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Mortality risk of patients with intestinal obstruction

BMC Cancer volume 24, Article number: 1062 (2024) Cite this article

Abstract

Background

Intestinal obstruction represents a severe intestinal disease associated with higher mortality rates. However, the determinants of mortality in patients with intestinal obstruction remain inadequately understood. This study sought to elucidate the potential risk factors associated with mortality in the context of intestinal obstruction during the COVID-19 pandemic.

Methods

A retrospective analysis was performed on a cohort of 227 patients diagnosed with intestinal obstruction at the First Hospital of Hebei Medical University, spanning the period from September 7, 2022, to January 7, 2023. The primary endpoint of the study was mortality within four weeks following discharge. Univariate and multivariable logistic regression models were utilized to evaluate the risk factors associated with mortality outcomes.

Results

A cohort of 227 patients diagnosed with intestinal obstruction (median age, 59.02 years [IQR, 48.95–70.85 years]) was included in our study. Malignant bowel obstruction (MBO) and COVID-19 were identified as independent risk factors for mortality among these patients. Notably, the mortality rate increased significantly to 38.46% when MBO was concomitant with COVID-19. Furthermore, postoperative pulmonary complications (PPC) (OR, 54.21 [death]; 95% CI, 3.17-926.31), gastric cancer (OR, 9.71 [death]; 95% CI, 1.38–68.18), VTE (Caprini Score ≥ 5) (OR, 7.64 [death]; 95% CI, 1.37–42.51), and COVID-19 (OR, 5.72 [death]; 95% CI, 1.01–32.29) were all determined to be independent risk factors for postoperative mortality. Additionally, gastric cancer could have emerged as one of the most severe risk factors for mortality in individuals with intestinal obstruction within the cohort of cancer patients, of which gastric cancer exhibited higher mortality rates compared to individuals with other forms of cancer.

Conclusion

The study identifies MBO, gastric cancer, COVID-19, PPC, and VTE as potential risk factors for mortality in cases of intestinal obstruction. These findings highlight the necessity for continuous monitoring of indicators related to these mortality risk factors and their associated complications, thereby offering valuable insights for the management and treatment of intestinal obstruction.

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Introduction

Intestinal obstruction represents a pathological condition marked by the partial or complete interruption of the transit of luminal contents through the gastrointestinal tract. In pediatric patients, intussusception is a predominant cause, whereas in adults, postoperative intestinal adhesions, hernias, and neoplastic growths are identified as primary etiologies of intestinal obstruction [1,2,3]. This condition can occur in either the small or large intestine, with small bowel obstructions being more prevalent than large bowel obstructions. Clinically, the hallmark presentations associated with intestinal obstruction include severe abdominal pain, vomiting, nausea, constipation, and abdominal distension. Notably, intestinal obstruction has been identified as a significant contributor to mortality among patients requiring emergent surgical interventions [4, 5]. The global mortality rate directly attributable to intestinal obstruction remains substantial, with a documented figure of 2.1 deaths per 100,000 individuals annually [4]. Currently, the majority of existing studies have predominantly focused on elucidating the etiological spectrum of the condition [2, 6], while comprehensive research elucidating the overarching risk factors for mortality in cases of intestinal obstruction remains relatively scarce.

At the onset of the COVID-19 pandemic, the virus emerged as a significant risk factor for perioperative mortality among patients undergoing various types of surgery, including those for benign diseases, cancer, trauma, and obstetrics [7, 8]. COVID-19-positive individuals demonstrated a perioperative mortality rate that was twice as high as that of their COVID-19-negative counterparts [9]. Clinical manifestations of COVID-19 affecting the gastrointestinal system, including symptoms such as anorexia, diarrhea, nausea, vomiting, and abdominal discomfort, generally present with moderate severity and are often self-limiting [10, 11]. Currently, despite extensive vaccination campaigns and potential reductions in the virulence of COVID-19, the disease continues to pose a significant global health challenge, evolving from a pandemic to an endemic condition [12,13,14].

Notably, a minority of COVID-19 patients have presented with cases of intestinal obstruction [10, 15], and several studies have documented cases of intestinal obstruction in pediatric patients testing positive for SARS-CoV-2 [16, 17]. However, the intricate interplay between COVID-19 and the manifestation of intestinal obstruction remains an enigma at the present juncture. Hence, the primary objective of the present study was to explore the determinants of mortality risk and further assess the impact of COVID-19 on patients with intestinal obstruction.

