Nutritional risk assessment in elderly patients undergoing emergency abdominal surgery for ileus

Authors

Abstract

AimThis study investigated the association between nutritional status and mortality in patients aged 65 and older who underwent emergency surgery for ileus. We aimed to evaluate whether nutritional assessment in the emergency department could serve as a reliable predictor of postoperative outcomes.
MethodsA retrospective cohort of patients aged ≥65 years diagnosed with ileus and treated with urgent abdominal surgery was analyzed. Demographic, clinical, and outcome data were collected from medical records. Nutritional and clinical status were assessed using the Nutritional Risk Screening-2002 (NRS-2002), Geriatric Nutritional Risk Index (GNRI), and Acute Physiology and Chronic Health Evaluation Score (APACHE) II scores. Statistical comparisons were performed using chi-square and Mann-Whitney U tests, and potential predictors of mortality were examined through univariate and multivariate regression analyses. A p-value < 0.05 was considered statistically significant.
ResultsThe study included 151 patients, of whom 93 (61.6%) were male, with a mean age of 77.1 ± 8.4 years. GNRI classification differed significantly between survivors and non-survivors (p < 0.001). Among all evaluated parameters, the GNRI score emerged as the strongest predictor of mortality (p < 0.001).
ConclusionIn geriatric patients undergoing surgery for ileus, GNRI was an effective tool for assessing nutritional status and was a superior predictor of postoperative mortality compared with NRS-2002 and APACHE II.

Keywords

Introduction

Malnutrition increases the risk of mortality, morbidity, and infection in hospitalized patients and significantly affects patient prognosis. The risk of malnutrition is higher in patients undergoing surgery. Numerous studies have shown that preoperative malnutrition increases the risk of postoperative complications and negatively affects long-term survival.^1,2
Intestinal obstruction (ileus) is a condition that prevents the forward passage of intestinal contents, leading to accumulation proximal to the obstruction site. Small bowel obstruction is usually caused by adhesions or hernias related to previous surgery, whereas large bowel obstruction is most commonly due to adhesions and stenosis resulting from cancer or recurrent diverticulitis. Less common causes of large bowel obstruction include sigmoid volvulus and hernia.3 Mechanical intestinal obstruction affects the small intestine approximately four times more frequently than the large intestine.³
Intestinal obstruction is a common condition in elderly patients, and the need for emergency medical care and surgical intervention has increased in parallel with the growing elderly population.⁴ Emergency surgical procedures in older adults are associated with higher morbidity and mortality rates than elective operations.^4,5 In addition, elderly individuals with intestinal obstruction are at increased risk of malnutrition. Early detection of malnutrition, a preventable condition in this age group, and timely interventions may reduce morbidity and mortality.⁶
Different assessment tools exist to evaluate nutritional status in older adults, and these screening tests are recognized as effective in predicting malnutrition. The Geriatric Nutritional Risk Index (GNRI) has been widely studied, especially in patients with malignant gastrointestinal tumors.^7,8 The Nutritional Risk Screening-2002 (NRS-2002) is used to identify patients at nutritional risk and to determine those who may benefit from nutritional interventions.⁹ The Acute Physiology and Chronic Health Evaluation II (APACHE II) is a tool used to evaluate the severity of a patient’s illness.¹⁰
The most appropriate malnutrition screening tool should be time-efficient, simple, low-cost, valid, reliable, consistent, and sufficiently sensitive to detect at-risk patients with minimal error. Most research to date has focused on patients in intensive care units.¹¹ However, data on nutritional status in patients admitted to the emergency department or undergoing emergency surgery remain limited. In this study, we assessed nutritional risk at admission in older adults presenting with ileus who required surgical intervention. The aim was to compare the prognostic performance of different nutritional assessment tools in this population and to identify the most suitable method for screening.

