mortality [Gelfand, M., 1976].

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 Cont.…

Ethiopia is one of the less developed countries where health related morbidity
and mortality are high. One of these major causes is intestinal obstruction.
According to different studies, the prevalence of IO ranges from 21 to 37% of
all surgically treated acute abdominal disorder cases in Ethiopia [Soressa, U.,
Mamo, A., Hiko, D. and Fentahun, N., 2016, Mustefa, M. and Lemessa, O.,
2016, ].

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 Cont.…

• Different Studies conducted in Ethiopia showed that the death rate after the
management of intestinal obstruction cases were 13.6%, 9.2%, and 2.5% in
South, East and Central Ethiopia respectively [Abdifatah, D.S. and Gudina,
E., 2016., Soressa, U., Mamo, A., Hiko, D. and Fentahun, N., 2016,
Demissie, M., 2001].

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 Cont.…

• Studies conducted in Debre Birhan ,Gondar and Mekele showed that the
magnitude of intestinal obstruction was higher than other non-traumatic
acute abdominal surgical cases [Yohannes, M., Fanta, M. and Molla, T.,
2017, Tsegaye, S., Osman, M. and Bekele, A., 2007, Berhane, Y., Girmay,
K. and Gebresilassie, A., 2016].

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 Cont.…

• It has been shown that surgical management can result in unfavourable

outcomes characterised by fatal and nonfatal postoperative complications,

with a high magnitude of unfavourable surgical treatment outcome

[Mariam, T.G., Abate, A.T. and Getnet, M.A., 2019, Lakshmi, Y.A. and

Reddy, K.N., 2020].

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 Cont.…

• Despite the high prevalence of intestinal obstruction, there is a paucity of

data concerning the magnitude and management outcome particularly in

South West Ethiopia. This study fills a gap of information on the

management outcome of intestinal obstruction and its associated factors.

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 1.3. Significance of the study

• Although several studies have been conducted to analyse the surgical

management outcome of IO in Western nations, the issue remains mostly
unstudied in Ethiopia. Only a few researches have been undertaken in north,
south, and central Ethiopia. There is a scarcity of studies on the surgical
management outcome of intestinal obstruction in Ethiopia, particularly in
the country's south western region.

04/04/2024 By Ferhan A.[BSc Candidate] 15

 Cont.…

• Thus, the findings of this study will close the Information gap and
provide baseline data on the surgical management outcome of IO,
which will aid health professionals especially those in charge of
performing surgeries in improving their understanding and patient
care.

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 Cont.…

• It will also assist in identifying the most frequent complications linked to

the surgical management of IO, addressing them effectively, and reducing

those complications for the future.

• Furthermore, the study will assist in enhancing the management of IO and

also assist IO patients in receiving the proper care from the medical facility.

Finally, I hope that findings will be used as an input for additional research

by other researchers.
04/04/2024 By Ferhan A.[BSc Candidate] 17
 2. OBJECTIVES

2.1. General Objective

• To assess the surgical management outcome of bowel obstruction and its

associated factors at Mettu Karl comprehensive specialized hospital, Mettu
Town, Ilu aba bora zone, Oromia region, south west Ethiopia, 2023.

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 2.2. Specific Objectives

• To assess the magnitude of surgical management outcome of bowel

obstruction at Mettu Karl comprehensive specialized hospital, Mettu
Town, Ilu aba bora zone, Oromia region, south west Ethiopia, 2023.

• To identify factors associated with surgical management outcome of

bowel obstruction at Mettu Karl comprehensive specialized hospital
Mettu Town, Ilu aba bora zone, Oromia region, south west Ethiopia,
2023.
04/04/2024 By Ferhan A.[BSc Candidate] 19
 3. METHODS AND MATERIALS

3.1. Study Area

• The research was carried out at Mettu Karl comprehensive specialised

hospital in Illu aba Bora zone, Mettu town, south western Ethiopia. Mettu is
located 600 kilometres from Ethiopia's capital city of Addis Ababa and 265
kilometres from Jimma.

