Albumin Levels in Nontraumatic Acute Abdomen Patients Undergoing Emergency Laparotomy: A Retrospective Study in the Intensive Observation Ward of Dr. Soetomo General Academic Hospital

Introduction: Acute abdomen is a critical medical emergency characterized by the abrupt onset of severe abdominal pain, often requiring emergency laparotomy. Emergency laparotomy, due to limited preoperative preparation, generally has a higher morbidity and mortality rate than elective surgery. Optimizing perioperative care, particularly by monitoring albumin levels, may improve outcomes, as albumin plays a crucial role in maintaining fluid balance, wound healing, and controlling inflammatory responses. Postoperative emergency patients at Dr. Soetomo General Academic Hospital are closely monitored in a specific ward known as the Intensive Observation Ward (Ruang Observasi Intensif/ROI).

Objective: To evaluate albumin levels in nontraumatic acute abdomen patients treated in ROI following emergency laparotomy.

Methods: This study used a retrospective descriptive study design and was conducted from January to June 2022. Patients under 18 with malignancy, trauma, gynecological or obstetrical cases, and incomplete medical records were excluded.

Results: The male and female number of 90 patients was equal, most patients were aged 41-50, and had a normal BMI. Generalized peritonitis was the most common indication, followed by acute appendicitis and bowel obstruction. Appendectomy and exploratory laparotomy were the primary procedures, mostly done in under 3 hours. Most patients had no prior laparotomy history. Most patients had normal albumin levels preoperatively, but these shifted to mild hypoalbuminemia postoperatively. Of 13 deaths, 12 involved preoperative hypoalbuminemia. The predominant PS-ASA scores were 2 and 3. Electrolyte imbalance, especially hypokalemia, was the prevalent preoperative complication. Frequent comorbidities included kidney disorders and hypertension. The average ROI stay was 2.1±1.59 days, with most patients staying for 1 to 3 days. Operation-related complications included intra-abdominal infections and bleeding, while medical complications involved electrolyte imbalances, sepsis, and metabolic acidosis.

Conclusion: Nontraumatic acute abdomen patients with low preoperative albumin levels tend to have higher rates of postoperative complications and mortality.

INTRODUCTION

Acute abdomen, a critical medical emergency, accounts for a significant proportion of surgical admissions globally, necessitating prompt diagnosis and intervention to prevent life-threatening complications (¹). Emergency laparotomy, a common surgical intervention for acute abdominal conditions, is associated with significant postoperative risks despite advancements in surgical techniques and perioperative care (²). Mortality rates range from 13% to 18%, with major complications affecting up to 50% of cases (³). These complications include intra- abdominal infections, bleeding, sepsis, and anastomotic leakage, all of which contribute to prolonged hospital stays (⁴,⁵).

Preoperative and postoperative albumin can be a predictor of outcomes of emergency laparotomy (⁶). Low preoperative and postoperative albumin levels were related to adverse postoperative surgical site infection, delayed wound healing, and death within 30 days. Besides, it is also significantly associated with postoperative complications (⁷). The other related risk factors include length of surgery, advancing age, high Physical Status-American Society of Anesthesiologists (PS-ASA) score (PS-ASA score ≥3), obesity, anemia, and the presence of comorbidities (⁸-¹²). A thorough understanding of risk factors, particularly in the case of hypoalbuminemia, is necessary for prevention. Patients classified as high risk may benefit from close monitoring and early intervention.

Because its levels fall during injuries and sepsis, albumin is regarded as a negative acute phase protein (⁷). The hypoalbuminemia condition is characterized by increases in the acute-phase proteins c-reactive protein (CRP), tumor necrosis factor (TNF)-α, interleukin (IL)-1, and IL-6, which are associated with enhanced morbidity and mortality, as well as prolonged inflammation. Hypoalbuminemia slows down the healing of wounds by reducing the activity of important proteins like epidermal growth factor receptor (EGFR), extracellular signal-regulated kinases (ERK)1 or ERK2, transforming growth factors (TGF)-β, and collagen (¹³). Thus, preoperative serum albumin is critical in determining a patient's postoperative outcome after major surgery (¹⁴). Low serum albumin also indicates postoperative complications and longer hospital stays (⁶).

