Factors affecting outcomes of patients with intestinal obstruction operatively managed at Alotau Provincial Hospital: a hospital-based cross-sectional study
Isaiah Borchem A , Ian Umo A * and Kennedy James AA
Abstract
Intestinal obstruction (IO) is the complete or partial blockage of the passage of intestinal contents. In Papua New Guinea, little is known about outcomes of IO. The aim of this study was to describe the operative outcomes of patients with IO and identify the factors associated with unfavourable outcomes at Alotau Provincial Hospital (APH).
A hospital-based cross-sectional study of patients diagnosed clinically with IO at APH was conducted from 1 January 2020 to 31 December 2022. Potential factors associated with having an unfavourable outcome were assessed using univariate logistic regression to determine the odds ratios (ORs). A P-value <0.05 was considered significant.
A total of 95 persons were admitted between 1 January 2020 and 31 December 2022 with IO requiring surgery. The median age was 34.8 years, and 65.2% (n = 62) of persons were males (65.2%). Adhesions were the most common cause of IO in this study, accounting for 27.4% (n = 26) of cases. There were significant odds of increased unfavourable outcome in persons with vomiting (OR 9.75, 95% CI 2.38–66.7, P = 0.001), abdominal distension (OR 2.30, 95% CI 1.14–8.52, P = 0.01), dehydration (OR 6.89, 95% CI 2.43–22.53, P = 0.0001), tachycardia (OR 3.80, 95% CI 1.39–11.45, P = 0.004), fever (OR 4.19, 95% CI 1.78–10.20, P = 0.0001), tachypnoea (OR 3.94, 95% CI 1.09–18.61, P = 0.01), hypotension (OR 1.85, 95% CI 1.21–2.85, P = 0.03), signs of IO on erect abdominal radiograph (OR 2.56, 95% CI 1.09–6.21, P = 0.01), leucocytosis (OR 4.19, 95% CI 1.78–10.2, P = < 0.0001), granulocytosis (OR 3.2, 95% CI 1.38–7.61, P = 0.003), and intensive care unit (ICU) admission (OR 6.3, 95% CI 1.98–24.01, P = 0.0001).
Intestinal obstruction remains a major surgical burden at APH, with adhesions being the most common cause. Clinical indicators such as vomiting, abdominal distension, dehydration, systemic inflammatory response, and ICU admission were significantly associated with unfavourable outcomes. These findings emphasise the importance of early recognition, timely referral, and surgical intervention, as well as the need to strengthen perioperative and critical care services in resource-limited settings such as Papua New Guinea.
Keywords: Alotau Provincial Hospital, bowel obstruction, intestinal obstruction, Milne Bay Province, mortality, outcomes, Papua New Guinea, risk factors.
Introduction
Intestinal obstruction (IO) is the complete or partial blockage of the passage of intestinal contents.1 In 2015, the World Health Organization reported 3.2 million cases of IOs, with a global mortality rate of 8.2%.2 Gender and age distributions of IOs differ with varying populations; however, the burden is evident in most low- to middle-income countries (LMICs) of Africa and South East Asia.1–3
In high-income countries, Crohn’s disease and neoplasms are the most common causes of IOs, compared with hernias and tuberculosis in more underdeveloped countries.4,5 A study by James et al. reported the surgical burden of IO to be the second most common surgical emergency seen in Papua New Guinea (PNG).6
Regardless of the aetiology, patients with small bowel obstruction can have impaired digestion and absorption of nutrients, and those with large bowel obstruction can experience impaired vitamin synthesis, water absorption, and bilirubin breakdown.4 If left untreated, the financial burden of surgically managing IOs can cost up to US$13,303.46 per patient.7
Management of IOs is associated with a high surgical burden and can be complicated by age, aetiology, location of obstruction, malnutrition, and delay in treatment.8 The availability of infrastructure, consumables, intensive care services, and general surgeons can influence the outcomes of such critically ill patients in resource-limited settings. Most studies on IO outcomes in LMICs have been conducted in Africa and Asia, with limited data within the Western Pacific Region.1–3
In PNG there have been no studies conducted on operative IO outcomes, and this further contributes to the lack of epidemiological studies within the Pacific region. Given the current knowledge gap, the aim of this study was to describe the operative outcomes of patients with IO and identify the factors associated with unfavourable outcomes in Alotau Provincial Hospital (APH) of PNG.
Materials and methods
Study design
A hospital-based cross-sectional study of patients diagnosed clinically with IO at APH was conducted from 1 January 2020 to 31 December 2022.
Study setting
APH is the only surgery-capable referral hospital in the Milne Bay Province of PNG, and it largely serves a maritime population of 339,275 people.9 The surgical ward has a 32-bed capacity and two functional operating theatres that provide for safe surgery and anaesthesia. Surgical services are provided by one paediatric surgeon, one general surgeon, three surgical registrars, and one clinical health extension officer.
