RAJIV GANDHI UNIVERSITY OF HEALTH SCINCES, BANGALORE

KARNATAKA

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS (in block letters) / DR. NARENDRANADH MEDA
S\O M VENKATESWARA RAO,
BHARANI PADU,
VEMSOOR (MD),
KHAMMAM (DT),
AP – 507164.
2. /

NAME OF THE INSTITUTION

/ J.S.S. MEDICAL COLLEGE,
MYSORE.
3. / COURSE OF STUDY AND SUBJECT
/ M.S., GENERAL SURGERY.
4. / DATE OF ADMISSION TO COURSE / 31-05–2007
5. /

TITLE OF THE TOPIC

/ CLINICO PATHOLOGICAL STUDY OF DYNAMIC SMALL BOWEL OBSTRUCTION.
6. / BRIEF RESUME OF THE INTENDED WORK
(6.1) Need for study:
Dynamic small bowel obstruction is defined as where the peristalsis is working against a mechanical obstruction. It is one of the most common causes of acute abdomen in surgical practice. The most common cause of small bowel obstruction is adhesions usually secondary to prior abdominal surgeries, The second most common cause is incarceration of intestine in hernia followed by neoplasms. The most common cause in pediatric age group is intussusception.
About 80% of bowel obstructions occur in the small intestine; the other 20% occur in the colon. It has been estimated that 1% of all hospitalizations, 3% of emergency surgical admissions to general hospitals, and 4% of major celiotomies (about 250,000) are secondary to bowel obstruction or procedures requiring adhesiolysis1. The overall mortality and morbidity of bowel obstruction is substantial. Mortality rates range from 3% for simple obstructions to as much as 30% when there is vascular compromise. Intestinal obstruction will recur in about 12% of patients after primary conservative treatment and in 8%-32% of patients after operative management for adhesive bowel obstruction1.
Intestinal obstruction due to adhesion is a subject of importance to all general surgeons. Its changing incidence, etiology and management have attracted increasing interest in recent years. The challenge presented is that of a benign condition causing severe morbidity and significant mortality in patients of all ages despite improvement in management with substantial workload for hospitals and costs to society.
As there are different causes for dynamic obstruction, the purpose of the present study is to identify the incidence of different causes and to ascertain a well-defined clinico–pathological profile of small bowel obstruction. Success in treatment of patient with acute intestinal obstruction depends largely upon early diagnosis, fluid management and early intervention to treat the pathological effects.