Materials and Methods

This was a retrospective observational cohort study. Patients diagnosed with ileus according to the International Classification of Diseases, 10th Revision (ICD-10 code: K56) who presented to the emergency department between January 1, 2018, and December 31, 2022, were identified from the hospital database. Among these patients, those aged 65 years and older who underwent surgical intervention due to ileus were included in the study. Patients were excluded if they were under 65 years old, had diagnoses other than ileus, received non-operative management, had postoperative findings unrelated to ileus, or had incomplete clinical or laboratory records.
Demographic characteristics, comorbidities, vital signs at emergency department admission, laboratory results, length of hospital stay, and hospital outcomes (discharge or death) were recorded from patient medical records. Nutritional and clinical assessments were performed for all included patients using GNRI, NRS-2002, and APACHE II scores. GNRI was calculated using the following formula: GNRI = (1.489 × serum albumin [g/L]) + (41.7 × current body weight/ideal body weight). GNRI was calculated with the formula: GNRI = (1.489 × serum albumin [g/L]) + (41.7 × current weight/ideal weight), and patients were classified into four risk categories: >98 (no risk), 92-98 (low risk), 82-91 (moderate risk), and <82 (high risk). Patients with NRS-2002 scores ≥ 3 were considered at high nutritional risk, while scores < 3 indicated no nutritional risk. APACHE II scores were calculated based on twelve physiological variables, age, and chronic health conditions.
Ethical ApprovalThis study was approved by the Ethics Committee of Adana City Training and Research Hospital Clinical Research (Date: 2024-12-05, No: 8/275).
Statistical AnalysisStatistical analyses were performed using SPSS version 25.0 (Statistical Package for the Social Sciences). Categorical variables are expressed as counts and percentages, while continuous variables are presented as mean ± SD or median (range). Chi-square tests compared categorical data, and the Mann-Whitney U test was applied for non-normal continuous variables. Correlations were assessed with Spearman’s rank correlation coefficient. Receiver operating characteristic (ROC) curves evaluated the predictive value of GNRI, NRS-2002, and APACHE II for mortality, with optimal cut-offs determined. Univariate and multivariate regression analyses identified factors affecting hospital stay. A p-value < 0.05 was considered significant.
Reporting GuidelinesThis study is reported in accordance with the STROBE guidelines.

Results

Of the 151 patients, 61.6% (n = 93) were male. The mean age was 77.1 ± 8.4 years. Hypertension was present in 65 patients (43%), making it the most prevalent comorbidity. During follow-up, 29 patients (19.2%) died, while 122 (80.8%) survived to discharge.
Comparison of age between survivors and non-survivors revealed no significant difference (p = 0.198). Mortality was significantly higher among male patients (24.7%) compared to females (10.3%) (p = 0.029). Variations in body temperature, systolic and diastolic blood pressure, and mean arterial pressure were significantly related to mortality (p = 0.026, p < 0.001, p = 0.006, and p = 0.002, respectively). In contrast, pulse rate and oxygen saturation showed no significant association with mortality (p = 0.404 for both). Patients who died had lower levels of albumin, total protein, hemoglobin, hematocrit, platelet and lymphocyte counts, systolic and diastolic blood pressure, mean arterial pressure, calcium, and GNRI scores compared with survivors (p < 0.001, p < 0.001, p < 0.001, p = 0.001, p = 0.006, p = 0.022, p < 0.001, p = 0.006, p = 0.002, p < 0.001, p < 0.001). In contrast, urea, glucose, AST, sodium, prothrombin time, international normalized ratio, activated partial thromboplastin time, NRS-2002 positivity (≥3), and APACHE II scores were higher in patients who died (p = 0.005, p = 0.001, p = 0.001, p = 0.023, p < 0.001, p < 0.001, p < 0.001, p = 0.043, p < 0.001). There was no significant difference in length of hospital stay between survivors and non-survivors (p = 0.161). The detailed data were provided in Supplementary Table 1.
According to NRS-2002, 84 patients (55.6%) were identified as being at nutritional risk. Based on the GNRI classification, 43 patients (28.5%) were categorized as high risk. The mean APACHE II score for the cohort was 15.1 ± 9.4.
NRS-2002 scores were higher in non-survivors compared with survivors (p = 0.043). GNRI showed a stronger association with outcomes, with risk category distributions differing significantly between the groups (p < 0.001). Among patients without GNRI-defined risk, only two deaths occurred, while 19 of 24 patients in the high-risk group died (p < 0.001). APACHE II scores, however, were similar between survivors and non-survivors (p = 0.089) (Table 1).
In univariate analyses, mortality was associated with age, sex, ischemic heart disease, fever, mean arterial pressure, glucose, urea, sodium, calcium, albumin, total protein, hemoglobin, hematocrit, platelet and lymphocyte counts, prothrombin time, international normalized ratio, activated partial thromboplastin time, as well as NRS-2002, GNRI, and APACHE II scores.
In the multivariate logistic regression analysis, variables with high correlation (r > 0.4) were excluded to prevent multicollinearity. The final model included ischemic heart disease, mean arterial pressure, glucose, urea, hematocrit, platelet and lymphocyte counts, NRS-2002 score, and GNRI (moderate/high risk). Among these, ischemic heart disease, lower mean arterial pressure, and GNRI were independent predictors of mortality. Ischemic heart disease increased the risk of death 2.9-fold, and patients with moderate or high GNRI risk had a 10.2-fold higher risk compared with those at no or low risk. Lower mean arterial pressure was also associated with increased mortality (OR ≈ 1.1 per unit decrease). The detailed data were provided in Supplementary Table 2.
ROC curve analysis was conducted to assess the ability of NRS-2002 and GNRI to predict mortality. GNRI showed better discriminative performance than NRS-2002 (Figure 1, Table 2).
Lower GNRI scores were associated with higher mortality risk. A GNRI cut-off of <86.5 provided a sensitivity of 82.8% and a specificity of 68.9%, whereas an NRS-2002 score ≥ 3 yielded a sensitivity of 72.4% and a specificity of 45.9%.