Therefore, this study investigated the albumin levels in patients with nontraumatic acute abdomen who are treated in the Intensive Observation Ward after emergency laparotomy.

METHOD

This study used a descriptive observational design with a retrospective approach. Ethical clearance was granted by the Ethics Committee of Dr. Soetomo General Academic Hospital on November 30, 2023 under approval number 1534/LOE/301.4.2/XI/2023.

The study included all patients with nontraumatic acute abdomen who were treated in the Intensive Observation Ward (Ruang Observasi Intensif/ROI) of Dr. Soetomo General Academic Hospital in Surabaya, Indonesia, after having emergency laparotomy between January and June 2022, totaling 251 patients.

Patients were excluded based on the following criteria: age under 18 years (n = 55), malignancy (n = 30), trauma (n = 16), obstetric cases (n = 19), gynecological cases (n = 16), and incomplete medical records (n = 25). After exclusions, 90 patients were included in the final sample.

All data were obtained from the patients’ medical records and processed using Microsoft Excel and Statistical Product and Service Solutions (SPSS) version 30 to generate descriptive statistics. The statistical measures used included frequency, percentage, mean, and standard deviation.

RESULTS AND DISCUSSION

Gender-wise, the male and female patients were equally distributed, having 1:1 female-to-male ratio. Other studies found that men were slightly more afflicted than women in non-traumatic acute abdomen. Shown in a study conducted by Danish et al. (¹⁵), the male-to-female ratio was 1.14:1. Likewise, a study in India found that the male-to-female ratio was 1.22:1 (¹). One of the possible reasons behind the higher number of male patients was the exclusion of obstetrical and gynecological cases.

Table 1.Demographic characteristics of the Patients

Variables	N (%)
Sex
Female	45 (50)
Male	45 (50)
Age (years)
18-20	8 (8.89)
21-30	15 (16.67)
31-40	10 (11.11)
41-50	20 (22.22)
51-60	8 (8.89)
61-70	17 (18.89)
>70	12 (13.33)
Mean ± SD (47 ± 18.94)
Nutritional Status
Severely Underweight	2 (2.22)
Underweight	13 (14.44)
Normal Weight	44 (48.89)
Overweight	19 (21.11)
Moderately Obese	9 (10)
Severely Obese	3 (3.33)
Morbidly Obese	0 (0)

As shown inTable 1, the patients were dominated by the age group of 41-50 (22.22%), followed by the 61-70 (17%) age group. Most of the other studies found that acute abdomen in their productive age, especially in the 2^ndand 3^rddecades. However, those studies also include nonsurgical intervention for acute abdomen (¹,¹⁶). The age group in this study possibly differs because the surgical intervention was more needed in the older age group, as in this study. The majority of the patients have a normal body mass index (BMI) (48.89%), followed by overweight (21.11%) and underweight groups (14.44%).

Table 2.Indication of laparotomy

Indication	N (%)
Generalized Peritonitis	30 (33.33)
Acute Appendicitis with Perforation	27 (29.99)
Bowel Obstruction	12 (13.33)
Hernia	6 (5.55)
Sigmoid Volvulus	3 (3.33)
GI Perforation	5 (5.55)
Burst Abdomen	3 (3.33)
Intestinal Evisceration	2 (2.22)
Periappendicular Abscess	4 (4.44)
Leakage Anastomosis	1 (1.11)
Complicated Intraabdominal Infection	1 (1.11)

As provided inTable 2, the most common indication in this study was generalized peritonitis (33.33%), followed by acute appendicitis (27.77%) and bowel obstruction (13.33%). Peritonitis mostly results from perforated appendicitis and hollow organ perforation. Peritonitis was also found as the most common indication for laparotomy in the Intensive Care Unit (ICU) of Prof. Dr. Kandou Central General Hospital, Indonesia

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