Predictive markers in estimating the need for early intensive care in patients with adhesive small bowel obstruction in the emergency department

Abstract

Introduction:

Adhesive small-bowel obstruction (ASBO) is a common condition requiring emergency room admission, and predicting the need for intensive care unit (ICU) hospitalisation is crucial for optimal patient management. This study aimed to investigate the predictive value of various scores and indices in determining ICU requirements in patients with ASBO.

Patients and Methods:

Seventy patients diagnosed with ASBO and managed nonoperatively were included in the study. Data on patient demographics, laboratory values, imaging findings, previous hospitalisations and comorbidities were collected. The Sequential Organ Failure Assessment (SOFA) score, Charlson Comorbidity Index (CCI) score and C-reactive protein (CRP)/albumin ratio were calculated. Patients were categorised into ICU and non-ICU groups for analysis.

Results:

The ICU group comprised patients with higher number of previous ASBO hospitalisations and longer hospitalisation days. Serum albumin levels were significantly lower and the maximum small-bowel horizontal diameter was significantly higher in the ICU group. The SOFA score and CCI score were significantly higher in the ICU group. The CRP/albumin ratio showed a trend towards significance.

Conclusion:

The number of days since the last stool discharge, SOFA score and CCI score demonstrated significant associations with ICU requirements in ASBO patients. These findings highlight the importance of assessing organ dysfunction, comorbidities and gastrointestinal function during patient triage. Our study provides valuable insights into predicting ICU need in ASBO patients, aiding in resource allocation and patient management.

INTRODUCTION

Small-bowel obstruction (SBO) is a frequent cause of emergency room admissions worldwide, with adhesions resulting from the previous surgeries being the primary cause.[1] Managing adhesive SBO (ASBO) in the emergency department poses a challenge as some patients requiring emergency surgery may not exhibit signs of strangulation or peritonitis. Imaging techniques are especially valuable in identifying cases requiring emergency surgery, such as intestinal ischaemia and perforation.[2]

Non-operative treatments for ASBO encompass intravenous hydration, nil per os (NPO) orders and nasogastric tube decompression.[2] Deciding when surgery should be performed for patients, except in cases of strangulation and perforation requiring immediate surgery, remains controversial. Some guidelines recommend surgical intervention if SBO persists for over 72 h, even in the absence of worsening symptoms.[3]

ASBO pathophysiology involves increased peristaltic activity initially, followed by a complete cessation of peristaltic activity.[4] Impaired reabsorption leads to dehydration, electrolyte imbalances and hypovolaemic shock. Malnutrition and vomiting exacerbate the fluid and electrolyte deficits.[5] Compression of intestinal vessels results in oedema, perfusion disorders and potential progression to ischaemia, peritonitis and sepsis. This cascade can cause ischaemic cell death, metabolic acidosis and profound metabolic disturbances.[6]

In emergency medical situations, accurately predicting the need for intensive care unit (ICU) hospitalisation is crucial for resource allocation and optimal patient management. Various scores and indices have been developed to assess the severity and prognosis of critically ill patients, aiding in this prediction process. This article analyses a study that investigates the predictive value of different scores and indices in determining the need for ICU hospitalisation.

The Sequential Organ Failure Assessment (SOFA) score[7] and the Charlson Comorbidity Index (CCI)[8] are useful in predicting ICU admission and mortality rates. Our study aims to identify patients with ASBO who present to the emergency department without immediate ICU needs but might require ICU care during the early phase of hospitalisation, using different scoring systems. This study holds significance as it is the first attempt to predict the need for ICU hospitalisation in patients with ASBO.

PATIENTS AND METHODS

Study design and participants

The study included seventy patients who were admitted to our general surgery clinic with a diagnosis of ASBO between January 2017 and December 2022 and were managed conservatively without surgery. Ethics committee approval (No: 2023/KK/97) was obtained from the local ethics committee of the institution. The study was conducted in accordance with the Declaration of Helsinki. Data of patients who presented to the emergency department and were diagnosed with ASBO were retrospectively analysed through the hospital information system (HIS, version 5.5). Patients who underwent surgery, those with missing data and patients subsequently diagnosed with non-ASBO were excluded from the study. Patients directly admitted from the emergency department to the ICU were also not included in the study. Demographic characteristics, laboratory values (including white blood cell count (WBC), C-reactive protein (CRP) level, neutrophil count, total bilirubin level, direct bilirubin level, albumin level, sodium level, potassium level and chloride level), abdominal X-ray radiograph and computed tomography (CT) findings (such as the maximum number of air–liquid levels and maximum horizontal diameter of the small intestine), previous hospitalisations for bowel obstruction, previous abdominal surgeries and comorbid diseases were recorded in an Excel file. SOFA score, CCI score and CRP/albumin ratio were calculated from the data from the emergency admission. The SOFA score includes the following parameters: ratio of partial pressure of oxygen in arterial blood (PaO₂) to the fraction of inspiratory oxygen concentration (FiO₂), platelet count, bilirubin, mean arterial pressure, Glasgow Coma Scale and creatinine (or urine output). CCI score was calculated according to the comorbid diseases.

