Typhoid ileal perforation in children: does clinical diagnosis alone justify laparotomy?

Introduction: Typhoid ileal perforation is one of the most common surgical complications of typhoid fever, with high morbidity and mortality in resource poor tropical areas in Africa and other developing countries. Objective: The aim of this study was to evaluate clinical diagnosis of typhoid ileal perforation as justification for laparotomy. Method: A retrospective study from January 2008 to December 2011 in the Paediatric Surgery Division of the University of Abuja Teaching Hospital. Results: The age group most commonly affected was aged 6-9 years (43.5%); there were 20 (43.5%) males and 26 (56.5%) females. The commonest clinical features were fever, vomiting, abdominal pain, tenderness and distension (52.3%). Thirty one (67.4%) of the patients did not have any diagnostic radiological investigations. Fifteen (32.6%) patients had superficial wound infection, ten (21.7%) died, eleven (23.9%) had no complications. Conclusion: We advocate that under circumstances where urgent diagnostic radiological and laboratory investigations are not available promptly, clinical diagnosis of typhoid ileal perforation, especially signs of peritonitis should justify an emergency laparotomy

Hemorragia pulmonar y síndrome de dificultad respiratoria aguda como complicaciones inusuales de la fiebre tifoidea / Pulmonary haemorrhage and acute respiratory distress syndrome as unusual complications of typhoid fever

La hemorragia pulmonar y el síndrome de dificultad respiratoria aguda son complicaciones infrecuentes de la fiebre tifoidea, y la endotoxemia producto de la sepsis es un factor causal común. Se describe a un paciente de sexo masculino, indio, joven, inmunocompetente, con hemorragia pulmonar, síndrome de dificultad respiratoria aguda y choque séptico en el curso de la fiebre tifoidea, con hemocultivos negativos y cepa de Salmonella typhi, aislada en coprocultivo, resistente a la ciprofloxacina. El paciente tuvo una respuesta satisfactoria al tratamiento convencional para el daño pulmonar con ventilación mecánica, el antibiótico por sensibilidad del antibiograma y la administración de hemoderivados.

Prevalencia de complicaciones en casos confirmados de fiebre tifoidea ingresados en el Hospital Nacional de Niños Benjamín Bloom durante el periodo de 2009 ­ 2012 / Prevalence of complications in confirmed cases of typhoid fever admitted to the Benjamín Bloom National Children's Hospital during the period 2009 ­ 2012

La Fiebre tifoidea es una enfermedad infecciosa de transmisión fecohídrica, cuyo agente etiológico bacteriano, pertenece al género Salmonella, ser. Typhi, S. ser. Paratyphis A, S. ser. Paratyphis B (Schottmuelleri) y S. ser.Paratyphis C (Hirschfeldii). Según la Organización Mundial de la Salud se produce unos 21 millones de caso por año en el mundo, de los cuales entre el 1- 4% presentan complicaciones médico ­ quirúrgicas importantes y en algunos casos suelen ser fatales. El presente trabajo nace como una guía de estudio que se realizó con el objetivo principal de determinar la Prevalencia de las complicaciones en casos confirmados de fiebre tifoidea ingresados en el Hospital Nacional De Niños Benjamín Bloom durante el periodo de 2009 a 2012. Se realizó un estudio descriptivo, retrospectivo y transversal a través de la revisión de expedientes clínicos de los pacientes que cumplieron con los criterios de inclusión previamente aprobado por el comité de ética del Hospital de Niños Benjamín Bloom. Entre los años 2009 a 2012 egresaron 87 pacientes con diagnóstico de fiebre tifoidea de los cuales solo 47 cumplen con los criterios de inclusión del estudio. El 38.2% (18) de los pacientes estudiados presentaron una o más complicaciones durante los años 2009 a 2012. La aparición de complicaciones fue tan temprano como a la 1a semana y tardía como los 2 meses, además, se reportó un paciente fallecido que representa el 4.54% de los pacientes complicados por la enfermedad y el 2.1%de los pacientes estudiados. La edad escolar (de 5 a 10 años) es la más afectada sin predilección de género y el diagnóstico clínico es el primer método utilizado ayudado por el hemocultivo como prueba diagnóstica más utilizada

Role of primary closure in the management of early cases of typhoid intestinal perforation, in our set up

