BIOCHEMICAL PREDICTORS OF ENTEROCOLITIS IN CHILDREN WITH COLORECTAL ANOMALIES POST COLOSTOMY AT UNIVERSITY COLLEGE HOSPITAL, IBADAN

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O.O Ogundoyin^1,2, D.I Olulana^1,2, K.I Egbuchulem¹

1. The Division of Paediatric Surgery, University College Hospital, Ibadan.
2. Department of Surgery, University of Ibadan, Ibadan

Abstract

Background: A large proportion of patients with preoperative enterocolitis still have enterocolitis persisting even after surgery while others resolve thereafter. Some researchers have studied Calprotectin, C–reactive protein (CRP), Blood and Plasma viscosity as markers of inflammation, hence, the choice of their use. The aim of the study is to determine the sensitivity and reliability of Calprotectin, C–reactive protein (CRP), Blood and Plasma viscosity as biochemical predictors of enterocolitis in children with colorectal anomaly post-surgery at University College Hospital Ibadan.

Patients and Methods: This is an observational analytic study of 32 patients with either Hirschsprung’s disease or Anorectal malformation carried out over a year period. The demographic data of the patients, clinical condition and the preoperative and postoperative readings of the biochemical analytes were recorded in a chart. Statistical analysis were carried out using SPSS version 23 and test for statistical association done.

Results: The incidence of Hirschsprung associated enterocolitis is 12.5%and for Ano rectal malformation 6.3 %. Gender difference was not statistically significant even with the observed clinical difference. Plasma viscosity and blood viscosity correlate positively with each order. C-reactive Protein and Calprotectin did not predict enterocolitis in this study and the Sensitivity of blood viscosity at T1 and T2 is as low as 66% with a Positive Predictive Value of 25 %.

Conclusion: The incidence of Enterocolitis associated with Hirschsprung’s disease and Anorectal malformation is 19 %. Calprotectin and C-reactive protein did not predict enterocolitis in this patients. The outcome of care was satisfactory in over 90 % of the patients.

Keywords: Biochemical predictors, Children, Enterocolitis, Ibadan

Introduction

A retrospective study of one hundred and thirty children at the University College Hospital, Ibadan by Ogundoyin et al.,¹ on the pattern and outcome of childhood intestinal obstruction showed that anorectal malformations (22.4%) and Hirschsprung’s disease (13.9%) were among the most common causes of congenital intestinal obstruction.

Hirschsprung’s disease-associated enterocolitis (HAEC) in neonates occur in about 16% of patients and presents with greater likelihood of progression to septic shock and toxic mega colon in the older children especially after surgery.^2-4.

In the case of a large recto urethral fistula, the patient frequently passes urine into the colon. A more distal colostomy allows urine to escape through the distal stoma without significant absorption, however, with a more proximal colostomy; the urine remains in the colon and is absorbed, with increased possibility of sepsis. Also patients with ARM presenting late will have prolonged distention of the rectal pouch and may produce an irreversible hypo motility disorder, leading to severe constipation later in life with possibility of associated enterocolitis. Post Posterior Sagittal Anorectoplasty (PSARP) stricture, though rare may precipitate recurrent constipation and possible enterocolitis.⁵.

Mortality due mainly to late recognition and treatment has been reported to be between 1% and 5% of the children undergoing operation for HD.⁶ Early clinical and radiological signs of enterocolitis are often nonspecific, hence, the need for accurate prediction of enterocolitis at an early stage to obviate this delay in diagnosis and its unfavourable sequelae. Several researches have studied Calprotectin, C–reactive protein (CRP) and Plasma viscosity as markers of inflammation

CRP when used alone may not be able to accurately predict intestinal inflammation, combination with calprotectin increases the yield and gives a better diagnostic accuracy. As specificity increased when adding calprotectin measurement, false positive test results decreased dramatically.⁷

Several studies have also highlighted the usefulness of plasma and blood viscosity as markers of inflammation in that it has a high sensitivity, high negative predictive value, though low specificity and fewer false negative results.^{8, 9}

This study seeks to determine the incidence of enterocolitis in patients with HD and ARM, determine the validity and reliability of these biomarkers and also determine the outcome of treatment of patients with HAEC and ARM associated enterocolitis.

PATIENTS AND METHODS
This study was conducted in the Division of Paediatric Surgery, Department of Surgery, University College Hospital (UCH) Ibadan between January 2017 and December 2017. Thirty two consecutive patients aged first day of life to 15 years with HD or ARM presenting with intestinal obstruction and scheduled for surgery were prospectively enrolled over a year period.

Enterocolitis is defined by the presence or persistence of fever, passage of frequent watery stool and biochemical evidence of leukocytosis in the setting of intestinal obstruction due to Hirschsprung’s disease (HD) or Ano rectal malformation (ARM).

It occurs either pre operatively or post operatively. Eight milliliters of venous blood samples were taken from the patients on three different occasions, at diagnosis of HD or ARM and or enterocolitis (preoperatively) while the second and third samples were taken on the second- and fourth-day post-surgery respectively

The blood samples were centrifuged immediately, and sera stored at – 80 oC until batch analysis for Calprotectin and C-reactive protein assay while Plasma and blood viscosity were carried out within 48 hours of collection. NSAIDs were omitted from routine analgesia as part of intra and peri-operative analgesia by the anesthesiologist because of the association with enteropathy. Children on NSAIDs within the last three weeks prior to sample collection; Patients with focus of sepsis such as acute otitis media, tonsillitis, rheumatoid arthritis, respiratory infections et cetera; Patients who have had colostomy or pull-through surgery before presentation were all excluded fromparticipating in the study as they can also elaborate some level of plasma Calprotectin

The data was collected and entered in a proforma which was used for analysis.

Statistical analyses were carried out using SPSS version 22 and descriptive data were represented in tables and test for statistical association done using Students ttest, ANOVA and regression analysis for the outcome variables such as length of hospital stay, serum levels of bio markers and the presence or absence of post operative enterocolitis were carried out. Ethical approval was received from the joint UI/ UCH Ethical committee.