Methods

In this retrospective study, a total of 227 patients diagnosed with intestinal obstruction were retrospectively enrolled at the First Hospital of Hebei Medical University between September 7, 2022, and January 7, 2023. All patients were followed up for 4 weeks to assess patient mortality and COVID-19 infection status after discharge. Patients, who tested positive for SARS-CoV-2 within a 2-week period prior to hospital admission and within a 4-week period following discharge, were categorized as COVID-19 positive.

The inclusion criteria were as follows: (a) patients exhibiting symptoms including abdominal pain, abdominal distension, and an inability to pass bowel movements (feces) or gas; (b) a CT scan indicating small bowel diameter ≥ 3.5 cm, a colon diameter ≥ 6 cm, or a cecal diameter ≥ 9 cm; (c) availability of complete clinical medical records; and (d) obtained informed consent. The exclusion criteria were: (a) patients with a history of SARS-CoV-2 infection; and (b) patients with concurrent mental illness or cognitive impairment.

The criteria for diagnosing Malignant Bowel Obstruction (MBO) typically entails clinical evidence of intestinal obstruction secondary to either an intra-abdominal primary cancer with incurable disease or a non-intra-abdominal primary cancer with evident intraperitoneal disease [18]. Venous thromboembolism (VTE) risk level was evaluated based on Caprini model: low risk (0–1), moderate risk (2), high risk (3–4), and highest risk (≥ 5) [19]. The Nutritional Risk Screening (NRS2002) is utilized for evaluating nutritional risk: nutritional support (≥ 3) [20]. Ethical approval for this retrospective study was obtained from the Ethics Committee of the First Hospital of Hebei Medical University (Ethics Protocol Number: [20230820]).

Statistical analysis was performed on September 3, 2023. The clinical baseline characteristics of inpatient were listed in Supplementary Table 1. Baseline characteristics of patients with intestinal obstruction were further compared among different groups (variable included death and surgery) through the χ [2] test, Fisher’s exact test, or univariate logistic regression (Sup. Tables 2–4). Furthermore, multivariable logistic regression was used to identify independent mortality risk factors in patients with or without surgery (Tables 1 and 2). All statistical analyses were executed using Stata MP 16, and statistical significance was determined using a two-sided hypothesis test where P < 0.05 was considered statistically significant.

Table 1 Multivariable logistic regression models for estimating the mortality risk of patients with intestinal obstruction
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Table 2 Multivariable logistic regression models for examining the effect of surgery on the mortality risk of patients with intestinal obstruction
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Results

Baseline characteristics of patients with intestinal obstruction

Between September 7, 2022, and January 7, 2023, a cohort of 227 patients diagnosed with intestinal obstruction (median age, 59.02 years [IQR, 48.95–70.85 years]; intestinal obstruction medical record, 286.28 days [IQR, 5.00–90.00 days]; 109 [48.02%] were female and 118 [51.98%] were male; 23 [11.50%] death and 177 [88.50%] live; 120 [52.86%] with cancer and 107 [47.14%] without cancer; 150 [66.67%] with small intestinal obstruction and 75 [33.33%] without large intestinal obstruction; 127 [55.95%] with benign bowel obstruction (BBO) and 100 [44.05%] without MBO; 106 [46.70%] with surgery and 121 [53.30%] without surgery) was identified at The First Hospital of Hebei Medical University. Notably, 41 patients (18.06%) were diagnosed with COVID-19 during this period. Comprehensive baseline characteristics of the patients with intestinal obstruction are provided in Supplementary Table 1.

Mortality risk factors in patients with intestinal obstruction

In our cohort, results from the univariate logistic regression model revealed that MBO (OR, 4.23 [death]; 95% CI, 1.59–11.25; P = 0.004), nutritional support (NRS2002 ≥ 3) (OR, 3.87 [death]; 95% CI, 1.10-13.52; P = 0.034), gastric cancer (OR, 3.55 [death]; 95% CI, 1.23–10.28; P = 0.019), VTE (Caprini Score ≥ 5) (OR, 3.32 [death]; 95% CI, 1.15–9.55; P = 0.026), COVID-19 (OR, 2.61 [death]; 95% CI, 1.01–6.71; P = 0.046), and age (OR, 1.03 [death]; 95% CI, 1.00-1.06; P = 0.039), were linked to an increased risk of mortality in cases of intestinal obstruction. Conversely, a higher lymphocyte ratio (OR, 0.95 [death]; 95% CI, 0.91–0.99; P = 0.020) was associated with a reduced risk of mortality (Sup. Table 2).

