Material and Methods
The medical records of adult patients (>18 years old) who hospitalized due to SBO in Mus State Hospital, which is a rural hospital in East Turkey, between May 2018 and September 2019 were collected prospectively and reviewed retrospectively. Patient data were collected from the patient files and hospital software database.
Patients with SBO due to excessive consumption of oleaster-leafed pear(Figure 1) and patients with adhesive SBO were included in the study. Patients with an incarcerated hernia, internal hernia, primary malignant obstruction, bezoars, gallstone ileus, drug / hypokalemia-related paralytic ileus, volvulus, intussusception, any colonic obstruction, and early (≤ 6 weeks from index abdominal operation) postoperative obstruction were excluded. Patients with haematological disorders, chronic renal failure, urinary system disease, congestive heart failure, active cancer, and those with incomplete records were also excluded from the study. After the initial evaluation, 74 patients who met the study criteria were included. Patients were divided into two groups as SBO due to excessive consumption of wild pear (Group 1), and adhesive SBO (Group 2).
Patient characteristics such as age, sex, comorbid diseases, number of previous abdominal operations and type of incisions, history of previous intestinal obstruction; and clinical features including duration of complaints, duration of hospital stay, duration of nasogastric tube drainage, time of enteral feeding, duration of radiological recovery (time until the disappearance of air-fluid levels on erect plain radiograph), operations and presence of recurrence during the follow-up were reviewed. In addition, blood parameters including white blood cell (WBC) (reference range: 4500-10000/μL), C-reactive protein (CRP) (reference range: 0-5 mg/dL), blood urea nitrogen (BUN) (reference range: 8-20 mg/dL), creatinine (reference range: 0.6-1.2 mg/dL for men and 0.5-1.1 mg/dL for women), BUN/creatinine ratio (reference range: 10-20) and potassium values (reference range: 3.5–5.1 mmol/L) were noted at the day of admission to the emergency department in all patients. Approximate amount of wild pear which patients in Group 1 consumed was also recorded at the first admission. Patient characteristics and study parameters were compared between the two groups.
All patients were evaluated in emergency service. Diagnosis of bowel obstruction was established according to history, physical examination, laboratory and radiological examination (Figure 2) of the patients. The last meal/food before the complaints started were questioned. In suspicion of bowel obstruction, a nasogastric tube and urinary catheter were inserted and an enema was applied. Enteral feeding was stopped and the intravenous fluid was administered. Patients whose clinical evaluation was compatible with a complete obstruction underwent emergency surgery. When partial bowel obstruction were determined, patients were hospitalized for further examination and management. Patients with a partial obstruction were administered intravenous fluid and enema, and oral intake was stopped. Daily blood parameters and plain abdominal radiographs were performed. If clinical improvement was obtained, nasogastric and urinary catheters were removed and oral intake was started. If there was no response to conservative treatment in the first 72 hours or peritoneal irritation signs appeared in any time, surgical intervention was decided. Open surgery was the preferred approach due to lack of experience in laparoscopic adhesiolysis. The colonoscopic examination was performed to exclude colonic obstruction if a patient has not undergone colonoscopy in the last one year. Follow-up of the patients continued until May 2020.
Written permission for this study was obtained from the administration of the Mus State Hospital (Date: 04/30/2020, Decision No: 7407). Ethics committee approval was obtained from the Non-Interventional Clinical Studies Institutionel Review Board of Izmir Kâtip Celebi University (Decision number: 877, Decision date: 09.17.2020) due to the absence of a local ethics committee in Mus city. Written informed consents were obtained from all patients. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki.