2. 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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3. 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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4. 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’s
patches into the circulation.(reaches various
organs). There is sensitization of the lymphoid
tissue.
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5. 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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6. 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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7. 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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8. 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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9. GENERAL EX
Depending on the stage of the illness
Very ill patient
Dehydrated
Pale
Pyrexia
Wasted
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11. 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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12. 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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13. INVESTIGATIONS
The 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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14. 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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15. 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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16. 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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17. 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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18. RESUSCITATION
Correction of fluid and electrolyte deficits:
Nasogastric decompression
Urethral catheter:
Reversal of hypoxia
Blood transfusion:
Antibiotic therapy:
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19. 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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20. 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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21. 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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22. ILEOSTOMY
The perforation (if single) or the proximal
and distal ends (following segmental
resection) of the intestine are exteriorised
as 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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23. 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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24. 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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26. PROGNOSIS
Age of patient
Duration of perforation before surgery
Degree of fluid and electrolyte correction
GI hemorrhage
Number of perforation
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27. 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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28. REFERENCES
Emmanuel .A Ameh., Paediatric Surgery;A
comprehensive 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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Hinweis der Redaktion
Those organisms that survive the acidity of the stomach
Some organisms pass into the gall bladder, where they multiply and remain. Invasion of the wall of the gall bladder lead to cholecystitis. Bacteria are also excreted in the stool at this phase. Note separation of slough from ulcers may lead to severe heamorrhage or perforation.
Diarrhea may set in the early stage of the disease but constipation sets in later the course of the illness.
Generalised tenderness with guarding is present; this finding, however, may not be remarkable, especially in patients who perforateunder medical treatment
platelet count is ascertained, particularly in patients with evidence of coagulopathyleucopaenia is a more common finding inpatients with uncomplicated typhoid fever
. May be as high as 96% in those with typhoid colonic perforation. The extent ofpneumoperitoneum is important as it may be necessary to vent theair to improve respiration and reduce hypoxia. Pulmonaryconsolidation may be present in those with chest infection.
Frequently, all that can be seen is a diffuse opacity in most of the abdomen, particularly in those presenting late with intraperitoneal collection. The shadowof a distended gallbladder may be obvious, suggesting cholecystitis.
Correction of fluid and electrolyte deficits: Care needs to betaken to achieve adequate correction. A common cause of death isinadequate replacement of fluid and electrolyte deficits. Four to sixhours may be needed to achieve adequate correction.• Dextrose: Intravenous dextrose in 0.18-0.45% N saline is used inchildren younger than 5 years of age (the amount of saline usedwill depend on the serum level of Na+). In older children, dextrosein 0.9% N saline is used. Large volumes of fluid may be required:20 ml/kg by bolus infusion is given initially in severely dehydratedpatients and those presenting in shock. Ten ml/kg may be repeatedafter 1 hour if urine output is not satisfactory (never give bolusinfusion of any potassium-containing fluid). Thereafter, adjustinfusion to maintain a urine output of 1.5–2 ml/kg/hr.• Potassium (K+): Once the child is making adequate urine, give atleast a daily requirement of K+ (1–2 mmol/kg/day) until a serumbiochemistry result is available. Thereafter, any calculated deficitis added to the daily requirement. The amount of potassiumrequired is added to the intravenous fluid and administered over18 to 24 hours (do not give more than 10 mmol of K+ in an hourunless the child is in the intensive care unit (ICU) and is beingmonitored using an electrocardiogram (ECG)).2. Nasogastric decompression: An appropriate size nasogastric tubeis inserted and the stomach decompressed by low pressure suction orintermittent aspiration. This will also help in reducing the pressure onthe diaphragm and improve respiration.3. Urethral catheter: An indwelling urethral catheter is left in placeto ensure adequate monitoring of urine output.4. Reversal of hypoxia: Hypoxia is a common problem that mayaffect the integrity of intestinal anastomosis as well as survival.Respiration may be impaired by abdominal distention, peritonitis, andpresence of a large pneumoperitoneum. If the pneumoperitoneum islarge (see Figure 17.3), insert a size 16G–18G intravenous cannulain the right or left upper quadrant (depending on the site of maximalair collection) to vent the collected gas (avoid the lower borderof the liver, if enlarged). The cannula is removed after adequateventing. This manoeuvre often helps to improve respiration and reducehypoxia. Administer 100% oxygen by nasal catheter until surgery.Oxygen administration may need to be continued for up to 6 hourspostoperatively in very ill children.5. Blood transfusion: This is necessary to correct anaemia if thehaemogram is <8 gm/dl (packed cell volume of <24%). Anaemia isalways corrected before surgery to minimise hypoxia. A rough estimatefor blood transfusion is 20 ml/kg body weight to attempt to correct theanaemia before surgery.6. Correction of coagulopathy: A vitamin K injection, 10 mg daily,is given and maintained for at least 5 days.7. Antibiotic therapy: Intravenous, broad-spectrum antibiotics arecommenced immediately when the diagnosis of typhoid is suspected.The antibiotics may need to be changed later if there is no improvementand culture results become available. A commonly used effectiveantibiotic combination is one of the following:• Chloramphenicol (50–75 mg/kg/24 hours in 6-hour dosing) + gentamicin(3–5 mg/kg/24 hours in 8-hour dosing) + metronidazole(7.5 mg/kg/dose given in 8-hour dosing).• Amoxicillin [50–75 mg/kg/24 hours in 8-hour dosing (or ampicillin,50–75 mg/kg/24 hours in 6-hour dosing)] + gentamicin (3–5mg/kg/24 hours in 8-hour dosing) + metronidazole (7.5 mg/kg/dose given in 8-hour dosing).• Third-generation cephalosporin + metronidazole.
The resected length of intestine is always measured and documented. Then intestinalcontinuity is restored by end-to-end anastomosis. The resectedsegment is sent to the lab for histopathology.
complication rate maybe significantly higher in children younger than 5 years of age.Mortality is<15% in those presenting within 24hrs and >80% in those presenting more than 4days