Subsequently, a multivariable logistic regression model was employed to identify independent risk factors for mortality in intestinal obstruction. Our results indicated that MBO (OR, 3.86 [death]; 95% CI, 1.20-12.38; P = 0.023) and COVID-19 (OR, 3.66 [death]; 95% CI, 1.11–12.04; P = 0.033) remained significantly associated with an elevated risk of mortality in cases of intestinal obstruction (Table 1). Additionally, the lymphocyte ratio (OR, 0.95 [death]; 95% CI, 0.90-0.999; P = 0.046) was identified as a protective factor, reducing the risk of mortality in intestinal obstruction (Table 1). Within our cohort, patients diagnosed with MBO or COVID-19 exhibited a significantly higher mortality rate in comparison to those without MBO (19.32% vs. 5.36%) or COVID-19 (21.05% vs. 9.26%), respectively (Fig. 1A). Notably, the mortality rate was further exacerbated when MBO co-occurred with COVID-19, reaching 38.46% in patients with intestinal obstruction (Fig. 1B). In summary, our findings suggest that both MBO and COVID-19 stand as independent risk factors for mortality in cases of intestinal obstruction.

Fig. 1
figure 1

Mortality rates in patients with intestinal obstruction

(A) Mortality rates in intestinal obstruction patients with MBO or COVID-19

(B) Mortality rates in patients with intestinal obstruction, with or without concurrent MBO or COVID-19

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Postoperative mortality risk in patients with intestinal obstruction

Surgical intervention is widely acknowledged as an effective strategy for the management of intestinal obstruction [5, 21]. However, the identification of underlying risk factors contributing to mortality in patients undergoing surgery for intestinal obstruction continues to pose a significant challenge. Results derived from the univariate logistic regression model unveiled potential risk factors, including postoperative pulmonary complications (PPC), renal insufficiency, cancer, gastric cancer, VTE (Caprini Score ≥ 5), and COVID-19 (Sup. Table 3). Additionally, a multivariable logistic regression subgroup analysis was performed to further investigate the risk factors within the cohort undergoing surgical treatment for intestinal obstruction. In line with the findings from univariate analysis results, the multivariable logistic regression subgroup analysis demonstrated that PPC (OR, 54.21 [death]; 95% CI, 3.17-926.31; P = 0.006), cancer (OR, 11.46 [death]; 95% CI, 1.03-126.95; P = 0.047), gastric cancer (OR, 9.71 [death]; 95% CI, 1.38–68.18; P = 0.022), VTE (Caprini Score ≥ 5) (OR, 7.64 [death]; 95% CI, 1.37–42.51; P = 0.020), and COVID-19 (OR, 5.72 [death]; 95% CI, 1.01–32.29; P = 0.048) were identified as independent risk factors contributing to an increased perioperative mortality rate in cases of intestinal obstruction, while renal insufficiency not (Table 2).

Patients with postoperative intestinal obstruction who developed pulmonary complications or VTE (Caprini Score ≥ 5) exhibited significantly higher mortality rates compared to those without such complications. Specifically, the mortality rate was 75.00% for those with pulmonary complications versus 11.65% for those without, and 38.46% for those with VTE compared to 10.46% for those without (Fig. 2A and B). Furthermore, the overall postoperative mortality rate among patients with COVID-19 was notably higher at 28.57%, in contrast to 10.47% among those without COVID-19 (Fig. 2C). Notably, the analysis revealed no statistically significant difference in mortality rates between patients who tested positive for COVID-19 preoperatively versus postoperatively among those with intestinal obstruction (Fig. 2D).

