TYPHOID ILEAL

PERFORATIONDR BASHIR YUNUS

DEPT OF SURGERY

AKTH

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INTRODUCTION

The most common surgical complication of

typhoid fever. Remains a problem in

developing countries due to gross defect in

sanitation and lack of portable water. It is

associated with significant morbidity and

mortality due to late presentation. The

diagnosis is mainly clinical. Surgery remains

the gold standard of treatment after

adequate resuscitation.

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EPIDEMIOLOGY

Global incidence of typhoid fever is 21million

cases annually with 1-4% mortality

predominantly in 5-15years. Children account

for >50% of all cases of typhoid ileal perforation

with peak age of 5-9years. Has equal M:F ratio in

children in contrary to adult with higher male

prevalence. Perforation rate is about 10% in

children which increase with age reaching a

high of 30% by the age of 12years. Has higher

incidence in rainy season.

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PATHOGENESIS The infection is caused by the

bacteria, Salmonella typhi (a gram-negative rod found only in humans), and rarely by Salmonella paratyphi A,B and C

Transmission is by feco-oral due to fecal contamination of food and water

1st week bacteremia; the organisms multiply the intestine, passes through the peyer’spatches into the circulation.(reaches various organs). There is sensitization of the lymphoid tissue.

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PATHO… CT

By the 2nd week, organisms are mopped

up from the circulation by the

reticuloendothelial system esp. the kuffer

cells of the liver. There is multiplication of

the organism, necrosis of the RE

cells, release into the circulation leading

to the septicemic phase of the illness.

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PATHO….CT

The organisms are also released into the bile

through which they reach the intestine.

Invade the previously sensitized peyer’s

patches and multiply there. Hypersensitivity

reaction occurs with swelling of the peyer’s

patches and congestion of the submucosal

and muscular layers. Blockage of the

capillaries lead to necrosis and ulceration

and subsequent bleeding or perforation usu

at the 3rd week.

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PATHOLOGY ULCERS; shallow irregular oval ulcers disposed

longitudinally on the antimesenteric border of the ileum esp. terminal ileum.

Perforation may be small or wide up to 2.5cm. Most within 45cm from the ileocecal junction. They are multiple in 20% of patients.

Histologically, tissue around perforation shows infiltration by lymphocyte,macrophages and few neutrophils. The macrophages may ingest RBCs to produce typhoid cells.

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CLINICAL FEATURES

History of fever, 2-3weeks preceding the

onset of abdominal pain.

Abdominal pain

± hematochezia prior to onset of pain

Diarrhea or constipation.

± jaundice may be a complaint.

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GENERAL EX

Depending on the stage of the illness

Very ill patient

Dehydrated

Pale

Pyrexia

Wasted

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CVS

Tachypnea

Hypotension

shock

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CHEST

respiratory function is compromised by

chest infection, which is worsened by the

marked abdominal distention(if present).

Crepitation may be heard, sometimes

bilaterally, indicating that pneumonia has

set in and is worsening the condition

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ABDOMEN Generalized tenderness

Rebound tenderness

Guarding

Rigidity

Diminish or absent bowel sounds

Tenderness and fullness in the recto-vesical or recto-uterine pouch, suggesting a pelvic collection of pus.

Blood may be seen on the examining finger in patients with bleeding.

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INVESTIGATIONSThe diagnosis of is often clinical, based on Hx, features of peritonitis and investigations are done to

support the diagnosis

identify deficits, as well as to

ascertain the fitness of the patient for surgery

NOTE THAT RESUSCITATION TAKES PRECEDENCE OVER INVESTIGATIONS, WHICH SHOULD NOT DELAY INTERVENTION AFTER RESUSCITATION IS COMPLETE.

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Serum electrolytes, urea, and creatinine:

↓K⁺ (Hypokalaemia is a troublesome problem), ↓Na⁺,↓Cl⁻,↓HCO₃⁻,↑Urea

Complete blood count:

anaemia. , leucocytosis and neutrophilia

Blood grouping and cross matching:

For correcting anaemia or intraoperative use.

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Plain radiography:

Chest and upper abdomen (erect film): Some patients with intestinal perforation

present evidence of air under the

diaphragm. This is present in about 55% of

children. Absence of air under the

diaphragm, however, does not exclude

perforation.

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Full abdomen (erect and supine):

The intestines may show dilatation and

oedematous walls. Patients who are too sick

for erect film should have a lateral decubitus

film to identify pneumoperitoneum.

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Microbiological cultures:

Blood and urine, as well as an operative

specimen of intraperitoneal fluid/pus, are

cultured to identify

the Salmonella organism and any

superimposed infections.

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RESUSCITATION

Correction of fluid and electrolyte deficits:

Nasogastric decompression

Urethral catheter:

Reversal of hypoxia

Blood transfusion:

Antibiotic therapy:

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DEFINITIVE TREATMENT

The definitive treatment for intestinal

perforation is operative to evacuate faecal

contamination and prevent further contamination.

LAPAROTOMY + SURGICAL OPTIONS;

Simple closure of perforations

Segmental resection of affected intestine

Enterostomy

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SIMPLE CLOSURE

single perforation,

if perforations are far apart

if the number of perforations are so numerous

that resection may result in a short gut.

The edge of the perforation is excised

circumferentially (the excised edge is sent to

the lab for histopathology). Then simple

closure is achieved by a single layer OR

double layer

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RESECTION & ANASTOMOSIS

Large solitary perforation

Multiple perforation in close vicinity to each other.

Adjacent bowel is friable/ near perforation

The resection margin should be healthy and free of evidence of inflammation such as oedema.

A limited right hemicolectomy may be necessary if the most distal perforation is too close to the ileocaecal junction for safe anastomosis ( <3 cm).

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ILEOSTOMY

The perforation (if single) or the proximal and distal ends (following segmental resection) of the intestine are exteriorisedas stoma, to be closed at a later date when oedema has subsided and the patient is fit(8-12weeks).

An enterostomy is performed if the child is too sick or intestinal oedema is too extensive for safe anastomosis or simple closure.

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POST OP MGT Strict fluid and electrolyte mgt

The chosen antibiotic regime(base on result of culture) is continued postoperatively until the temperature returns to normal. Thereafter, the drugs are continued orally (if an oral form is available) for 7–14 days.

Correction of aneamia

Close monitoring of vital signs

Daily monitoring for intra-abdominal collection

Nutritional rehabilitation

Wound dressing

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POST OPERATIVE

COMPLICATIONS

Prolonged ileus

Surgical site infection

Abdominal wound dehiscence

Anastomotic leakage or complete

breakdown of the anastomosis

Enterocutaneous fistula

Intraperitoneal abscess

Adhesion intestinal obstruction

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Reperforation

Hypoproteinaemia

Pleural effusion

Transient psychosis

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PROGNOSIS

Age of patient

Duration of perforation before surgery

Degree of fluid and electrolyte correction

GI hemorrhage

Number of perforation

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CONCLUSION

Typhoid perforation is a challenging

surgical condition especially in

developing countries. Prompt

diagnosis, aggressive resuscitation,

and proper choice of surgical

procedure is necessary to reduce

its morbidity and mortality.

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REFERENCES

Emmanuel .A Ameh., Paediatric Surgery;Acomprehensive text for Africa.

E.A Badoe.,Principle and practice of surgery; Including pathology in the tropics. 4th Ed.

Indian journal of clinical practice, Vol.12,No.10, March 2002.

Nelson Awori., Primay surgery Vol. 1online ed.

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