Study participants
The inclusion criteria for the study were consecutive patients admitted with partial or complete non-traumatic clinical IO managed operatively. The criteria for operative management were persons with IO that had either no improvement on conservative management for 48 h or peritonism on abdominal palpation. Conservative management involved keeping patients nil by mouth, insertion of a nasogastric tube and indwelling catheter for drainage, electrolyte and hydration optimisation, and regular intravenous antibiotics for up to 48 h. Patients with traumatic bowel obstruction or missing information from their charts and those who absconded from treatment were excluded from the study.
The minimum sample size was obtained using the Yamane formula (n = N/1 + N (e)2);10 where n = sample size, e = margin of error, and N = population size. Population size (N) was 120 (number of bowel obstruction cases from 2020 to 2022). Margin of error (e) was taken as 0.05. The minimum sample size was calculated to be 92.
Variables and data collection
A standard data collection form was used to enter data on patient demographic and clinical characteristics. All data were obtained from patient charts. These data were then verified by a separate investigator and entered into an Excel spreadsheet for analysis.
Demographic variables included age, sex, residency, and occupation. Age was reported in years. Sex was reported as either male or female. Occupation was reported as either ‘yes’ for being employed or ‘no’ for lacking any form of employment.
Clinical data included referral, time of presentation, constipation, abdominal pain, vomiting, abdominal distension, obstipation, hematochezia, previous abdominal surgery, comorbidities, dehydration, tachycardia, fever, tachypnoea, hypotension, oliguria, erect abdominal radiograph, erect abdominal radiograph with signs of IO, complete bowel obstruction, leucocytosis, granulocytosis, anaemia, thrombocytopenia, increased creatinine, hypokalaemia, diagnosis, mechanical obstruction, time to operation, intraoperative time, operation findings, surgeon, and mortality.
Referral was reported as either being referred from a health centre to APH (yes) or presenting directly to APH (no). Time to presentation was reported as either more than 24 h (yes) or less than 24 h (no) to being admitted by the surgical team and did not include conservative management. Constipation in this study referred to having three or fewer bowel movements in a week. Hematochezia was defined as passage of fresh blood per anus, with or without stools.
Previous abdominal surgery was reported as either yes or no. Comorbidities included other unassociated medical conditions not related to the IO and were reported as either yes or no for the presence of these comorbidities. Fever was defined as being equal to or higher than 37.5°C on admission. Tachypnoea was breathing rate of more than 25 breaths per minute on admission. Tachycardia was heart rate of more than 100 beats per minute on admission. Hypotension was defined as systolic blood pressure less than 90 mmHg on admission.
For patients who had erect abdominal radiographs done, radiograph findings of three or more air fluid levels were radiographically assessed as IO. Persons with abdominal distension, abdominal pain, constipation and vomiting were assessed as having complete clinical bowel obstruction.
Leucocytosis was defined as a white cell count of more than 10,000/cm3. Thrombocytopenia was reported for persons with platelet counts less than 100,000/cm3. Increased creatinine was reported for creatinine values more than 133 µmol/L, and hypokalaemia was defined as potassium levels less than 3 mEq/L.
Time to operation was reported as either less than 24 h or more than 24 h. Intraoperative time was reported as either being less than 2 h or more than 2 h. Mechanical obstruction was defined in this study as intraoperative findings of obstruction as a result of extramural causes. Operation referred to the type of surgical procedure done intraoperatively, and surgeon referred to the lead surgeon either being the specialist surgeon or surgical registrar. Patients were admitted to the intensive care unit if they were in sepsis and required ventilator support post-surgery. Mortality was defined in this study as intraoperative death or in-hospital perioperative death up to 1 month post-surgery. Unfavourable outcomes, defined as death or postoperative complication prior to discharge from hospital (see Table 1 for list of complications), were the outcomes of interest.
Complications | Number (%) | |
---|---|---|
Sepsis | 18 (41.86) | |
Wound infection | 10 (23.26) | |
Malnutrition | 6 (13.95) | |
Anaemia secondary to intraoperative blood loss | 2 (4.65) | |
Pneumonia | 2 (4.65) | |
Bladder injury | 1 (2.33) | |
Heart failure | 1 (2.33) | |
Peptic ulcer disease | 1 (2.33) | |
Incisional hernia | 1 (2.33) | |
Seroma | 1 (2.33) |
Statistical analysis
Statistical analysis was performed using Open Epi Info version 3.01. Categorical variables were reported as numbers (percentages) and continuous variables as mean (95% confidence interval [CI]) or median (interquartile range) depending on their frequency distribution.