Fig. 2
figure 2

Postoperative mortality rates in patients with intestinal obstruction

(A) Mortality rates in patients with intestinal obstruction, with or without PPC

(B) Mortality rates in patients with intestinal obstruction, stratified by VTE Caprini Score (≥ 5) and surgery

(C) Mortality rates in patients with intestinal obstruction, stratified by COVID-19 and surgery

(D) Mortality rates in patients with intestinal obstruction, based on their COVID-19 test results before or after surgery

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In relation to cancer, our findings revealed that patients with cancer experiencing intestinal obstruction had a significantly elevated postoperative mortality rate of 21.56%, compared to 7.14% in patients without cancer (Fig. 3A). Additionally, individuals with gastric cancer demonstrated even higher postoperative mortality rates of 57.14%, in contrast to 11.00% in those without gastric cancer (Fig. 3A and B). Similarly, the mortality rate for patients with gastric cancer was higher than that for individuals without gastric cancer (27.27% vs. 9.55%), as well as those with other types of cancer (Fig. 3C and D), suggesting that gastric cancer may represent the most severe risk factor for mortality in individuals with intestinal obstruction among cancer patients. In addition, we conducted an analysis of baseline characteristics in 31 patients with gastric cancer. Remarkably, our study revealed that 28 (96.55%) patients exhibited a lower BMI than 23.9, 24 (77.42%) patients required nutritional support (NRS2002 score ≥ 3), 19 (61.29%) patients had malignant bowel obstruction (MBO), and 11 (35.84%) patients necessitated surgical intervention. Additionally, patients with gastric cancer showed lower lymphocyte ratios at 18.68% [IQR, 11.60–30.20%], prealbumin levels at 156.67 mg/L [IQR, 122.20-195.50 mg/L], and albumin levels at 38.28 g/L [IQR, 32.60–41.80 mg/L]. Meanwhile, gastric cancer patients exhibited elevated levels of C-reactive protein at 20.64 mg/L [IQR, 1.31–15.83 mg/L], IL-6 at 13.52 pg/mL [IQR, 2.25–14.20 mg/L], FNP at 5.27 mg/L [IQR, 0.72–4.22 mg/L], and D-dimer at 1.85 mg/L [IQR, 0.32–1.52 mg/L] (Sup. Table 4). Taken together, these results highlight that PPC, gastric cancer, VTE, and COVID-19 are independent risk factors for postoperative mortality in cases of intestinal obstruction.

Fig. 3
figure 3

Mortality rates in intestinal obstruction patients with cancer. (A) Mortality rates in patients with intestinal obstruction, stratified by cancer and surgery. (B) Mortality rates in patients with intestinal obstruction, stratified by gastric cancer and surgery. (C) Mortality rates in intestinal obstruction patients with cancer, gastric cancer, colorectal cancer, or other cancer. (D) Mortality rates in intestinal obstruction patients, with or without gastric cancer

Full size image

Discussion

In this retrospective cohort study of 227 patients with intestinal obstruction, our findings indicate that MBO, gastric cancer, COVID-19, PPC, and VTE are significant mortality risk factors that warrant careful consideration by clinicians.

MBO represents a severe complication in patients with advanced oncological conditions, particularly those with abdominal cancers [22]. Notably, over half (52.86%) of the patients with intestinal obstruction in our study had concomitant cancer, with gastric cancer comprising 25.83% (31/120) of all cancer cases among these patients. Gastric cancer is associated with an elevated risk of postoperative mortality in patients presenting with intestinal obstruction; however, surgical intervention is comparatively less frequent among gastric cancer patients (9.09% vs. 18.87%). Obstruction of the gastric outlet, gastroesophageal junction, or small bowel represents common late-stage complications of gastric cancer, and their concurrent occurrence may culminate in a more severe clinical trajectory [23, 24]. The poor prognosis observed in gastric cancer patients with intestinal obstruction is likely attributable to delayed diagnosis.

COVID-19 infections were correlated with an elevated mortality risk in patients with intestinal obstruction (21.05% vs. 9.26%). The overall postoperative mortality rate in the cohort with COVID-19 (28.57%) was significantly higher compared to the cohort without COVID-19 (10.47%). Importantly, a substantial prevalence of physical performance impairment has been documented in patients diagnosed with COVID-19 [25], which may partially explain the observed adverse association of COVID-19 in intestinal obstruction. Furthermore, it is notably significant that, during the early stages of the pandemic, critically ill COVID-19 patients demonstrate an increased vulnerability to gastrointestinal complications [13]. The disproportionately high incidence of intestinal obstruction and ischemic bowel disease can be partially ascribed to severe COVID-19-induced coagulopathy [13, 26].