Patients were categorised into two groups: those requiring ICU hospitalisation and those who did not require ICU follow-up. Patients were transferred to ICU follow-up if they developed septic shock or had a Glasgow Coma Scale of 8 or less. Septic shock was generally defined as the mean arterial pressure below 65 mmHg and the need for vasopressors in patients despite intensive intravenous patients should be admitted to the ICU or not was made by experienced intensive care doctors.

Treatment protocol

Patients received NPO follow-up, intravenous hydration and broad-spectrum antibiotics to prevent bacterial translocation. Nasogastric tube insertion and monitoring were performed, and patients who did not show improvement within 72 h underwent surgery and were excluded from the study. Patients exhibiting evidence of ischaemia, peritonitis or perforation during serial physical examination follow-ups were also operated on and excluded.

Statistical analysis

The Kolmogorov–Smirnov test was used to assess the normal distribution assumption. Categorical data were presented as numbers (n) and percentages (%), whereas quantitative data were reported as a mean ± standard deviation or median (min–max), depending on the normality of the distribution. The Student’s t-test was used to compare mean differences between groups, and the Mann–Whitney U-test was applied for non-normally distributed variables. Odds ratios, 95% confidence intervals and Wald statistics were calculated for each independent variable. Statistical analysis was performed using IBM SPSS Statistics version 22™ (IBM Corporation, Istanbul, Turkey), and a P < 0.05 was considered statistically significant.

RESULTS

The study included a total of seventy patients with ASBO, with a mean age of 59.0 years. There was no significant difference in age between the two groups. Amongst the patients, 51.4% were male and 48.6% were female. One patient required surgery during his stay in the ICU and the patient recovered after bridectomy. One patient in the ICU died due to sepsis. There was no significant difference between the two groups regarding the previous abdominal surgeries. However, the patient group requiring ICU had a significantly higher number of previous ASBO hospitalisations and longer hospitalisation durations. Analysis of laboratory values revealed no significant differences in WBC, CRP level, total protein, direct-indirect bilirubin, neutrophil count, potassium level, sodium level and chloride level between the two groups. However, the serum albumin level was significantly lower in the ICU-requiring group. In addition, the maximum horizontal diameter of the small bowel was significantly larger in the ICU-requiring group (3.7 vs. 5.1, P = 0.004) [Table 1].

Table 1.

Demographic and clinical features, laboratory measurements and radiological findings of the cases according to the groups hospitalised and not hospitalised in the intensive care unit

	Patients who do not require hospitalisation in the ICU (n=63)	Patients admitted to the ICU (n=7)	P-value
Age (year)*	56.3±15.5	66.3±19.9	0.064†
Gender, n (%)
Male	32 (50.8)	4 (57.1)	>0.999‡
Female	31 (49.2)	3 (42.9)
History of operation due to tumour, n (%)	25 (39.6)	3 (42.8)	0.515‡
Surgery before ASBO attack, n (%)
Laparoscopic	4 (6.3)	0	0.500¶
Open	53 (84.2)	5 (71.4)
Conversion	6 (9.5)	2 (28.6)
Number of previous hospitalisations due to ASBO**	0 (0–3)	1 (0–2)	0.017¥
Previous hospital stay due to ASBO (days)**	0 (0–14)	4 (0–15)	0.012¥
Admittance laboratory values
WBC* (×109/L)	10.6±4.5	10.2±6.0	0.800†
CRP** (mg/dL)	6.3 (0.2–328.8)	10.7 (0.5–379.8)	0.364¥
Neutrophil** (%)	80.5 (40.7–93.6)	82.2 (56.9–94.2)	0.320¥
Total bilirubin** (mg/dL)	0.62 (0.12–2.36)	0.72 (0.36–1.59)	0.796¥
Direct bilirubin** (mg/dL)	0.25 (0.01–0.78)	0.31 (0.05–1.09)	0.357¥
Total protein* (g/L)	72.6±7.2	67.4±13.2	0.098†
Albumin* (g/L)	39.9±6.5	32.2±5.6	<0.001†
Natrium** (mEq/L)	138.7 (127.0–144.0)	136.0 (134.0–140.0)	0.315¥
Kalium** (mEq/L)	4.1 (3.0–5.4)	3.9 (3.0–4.6)	0.610¥
Chlorine* (mEq/L)	101.5±4.4	99.0±5.0	0.229†
Admittance AXR air–fluid level number**	9 (2–16)	7 (3–15)	0.694¥
Admittance CT scan largest diameter (cm) of horizontal section of small intestine**	3.7 (1.9–5.9)	5.1 (3.9–7.9)	0.004¥

*Mean±SD or **Median (minimum–maximum), ^†Student’s t-test, ^‡Fisher’s exact test, ^¶Fisher–Freeman–Halton test, ^¥Mann–Whitney U-test. Descriptive statistics. ICU: Intensive care unit, AXR: Standing direct abdominal X-ray radiograph, ASBO: Adhesive small-bowel obstruction, CT: Computed tomography, CRP: C-reactive protein, WBC: White blood cell, SD: Standard deviation

Patients who experienced delayed stool discharge required ICU care for a longer duration. The SOFA score was significantly higher in the ICU-requiring group (0 vs. 1, P = 0.00). Similarly, the CCI score was significantly higher in the ICU-requiring group (1 vs. 2, P = 0.022) [Table 2].