Discussion

Malnutrition is common among older adults in various healthcare environments, including hospitals and home care, and it has been linked to poorer clinical outcomes.¹ Early detection of patients at nutritional risk is important, as providing timely nutritional support can help reduce hospital stay and lower morbidity and mortality rates. Although multiple assessment tools exist for evaluating nutritional status in the elderly, many depend on patient-reported history and physical examination, which can limit their usefulness in acute care settings.^12,13
The GNRI is a simple and objective method for assessing nutritional status.¹⁴ Low GNRI scores have been studied in various patient groups, including those with head and neck cancer and obstructive colorectal cancer, and have been associated with poorer survival.¹⁵ GNRI has also been linked to postoperative recovery and mortality in elderly patients undergoing major abdominal or oncological surgery.^2,7,8 In our study, GNRI was found to be an independent predictor of mortality in elderly patients with ileus undergoing emergency surgery.
The management of ileus in elderly patients is often challenging due to the high prevalence of comorbid conditions and pre-existing nutritional deficiencies. Advanced age, diabetes, male sex, malignancy, and a history of abdominal surgery have previously been reported as predictors of morbidity and mortality in patients with ileus and bowel obstruction.³ In addition, tachycardia, abnormal leukocyte counts, and comorbidities have been associated with increased morbidity in patients undergoing surgery for mechanical bowel obstruction.¹⁶ In our study, no significant difference in mean age or diabetes status was observed between survivors and non-survivors. However, the presence of ischemic heart disease was associated with worse outcomes, suggesting that cardiovascular comorbidity plays an important role in this population. This observation was supported by previous studies indicating that cardiovascular and respiratory diseases were major contributors to complications in elderly surgical patients.¹⁷
Low GNRI values have been associated with poor prognosis and increased mortality in geriatric patients hospitalized for heart failure.¹⁸ GNRI incorporates both serum albumin and body weight parameters, which may provide a more comprehensive assessment of nutritional and inflammatory status. Albumin alone is influenced by inflammatory conditions and may not reliably reflect nutritional status. Previous studies have shown that GNRI is superior to albumin and body mass index in predicting outcomes.¹⁹ Similarly, our findings suggest that GNRI offers greater prognostic value than albumin alone for predicting mortality in elderly patients with ileus.
The NRS-2002 is a nutritional screening tool recommended by the European Society for Clinical Nutrition and Metabolism. It is widely used in hospitalized and critically ill patients.²⁰ Although high NRS-2002 scores have been associated with adverse outcomes in some studies, their ability to predict mortality may be limited in certain clinical settings.²¹ In our study, NRS-2002 scores differed between survivors and non-survivors; however, NRS-2002 did not independently predict mortality in multivariate analysis.
APACHE II is a widely used severity scoring system in intensive care and emergency surgical settings. Previous studies have reported associations between higher APACHE II scores and postoperative complications, disease severity, and mortality in patients undergoing emergency abdominal surgery.²² However, in our cohort, APACHE II scores were not independently associated with mortality. This finding may be related to the advanced age and relatively homogeneous critical status of the study population, as all patients underwent surgery and were managed in the intensive care unit during both the preoperative and postoperative periods.

Limitations

This study has some limitations. First, its retrospective design could have led to selection and information biases. Second, being conducted at a single center may limit the generalizability of the results and contribute to the relatively small sample size. Additionally, height and weight data used for calculating nutritional scores were collected retrospectively and might be inaccurate. Finally, nutritional assessments were performed only at hospital admission, which may not reflect changes in nutritional status during the patient’s stay.

Conclusion

In our study, GNRI measured preoperatively was found to be a simple and objective tool for assessing nutritional risk in patients aged 65 and older undergoing surgery for ileus. GNRI demonstrated predictive value for mortality and performed as well as or better than NRS-2002 in discriminating outcomes. Conducting nutritional assessment at the time of emergency department admission may help identify high-risk patients early and guide clinical management.

Declarations

Abbreviations

APACHE II: Acute Physiology and Chronic Health Evaluation II
GNRI: Geriatric Nutritional Risk Index
ICD-10: International Classification of Diseases, 10th Revision
NRS-2002: Nutritional Risk Screening-2002
ROC: Receiver operating characteristic
SD: Standard deviation
SPSS: Statistical Package for the Social Sciences
STROBE: Strengthening the Reporting of Observational Studies in Epidemiology

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About This Article

Received:

February 19, 2026

Accepted:

April 1, 2026

Published Online:

April 7, 2026