COVID-19 has been linked to an elevated risk of developing PPC and VTE [13, 27,28,29]. However, our investigation did not reveal a definitive interaction suggesting that PPC and VTE were directly associated with COVID-19. This finding may be constrained by the relatively small sample size of cases involving PPC and VTE. Despite this limitation, the significance of PPC and VTE should not be underestimated in patients with obstruction, particularly those undergoing surgical procedures. Pulmonary complications are commonly observed following abdominal surgery and represent substantial risk factors for prolonged hospitalization and increased morbidity [30, 31]. Furthermore, early interventions, pharmacological prophylaxis, and the utilization of mechanical compression devices play a critical role in preventing VTE in patients with intestinal obstruction [32, 33].

In conclusion, this study highlights the potential mortality risk factors associated with patients suffering from intestinal obstruction. These risk factors function as critical indicators for identifying patients at elevated risk, thereby necessitating prompt intervention. The findings underscore the imperative for early detection and the implementation of targeted management strategies to improve clinical outcomes and enhance the quality of care for this vulnerable population. This study is subject to several significant limitations. Due to its retrospective design, we are limited to establishing associations rather than causal relationships between intestinal obstruction and the identified risk factors. Additionally, the occurrence of rare events, such as PPC and renal insufficiency, may introduce data skewness. This skewness can inflate the upper bound of the confidence interval to a degree that compromises its practical utility. Subsequent research will be imperative to comprehensively evaluate the underlying factors contributing to mortality in cases of intestinal obstruction.

Data availability

Data is provided within the manuscript or supplementary information files.

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Funding

The author(s) declared financial support was received for the research, authorship, and/or publication of this article. This work was supported by the National Natural Science Foundation of China (U23A20432), the Natural Science Foundation of Hebei (H2021206306, H2023206290); 2022 & 2023 Hebei introduction of Foreign Expert Intelligence Projects (No. YZ202201 & YZ202305), PI Team Supporting Fund of the First Hospital of Hebei Medical University (03000191);Construction Funds of Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment from The First Hospital of Hebei Medical University(02-000497).

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Author notes

  1. Yuanyuan Wang, Wei Li, Chuan-min Zhou and Zifeng Zhao contributed equally to this work.

Authors and Affiliations

  1. Gastrointestinal Disease Diagnosis and Treatment Center, The First Hospital of Hebei Medical University, Hebei, China

    Yuanyuan Wang, Wei Li, Chuan-min Zhou, Zifeng Zhao, Jianwei Ma, Haibo Jiang, Ming Wei, Yingchao Gao, Yongjun Dai, Xing Zhang, Ning Yang, Feng Feng, Jian Zhang, Yiding Ji, Jianjie Liu, Chao Zhang, Like Li, Xia Jiang, Zhongxin Li & Zengren Zhao

  2. Department of General Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, The First Hospital of Hebei Medical University, Hebei, China

    Yuanyuan Wang, Wei Li, Chuan-min Zhou, Zifeng Zhao, Jianwei Ma, Haibo Jiang, Ming Wei, Yingchao Gao, Yongjun Dai, Xing Zhang, Ning Yang, Feng Feng, Jian Zhang, Yiding Ji, Jianjie Liu, Chao Zhang, Like Li, Xia Jiang, Zhongxin Li & Zengren Zhao

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  18. Xia Jiang
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  19. Zhongxin Li
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  20. Zengren Zhao
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Contributions

CMZ, XJ and ZFZ analyzed the data wrote the main manuscript text, YYW, WL, JWM, HBJ, MW, YCG, YJD, XZ, NY, FF, JZ, YDJ, JJL, and LKL collected the data, and ZXL and ZRZ reviewed the manuscript. All authors reviewed the manuscript.

Corresponding authors

Correspondence to Zhongxin Li or Zengren Zhao.

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Ethical approval and consent to participate

Written informed consent was obtained from participants (or their parent or legal guardian in the case of children under 16). Ethical approval for this retrospective study was obtained from the Ethics Committee of the First Hospital of Hebei Medical University (Ethics Protocol Number: [20230820]).

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Not applicable.

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The authors declare no competing interests.

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Cite this article

Wang, Y., Li, W., Zhou, Cm. et al. Mortality risk of patients with intestinal obstruction. BMC Cancer 24, 1062 (2024). https://doi.org/10.1186/s12885-024-12834-1

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Keywords

BMC Cancer

ISSN: 1471-2407

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