Table 2.

The value of different scores and indices created in emergency service admission in predicting the need for hospitalisation in the intensive care unit

	Patients who do not require hospitalisation in the ICU (n=63)	Patients admitted to the ICU (n=7)	P-value
The number of days since the last stool discharge	1 (0–3)	3 (1–4)	0.010¥
SOFA score	0 (0–4)	1 (0–2)	0.000¥
CCI	1 (0–6)	2 (0–7)	0.022¥
CRP/albumin	0.136 (0.01–8.83)	0.400 (0.01–11.61)	0.16¥

^¥Mann–Whitney U-test. ICU: Intensive care unit, SOFA score: Sequential Organ Failure Assessment score, CCI: Charlson Comorbidity Index, CRP: C-reactive protein

Figure 1 presents a histogram graph illustrating the relationship between CCI and the need for ICU care.

Figure 1.

Histogram plot of the relationship between Charlson Comorbidity Index and intensive care unit requirement. CCI: Charlson Comorbidity Index, ICU: Intensive care unit

DISCUSSION

ASBO is characterised by impaired small intestinal mucosal absorption, compromised blood circulation and increased intestinal oedema. These factors can lead to bacterial translocation, electrolyte imbalances and even sepsis.[9] Identifying high-risk patients and predicting the need for ICU admission can facilitate closer monitoring and potentially reduce mortality and morbidity. In our study, we aimed to predict post-admission ICU requirement in ASBO patients using the SOFA score, CCI and CRP/albumin ratio.

The previous studies have shown that the CRP/albumin ratio can be useful in predicting complications and infections in patients, with higher ratios indicating a worse prognosis.[10,11] In our study, although the CRP/albumin ratio was higher in the ICU-requiring group, the difference was not statistically significant.

Serum albumin levels tend to decrease in response to nutritional deficiencies, stress and major surgery. Hübner et al. found a correlation between albumin decrease and the severity of stress and trauma, as well as complications and prolonged hospitalisation.[12,13] Similarly, in our study, low albumin levels were associated with ICU requirements after hospitalisation.

The diagnosis of ASBO, as recommended by guidelines, involves the use of intravenous contrast-enhanced CT to evaluate for acute bowel ischaemia and exclude other causes of SBO.[14] Measuring the diameter of dilated small-bowel loops also provides valuable information. In our study, increased small-bowel diameter was associated with a higher ICU requirement. Increased intraluminal pressure resulting from the larger diameter may contribute to ischaemia, electrolyte disturbances and sepsis, thereby increasing the need for ICU care. The duration since the last stool discharge showed a similar correlation, indicating increased intraluminal pressure and bacterial translocation as possible contributing factors.

The SOFA score, originally used for sepsis-related organ failure, has gained recognition for predicting prognosis in the various diseases due to its ease of use. Sumi et al. demonstrated a strong correlation between strangulated ileus, mortality and the SOFA score.[9] Consistent with these findings, our study showed a significantly higher SOFA score in the ICU-requiring group. This may be attributed to partial organ dysfunction caused by systemic inflammatory mediators released from the small intestine after partial ischaemia.

ASBO is more common in advanced age, and the presence of comorbidities increases the risk of complications, irrespective of age. Quero et al. reported higher complication and mortality rates in ASBO patients managed conservatively without surgery and those with high CCI scores.[15] Similarly, in our study, the ICU-requiring group had a higher CCI score.

The SOFA score and CCI were found to be useful in predicting the need for ICU admission in ASBO patients. Considering these scores alongside laboratory and imaging findings during emergency admissions can aid in triaging patients. This study contributes to the understanding of predicting ICU requirements in patients with ASBO. Our study has some limitations. The most important of these is the small number of patients. Another limitation is that the study is retrospective. Prospective studies are needed on this subject.

CONCLUSION

Our study emphasises the importance of utilising specific scores and indices to predict the requirement for ICU admission in emergency medical cases, particularly in patients with ASBO. We found that the number of days since the last stool discharge, the SOFA score and the CCI score were significantly associated with the ICU admission. These findings highlight the significance of evaluating organ dysfunction, comorbidities and gastrointestinal function when triaging ASBO patients. This study is particularly valuable as it is the first of its kind to focus on predicting the need for ICU care in ASBO patients.

Financial support and sponsorship

The author reports that there is/are no financial support and/or sponsors included in the research that may affect the outcome of the study.

Conflicts of interest

There are no conflicts of interest.