(6.2) Review of literature

The dynamic small bowel obstruction date back to antiquity, forms of bowel obstruction like strangulated hernia, intussusceptions was known to the ancient Egyptians. Bowel obstruction was observed by Hippocrates2. The earliest operation recorded was probably performed by Praxagorns (350.B.C) who created an enterocutaneous fistula to relieve obstruction. Application of cautery over the swelling was advised to encourage cicatrisation and prevent recurrent hernias. In 5th century, in the test books of Sushrutha Samhitha strangulated hernia was considered incurable2.
Franco (1561) is to be regarded as the originator of planned direct attack upon strangulated hernia, who made an incision over the swelling and divided the constriction band3.
John Hunter (1761) as a surgical pathologist described intussusceptions. The treatment of intestinal obstruction before the year 1800 was essentially the same as that of constipation3.
Sir Astley Cooper (1804) had tried suspending the patient in an upside down position over the attendants shoulder as a preliminary to taxis in reduction of hernia2. The excellent summary of the subject of intestinal obstruction was written by sir Frederick Treves in 1884, which won him the first Jackson ion prize, which was awarded by the royal college of surgeons of England4.
The inverted posture was long a therapeutic device in the management of intestinal obstruction, especially for reduction of intussusceptions and was advocated by Jonathan Hutchison (1878)2.
Kusmaul introduced gastric lavage for pyloric obstruction to induce peristalsis, by 1884. He was enthusiastic over its use as a therapeutic device for bowel obstruction as late as 1881, Mortin and Hare continued to extoll the virtues of gastric lavage in coping with the problems of bowel obstruction. Elliot in 1895 was the first to perform resection of gangrenous bowel following mesenteric vascular occlusion5.
In 1911 Schwartz published his first paper describing and illustrating the different pattern of fluid and gas, which can be seen in plan x-ray of the abdomen in bowel obstruction5.
Wilkie in 1913 appreciated the different between simple and strangulated hernias. Olsson and Pavlin (1926-1927) used column of barium, permitting fluoroscopy confirmation of reduction of intussusceptions6.
Franster and Hauster (1924) pointed out that death occurs from shock only when long loop of bowel was involved in strangulation2. In 1926, Williams showed that presence of anaerobic bacterial infection in strangulated Bowel and also suggested it to be the cause of death in such cases. The role of antibiotics was recognized later in between 1940 - 1950 and was shown that it can retard the growth of bacteria7.
In 1947, Noer and colleagues in 1952 confirmed circulatory disturbances brought about by increased distention8.
Wright and Hobson first described the experimental use of doppler ultrasonography to determine the viability of ischemic bowel in 19759.
Fluid replacement, intestinal decompression antibiotics and improvement in surgical and anesthetic techniques have reduced the mortality rate in simple intestinal obstruction. However the recognition and treatment of strangulation bowel obstruction still remains a challenge for surgeons today9.
(6.3) Aims & objectives of study.
1. To study dynamic small bowel obstruction with respect to age and sex distribution.
2.  Evaluation of various modes of clinical presentation.
3.  Electrolyte imbalance in dynamic obstruction.
4.  To study the etiological factors and modalities of surgical
treatment.
7. / Material & methods
7.1) Source of date
The source of date is from the in patients of J.S.S. Hospital, Mysore diagnosed to have small bowel obstruction during the study period from September 2007 to September 2009.
(7.2) Method of collection of data
The clinical study and management of dynamic small bowel obstruction which will be conducted at J.S.S. hospital, Mysore during the study period mentioned above. Fifty new cases of Dynamic small bowel obstruction will be selected for the study on the basis of purposive sampling technique.
The data will be collected in a pre-tested proforma by direct interview meeting the objectives of the study from history, clinical examination, relevant investigation, histopathology & relevant surgical procedures. The data collected will be tabulated according to various parameters like factors, Age and sex, sites of occurrence, diagnostic investigations, relevant surgical procedures depending on the site of obstruction and finally the out come of treatment in terms of post operative complications. The analysis of data will be made by appropriate statistical parameters.
Inclusion criteria
All the newly diagnosed cases of dynamic small bowel obstruction will be included in the study
Exclusion criteria
1)  Infants (<1 year).
2)  All cases of Adynamic small bowel obstruction.
3)  Iatrogenic cause for dynamic small bowel obstruction.
4)  Large bowel obstruction.
(7.3) Does the study require any investigations or interventions to be conducted on patient or other humans or animals? If so please describe briefly.
a)  Routine haematological and urine investigations.
b)  Relevant Biochemical investigation like blood sugar, serum electrolyte, serum amylase, blood urea, serum creatinine, stool for occult blood, etc.
c)  Ultrasounds scan of abdomen and pelvis.
d)  Barium meal follows through.
e)  ECG.
f)  X-Ray abdomen.
g)  CT scan.
h) CT angiography done when suspected mesenteric occlusion.
(7.4) Has ethical clearance been obtained from your institution in case of 7.3?
Yes, obtained from the ethical committee, J.S.S. Medical College,
Mysore, certificate enclosed.
8. / List of References:
1. Scott G.Houghton, Antonio Ramos De la Medina, Michael G. Sarr; Bowel obstruction. In Mechael J. Zinner, Stanley W. Astley Editors, Maingot’s abdominal operations.11th edition P. 481-482.
2. Wangensteen O H. Historical aspects of management of acute intestinal obstruction, Wangensteen O H editor 1969: P.63, 363– 383.
3. Mucha PJR, small intestinal obstruction, Ind J surg 1987 oct, Nov 10.11 :P 597-619.
4. Ramchandran CS, acute intestinal obstruction. Ind J Surg 1982:10,11:P 672-678.
5. Ellis H, Calne RY, Watson CJE. Mechanical intestinal obstruction, specific and special from of obstruction. The small intestine. In: Ellis H, Clane Ry, Watson CJE editors. General surgery 9th edition. Black well sciences 1998 p.177-193.
6. Jones RS, Claridge JA. Acute abdomen. Townsend CM, Beauchamp RD, Evers BM, Mattox KL, editors. Sabiston text book of surgery, 17th edition, Philadelphia; Saunders; 2004p.1219-1235.
7. Farquaharson M, Moron B. Operative management of small and large bowel obstruction. In: Farquaharson M, Moron B editor. Farquaharson’s textbook of operative general surgery, 9th edition. London: Hodder Arnold; 2005.p.409-433.
8. Play forth RH. Mechanical small obstruction and plea for the earlier surgical intervention. Ann Surg 1970; 171:p.783-788.
9. Cole GJ. A review of 436 cases of intestinal obstruction in
Ibanan. gut 1965; 6.p.151-162.
9. / Signature of the candidate
10. / Remarks of the guide / Small bowel obstruction is one of the commonest surgical emergencies we come across. Abdomen is known as pandora’s box. The exact cause of underlying etiological factors not known in most of the cases till it is explored. To know the commonest etiological factor prevailing in this area causing small bowel obstruction, we taken up this topic.
11. / (11.1) Name and designation of Guide (in block letters)
(11.2) Signature / DR.G.R.CHANDRASHEKAR
M.B.B.S, M.S
ASSOCIATE PROFESSOR OF SURGERY
J.S.S.MEDICAL COLLEGE,
MYSORE.
12. / (11.3) Head of the Department
(11.4) Signature / DR.S.B.VASANTH KUMAR
MS c, M.B.B.S, M.S, FICS.
PROFESSOR AND HOD,
J.S.S.MEDICAL COLLEGE, MYSORE.
13. / (12.1) Remarks of the chairman And
Principal
(12.2) Signature