• More than 2 million individuals in the catchment region are served by the
hospital.
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 Cont.…

• All services are provided by 12 specialists, 2 emergency surgeons, 114

nurses, 28 midwives, 13 laboratory technicians, 25 pharmacists, 21 regular
doctors, 1 dental surgeon, 6 anaesthetic nurses, 4 psychiatry nurses, 2
biomedical engineers, 6 radiographers, 2 public health professionals, and
159 supportive staff members, including a cleaner and a guard (From
Human Resource Management Bureau of MKCSH).

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 Cont.…

3.2.Study Design and Period

Hospital Based cross-sectional study was conducted by reviewing the past 2

years (From June 1 2021 to May 30 2023) secondary data on patients’
medical records available at the Mettu Karl Comprehensive Specialized
Hospital (MKCSH).

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 3.3. Population

3.3.1. SOURCE POPULATION

• The source population were all patients who received surgical

management For IO at Mettu Karl comprehensive specialized hospital.

3.3.2. STUDY POPULATION

• The study population comprises selected patients who received surgical

management For IO at Mettu Karl comprehensive specialized hospital.

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 3.4. Inclusion and Exclusion Criteria

3.4.1. INCLUSION CRITERIA

• The study included all cases of intestinal obstruction who were surgically
treated at MKCSH between June 1, 2021 and May 30, 2023.

3.4.2. EXCLUSION CRITERIA

• Patients who went home before completion of treatment, with lost cards and
cards with incomplete data for major variables were excluded.

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 3.4. Inclusion and Exclusion Criteria

3.4.1. INCLUSION CRITERIA

• The study included all cases of intestinal obstruction who were surgically
treated at MKCSH between June 1, 2021 and May 30, 2023.

3.4.2. EXCLUSION CRITERIA

• Patients who went home before completion of treatment, with lost cards and
cards with incomplete data for major variables were excluded.

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 3.5. Sample Size and Sampling Procedure

3.5.1. SAMPLE SIZE DETERMINATION

• The sample size for quantitative study was determined using single

population proportion formula; n= (Zα/2)2 p (1-p)/ d2

• Where: Z= Standard Normal deviation (1.96 for a 95% confidence level)n =

the sample size p= the proportion of the population (take p value 0.754

(75.4%)) from previous study [Mariam, T.G., Abate, A.T. and Getnet, M.A.,

2019.] d=margin of error (d=0.05).

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 Cont.…

• (n) = (1.96)2 x0.754 (1-0.754)

(0.05)2

Sample size (n) = 285

• By adding 10% for loss of data; the final sample size becomes 314.

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 3.5.2. SAMPLING TECHNIQUE AND PROCEDURE

• The simple random sampling technique was used to select the study

participants. A total of 792 patients were admitted to surgical ward of MKCSH

during the study period. During the procedure, the medical record numbers

were sorted from smallest to largest code (1–792). The required sample size

was obtained by using a simple random sampling technique. So, 314 cards

were selected randomly from 792 cards. But, among the sample size, only 285

cards were found with complete data. Cards/Medical records with incomplete

data were excluded from the study.

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 3.6. Variables

3.6.1. DEPENDENT VARIABLE

• Surgical management outcome of IO

3.6.2. INDEPENDENT VARIABLES

• Socio demographic characteristics: age, sex, residence.

• Preoperative clinical characteristics: presenting symptoms, duration of

illness, Time of stay in the hospital before surgery, WBC count,
Haemoglobin Level, preoperative diagnosis, and preoperative cares
received, comorbidity, and previous
04/04/2024
abdominal surgery.
By Ferhan A.[BSc Candidate] 29
 Cont.…

• Intra and postoperative clinical characteristics: intraoperative diagnosis,

type of intraoperative surgical procedure done, postoperative antibiotics
received, and length of hospital stay—after the surgery done until discharge
from the hospital inpatient service.

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 3.7. Data collection tools and method

• The data for the study was collected using a pretested checklist which assesses
socio-demographic variables, history, and outcome of intestinal obstruction.
Data were collected from patient record cards, registration books, and
anaesthesia charts available in the hospital by trained data collectors. First
medical registration numbers (MRN) of patients in the study period identified
from registration books (logbooks), and then their charts had been retrieved
from the card office. Finally, information from patient cards was extracted by
structured Format by three trained collectors.
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 3.8. Data quality management

• Pre-test was done on 5% of the sample size.

• Training was given to data collectors and supervisors on data collection

tools and data collection procedures for one day. Data collectors had been
supervised closely by the supervisors and the principal investigator.