To see the benefits of primary closure in typhoid intestinal perforation in early cases, regarding morbidity and mortality in KPK. Prospective study. Study was performed at teaching hospital of KMU-IMS, Kohat from March 2006 to March 2014. In this prospective study, we included 76 cases of single perforation of less than 24 hours in terminal ileum in typhoid fever patients, these patients had primary closure in 2 layers. Data was collected on a structured proforma. Patients' data included demography, clinical features, investigation post-operative complications, hospital stay and follow up. 76 cases were included in the study over 8 years. Mean age was 24 +/- 10.32 years with m:f ratio of 1:2.6. In 100 % cases pain abdomen, fever, tenderness in either right iliac fossa or generalized in the abdomen were observed. Widal test, Typhidot and blood culture was positive in 51 ,54 and 58 out of 76 patients in same order. Wound sepsis was a common post-operative complication 12/76 [15%] other post-operative complications were pulmonary infection, abdominal dehiscence, intra peritoneal abscesses and Intestinal haemorrhage. Mean duration of hospital stay was 13.34 +/- 4.20 days. Mortality was 1.3% Two layer primary closure is an effective procedure having good results. Both morbidity and mortality are low and associated with reasonable length of hospital admission

Role of gum chewing on the duration of postoperative ileus following lleostomy closure done for typhoid ileal perforation: a prospective randomized trial

There is ample evidence in the recent literature that gum chewing after elective colonic anastomosis decreases postoperative ileus [POI]. But there are very few studies on small bowel anastomosis done in relaparotomy cases. This study aimed to evaluate the effect of gum chewing on the duration of POI following small bowel anastomosis performed for the closure of intestinal stoma, made as temporary diversion in the selected cases of typhoid perforation peritonitis. Hundred patients undergoing elective small bowel anastomosis for the closure of stoma were randomly assigned to the study group [n=50] and the control group [n=50]. The study group patients chewed gum thrice a day for 1 h each time starting 6 h after the surgery until the passage of first flatus. The control group patients had standard postoperative treatment. Study and control group patients were comparable at inclusion. The mean time for the appearance of bowel sounds as well as the passage of first flatus was significantly shorter in the study group [P=0.040, P=0.006]. The feeling of hunger was also experienced earlier in study group cases [P=0.004]. The postoperative hospital stay was shorter in the study group, but the difference was not significant [P=0.059]. The cases of relaparotomy requiring additional adhesiolysis and small bowel anastomosis for stoma closure are benefited by postoperative gum chewing

Immunoblot analysis of sera in uncomplicated typhoid fever & with typhoid ileal perforation.

Background & objectives: Ileal perforation is a serious complication of typhoid fever. The exact reasons for the development of perforation in only a few of those infected with Salmonella Typhi is unknown, and it is likely that immunological factors are involved. Therefore we undertook this study to compare the antibody profile in patients with uncomplicated typhoid fever with those having ileal perforation by immunoblotting. Methods: Two groups of patients were included in the study. Group II comprised patients with uncomplicated typhoid fever (n=47), and group I with typhoid ileal perforation (n=33). The flagellar (H), lipopolysaccharide (LPS) and outer membrane protein (OMP) antigens of Salmonella Typhi were extracted and used to test patient sera for antibodies by immunoblotting Results: Immunoblotting using S. Typhi antigens enabled the detection of S. Typhi antibodies in the two groups of patients. A significant difference was seen in the response of these two groups of patients with respect to antibodies to flagella, lipopolysaccharide and outer membrane proteins. Antibodies to flagella were more pronounced among patients with uncomplicated typhoid fever, while anti-OMP antibodies were significantly associated with typhoid ileal perforation. Interpretation & conclusions: A comparison of antibodies in patients with uncomplicated typhoid fever and with ileal perforation revealed the differences in the antibody profiles of the two groups. Our study suggests that the difference in antibody response may in some way play a role in the pathogenesis of typhoid ileal perforation which can also potentially be exploited to develop suitable diagnostic tests.

Bilateral breast abscess: a rare complication of enteric fever.

Breast abscess is usually caused by Staphylococcus aureus in pregnant or lactating females. Salmonella spp. is occasionally associated with abscess formation in various organs, but breast abscess is a very rare complication. In enteric fever dissemination to multiple organ systems following bacteraemia can lead to localized abscess. We report a case of bilateral breast abscess due to Salmonella Typhi in an unmarried 35-year-old female without any predisposing conditions. She presented with fever and painful swelling of both the breasts. S. typhi was isolated from both breasts. Such rare cause must be suspected in females without any evident predisposing factors for effective management.