Potential factors associated with having an unfavourable outcome were assessed using univariate logistic regression to determine the odds ratios (ORs). A P-value <0.05 was considered significant.
Results
A total of 95 persons were admitted between 1 January 2020 and 31 December 2022 with IO requiring surgery. The median age was 34.8 years, and 65.2% (n = 62) of persons were males (65.2%). Adhesions were the most common cause of IO in this study, accounting for 27.4% (n = 26) of cases, as shown in Fig. 1. Of these cases, 20 had previous surgery.
Showing the number of surgical conditions causing intestinal obstructions from 1 January 2020 to 31 December 2022 at APH. TB; tuberculosis.

The complication rate was 45% (n = 43). Among those with complications, there were two deaths, giving a mortality rate of 2%. The median length of hospital stay was 6 days. Patient demographic and clinical characteristics are shown in Table 2.
Characteristics | Total (n = 95) | Unfavourable outcome (n = 43) | Favourable outcome (n = 52) | Odds ratio (CI 95%) | P-value | |
---|---|---|---|---|---|---|
Sex | ||||||
Male | 62 | 27 | 35 | 0.82 (0.35–1.94) | 0.33 | |
Female | 33 | 16 | 17 | |||
Occupation | ||||||
Yes | 20 | 8 | 12 | 0.76 (0.27–2.10) | 0.3 | |
No | 75 | 35 | 40 | |||
Referral | ||||||
Yes | 65 | 30 | 35 | 1.12 (0.46–2.73) | 0.4 | |
No | 30 | 13 | 17 | |||
Time to presentation >24 h | ||||||
Yes | 74 | 36 | 38 | 1.88 (0.69–5.51) | 0.11 | |
No | 21 | 7 | 14 | |||
Abdominal pain | ||||||
Yes | 80 | 39 | 41 | 2.59 (0.78–10.11) | 0.06 | |
No | 15 | 4 | 11 | |||
Vomiting | ||||||
Yes | 76 | 41 | 35 | 9.75 (2.38–66.27) | <0.001 | |
No | 19 | 2 | 17 | |||
Abdominal distension | ||||||
Yes | 68 | 35 | 33 | 2.30 (1.14–8.52) | 0.01 | |
No | 27 | 7 | 20 | |||
Constipation | ||||||
Yes | 79 | 35 | 44 | 0.80 (0.26–2.42) | 0.34 | |
No | 16 | 8 | 8 | |||
Hematochezia | ||||||
Yes | 18 | 11 | 7 | 2.19 (0.76–6.61) | 0.07 | |
No | 77 | 32 | 45 | |||
Complete intestinal obstruction | ||||||
Yes | 48 | 25 | 23 | 1.74 (0.76–40.72) | 0.09 | |
No | 47 | 18 | 29 | |||
Previous abdominal surgery | ||||||
Yes | 20 | 8 | 12 | 0.76 (0.27–2.10) | 0.3 | |
No | 75 | 35 | 40 | |||
Dehydration | ||||||
Yes | 65 | 38 | 27 | 6.89 (2.43–22.53) | <0.001 | |
No | 30 | 5 | 25 | |||
Tachycardia | ||||||
Yes | 69 | 37 | 32 | 3.80 (1.39–11.49) | 0.004 | |
No | 26 | 6 | 20 | |||
Fever | ||||||
Yes | 46 | 29 | 17 | 4.19 (1.78–10.20) | <0.0001 | |
No | 49 | 14 | 35 | |||
Tachypnoea | ||||||
Yes | 80 | 40 | 40 | 3.94 (1.09–18.61) | 0.01 | |
No | 15 | 3 | 12 | |||
Hypotension | ||||||
Yes | 9 | 7 | 2 | 1.85 (1.21–2.85) | 0.03 | |
No | 86 | 36 | 50 | |||
Signs of intestinal obstruction on erect abdominal radiograph | ||||||
Yes | 57 | 31 | 26 | 2.56 (1.09–6.21) | 0.01 | |
No | 38 | 12 | 26 | |||
Leucocytosis | ||||||
Yes | 46 | 29 | 17 | 4.19 (1.78–10.2) | <0.0001 | |
No | 49 | 14 | 35 | |||
Granulocytosis | ||||||
Yes | 47 | 28 | 19 | 3.2 (1.38–7.61) | 0.003 | |
No | 48 | 15 | 33 | |||
Anaemia | ||||||
Yes | 20 | 12 | 8 | 2.11 (0.77–6.03) | 0.07 | |
No | 75 | 31 | 44 | |||
Thrombocytopenia | ||||||
Yes | 10 | 7 | 3 | 1.91 (0.53–9.01) | 0.18 | |
No | 85 | 36 | 49 | |||
Creatinine >133 µmol/L | ||||||
Yes | 27 | 17 | 10 | 2.72 (1.08–7.06) | 0.01 | |
No | 68 | 26 | 42 | |||
Hypokalaemia n = 36 | ||||||
Yes | 28 | 14 | 14 | 0.34 (0.04–1.93) | 0.12 | |
No | 8 | 6 | 2 | |||
Time to operation >24 h | ||||||
Yes | 50 | 19 | 31 | 0.54 (0.23–1.22) | 0.07 | |
No | 45 | 24 | 21 | |||
Intraoperative time >2 h | ||||||
Yes | 48 | 24 | 24 | 1.46 (0.65–3.35) | 0.18 | |
No | 47 | 19 | 28 | |||
Surgeon | ||||||
General surgeon | 23 | 14 | 9 | 2.28 (0.87–6.20) | 0.05 | |
Surgical registrar | 72 | 29 | 43 | |||
Intensive care unit | ||||||
Yes | 19 | 15 | 4 | 6.3 (1.98–24.01) | <0.0001 | |
No | 76 | 28 | 48 |