• The completeness of each abstraction sheet had been checked by the

principal investigator and the supervisors daily.

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 3.9. Data analysis

• The collected data were checked for its completeness, coded and entered
into SPSS-22.0 statistical software for Processing and analysis.

• Frequency tables and graphs were used for descriptive analysis.

• Bi-variable and multivariable binary logistic regression was used to identify

factors associated with management outcomes.

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 Cont.…

• All variables with P-value < 0.25 during bi-variable analyses were taken as
candidates for multivariable logistic regression analyses.

• AOR (Adjusted odds ratio) with a 95% confidence interval was used to
show the strength of the association.

• The level of statistical significance was declared at a p-value less than 0.05.

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 3.10. Operational Definition
• Management outcome: the patient's state following the procedure, whether he
or she developed complications, was discharged alive, or died in the hospital.
• Unfavourable Management outcome: the patient's state following the
procedure if he or she develops any postoperative complications or dies before
being discharged from the hospital.
• Favourable Management outcome: the patient's condition following the
procedure and the absence of postoperative problems until the patient is
discharged from the hospital.

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 3.11. Ethical Consideration

• Mattu University Health Science College examined and approved the work.

• The department of public health provided ethical clearance and a

supportive letter.

• Participants' confidentiality was ensured by eliminating their names and

personal identifiers throughout the investigation.

• This study causes no damage or advantage to the patients who participate.

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 3.12. Dissemination of Findings

• The findings of the research will be presented to the Mattu University

Health Science College Department of Public Health.

• Similarly, the findings will be shared to MKCSH via seminar workshop in

order to take on measurements on the recommendations primarily
highlighted by the researcher.

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 4. RESULTS

4.1. Socio demographic characteristics

Variables Category Frequency(n) Percent (%)

Sex Male 193 67.7
Female 92 32.3
Age <5 32 11.2
5-14 6 2.1
15-40 140 49.1
41-60 81 28.4
>60 26 9.1
Residence Urban 57 20
04/04/2024 Rural 228
By Ferhan A.[BSc Candidate] 80 38
 3.2. Preoperative Clinical Characteristics

• The patients experienced a variety of symptoms and signs, the most prevalent of

which were abdominal pain, 254 (89.1%), nausea and vomiting 243 (85.3%),

abdominal distension 233 (81.8%), failure to pass feces/flatus 221 (77.5%) and

fever 59 (20.7%).

• 87 cases (30.5%) arrived within 48 hours of the onset of their illness, and 42

(14.8%) of all IO cases had at least one identified co-morbidity, Diabetes and

hypertension are two examples of such diseases.

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 Cont.…
• This study also found that 113 (39.6%) of the 285 patients had a history of

abdominal or pelvic surgery. SBO 183 (64.2%) was the most common

specific preoperative clinical diagnosis among the patients, followed by

LBO 102 (35.8%).

• Concerning the key elements of preoperative care evaluated in this study,

265 (93.0) patients received IV fluid, 146 (51.2%) received an NG tube, 87

(30.5%) received rectal tube deflation, and 216 (75.8%) received

preoperative prophylactic antibiotics.

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 4.3. Intra and Postoperative clinical
characteristics
Variables Category Frequency(n) Percent (%)
Intraop Diagnosis SSBO 105 36.8
GSBO 39 13.7
SLBO 96 33.7
GLBO 45 15.8
Intraop Procedure Resection and Anastomosis 75 26.3
Untwisting the Volvulus 54 18.9
Manual Reduction 23 8.1
Adhesiolysis and Band Release 60 21.1
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 Cont.…
Herniorrhaphy 12 4.2
Colostomy 54 18.9
Others 7 2.5
Post op antibiotics Not initiated 12 4.21
Initiated <5 days 271 95.1
Initiated >5 days 2 0.7
Length of hospital stay 1-4 days 88 30.9
5-8 days 156 54.7
≥9 days 41 14.4

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 4.4. Magnitude of Surgical management outcome

26% Magnitude of

favorable Surgical
outcome Management
un favorable
outcime outcome

74% of BO at MKCSH
2023 GC.

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 Types of postoperative complications

22.66%

17.33%
13.33%

12.00%

10.66%

9.33%

6.60%

4.00%

2.66%

1.33%
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