On univariate analysis, there were significantly increased odds of unfavourable outcome in persons with vomiting (OR 9.75, 95% CI 2.38–66.7, P = 0.001), abdominal distension (OR 2.30, 95% CI 1.14–8.52, P = 0.01), dehydration (OR 6.89, 95% CI 2.43–22.53, P = 0.0001), tachycardia (OR 3.80, 95% CI 1.39–11.45, P = 0.004), fever (OR 4.19, 95% CI 1.78–10.20, P = 0.0001), tachypnoea (OR 3.94, 95% CI 1.09–18.61, P = 0.01), hypotension (OR 1.85, 95% CI 1.21–2.85, P = 0.03), signs of IO on erect abdominal radiograph (OR 2.56, 95% CI 1.09–6.21, P = 0.01, leucocytosis (OR 4.19, 95% CI 1.78–10.2, P = < 0.0001), granulocytosis (OR 3.2, 95% CI 1.38–7.61, P = 0.003) and ICU admission (OR 6.3, 95% CI 1.98–24.01, P = 0.0001).
Discussion
IO is a common surgical condition managed operatively in PNG. In this prospective study, the mean age of patients presenting was 34.8 years, with a male predominance that was consistent with studies performed in Sub-Saharan Africa.8,10 Adhesions were the number one cause of IO, with 77.8% of patients travelling more than 2 h to seek surgical intervention.
In a study performed in 2018, a delay of more than 72 h was associated with a 39% higher chance of death within 30 days compared with patients who underwent surgery within 72 h.11 The mortality rate in this study was 2%. This is much lower than global rates of 5–30%.12 The rate of unfavourable outcomes was 45%, which is within global ranges of 37.3–54.3%.13,14 The most common complication was sepsis, which differed from studies in Ethiopia, Kenya and Nigeria that showed wound infections to be the most common cause of postoperative complication, with rates as high as 39.3%.10,14
Vomiting and abdominal distension were associated with unfavourable outcomes. This differs from findings from Girma et al., which indicated that diarrhoea and scrotal swelling are associated with poor outcomes.10 Clinical signs of a systematic inflammatory response (fever, hypotension, tachycardia, tachypnoea and leucocytosis) that progressed into sepsis were associated with unfavourable outcomes in this study.
The sensitivity of diagnosing IO from an erect abdominal radiograph is low.15 However, in this study the presence of radiological signs indicating IO was associated with two times the odds of an unfavourable outcome. Good clinical examination should thus allude to the presence of IO with radiographic confirmation that, if present, should prompt urgent surgical intervention.
Critically ill patients with bowel sepsis require intensive care management. In this study, 20% of patients were admitted to the ICU, which was associated with six times higher odds of death and complications than patients who were not admitted to the ICU. In fact, mortality rates postoperatively can be as high as 30% in some ICU settings.16
This study has a number of limitations. The small sample size limited further analysis of adjusted odds ratios. Information on nutritional feeds could not be properly ascertained in terms of commencement of oral feeds because the aetiology of IO was not uniform. Nonetheless, the study achieved its aims of describing the operative outcomes of patients with IO and identifying the factors associated with unfavourable outcomes at APH.
Conclusion
IO remains a major surgical burden at APH, with adhesions being the most common cause. Clinical indicators such as vomiting, abdominal distension, dehydration, systemic inflammatory response, and ICU admission were significantly associated with unfavourable outcomes. These findings emphasise the importance of early recognition, timely referral, and surgical intervention, as well as the need to strengthen perioperative and critical care services in resource-limited settings such as PNG.
Acknowledgements
The authors of this study would like to thank Dr Ikasa and Milne Bay Provincial Health Authority and Dr Yohang from University of Papua New Guinea for supporting this study.
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