Management of typhoid ileal perforation: a surgical experience of 44 cases

Typhoid perforation of ileum is a serious complication of typhoid fever. There are different surgical methods of repairing the perforation. The aim of this study was to report the surgical experience regarding treatment of typhoid ileal perforation in our setup. It wa a retrospective, observational study carried out at Departments of Surgery Unit I and Pathology, Peoples Medical College and Hospital Nawabshah from July 2003 to June 2008. Forty-four patients were admitted through causality as cases of acute abdomen, 28 [63.63%] were males and 16 [36.36%] females, with age range of 10-45 years. The diagnosis of typhoid perforation was made on clinical grounds, laboratory investigations, x-ray, ultrasound examination, and operative findings. Exploratory laparotomy was carried out and perforations were managed. The variables studied in the post operative period were wound infection, wound dehiscence, entero-cutaneous fistula, residual abscess, mortality, hospital stay and incisional hernia. Fever with abdominal pain and distension were the symptoms in all subjects followed by diarrhoea, vomiting and constipation Widal test more than 1:320 was positive in 35[79.45%] cases and typhi dot [IgM in all cases and IgG in 15] was positive in all cases. Blood culture was positive in 32 [72.7%] cases. X-ray abdomen revealed pneumoperitoneum in 22 [50%] cases. Ultrasound shows free peritoneal collection in 40 [90.90%] cases. On operation the abdominal cavity was heavily contaminated in 12 [27.27%] patients while in 32 [72.72%] patients the peritoneal cavity was having moderate contamination. 36 [81.81%] patients had single perforation and 8 [18.18%] patients had more than one perforation. In 32 [72.72%] patients perforations after freshening the ulcer were closed by single layered interrupted extra mucosal technique with vicryle 2/0, 4 [9.09%] needed resection and anastomosis and in remaining 8 [18.18%] loop ileostomy was made. The typhoid ileal perforation still carries high morbidity and mortality. The typhoid ileal perforation should always be treated surgically. There are many operative techniques to deal typhoid ileal perforation but no one is fool proof. Regardless of the operative technique timely surgery within 24 hours with adequate and aggressive resuscitation is a way to decrease the morbidity and mortality

Management of typhoid perforation

To Compare Primary repair and Ileostomy in patients with Typhoid perforation in terms of Morbidity and mortality in Sir Ganga Raam Hospital. Observational Comparison Study. 15[th] March 08 to 15[th] June 2009 in department of Surgery, Sir Ganga Ram Hospital Lahore. All the patients presented in surgical Emergency with typhoid perforation of all age groups and of both genders. Resuscitation followed by exploratory laparatomy with appropriate surgical procedure was done. 24 patients with typhoid perforation were observed with mean age group of 32 years. Male to female ratio of 3:1. Surgical intervention done was primary repair of perforation [N=9], Resection Ileostomy [N=12] and resection anastamosis [N=3]. Morbidity in term of hospital stay is high in patients with serious peritoneal contamination and in most cases resection Ileostomy has to be undertaken

Perforation operation interval as a prognostic factor in typhoid ileal perforation

To find out significance of perforation-operation interval [POI] in relation to early prognosis in patients with peritonitis due to typhoid Heal perforation [TIP]. Case series. Department of General Surgery, Jinnah Postgraduate Medical Centre [JPMC] Karachi, from October, 2004 to March, 2007. The study included 92 patients with generalized peritonitis diagnosed as typhoid Heal perforation Methods fulfilling the inclusion criteria. All non typhoidal and traumatic perforations were excluded from the study. Data was collected in the proforma designed for the study. The diagnosis of typhoid Heal perforation was established on the basis of history, clinical examination, radiology, isolation of Salmonella Typhi, and a positive Widal test. Histopathological confirmation of the diagnosis was also made. Out of 92 patients, 75 were males [81.5%] and 17 [18.5%] females, with male to female ratio of 4.4:1. The ages ranged between 15 to 50 years. The most common symptoms were fever [100%], abdominal pain [100%], constipation [81.5%], vomiting [76%] and distension of abdomen [69.5%]. The most common signs elicited on abdominal examination were tenderness [100%], guarding [72.8%] and absent gut sounds [65.2%] Out of 92 patients 12 patients [13%] presented within 24 hours of onset of severe abdominal pain [Group A]. Among late presenters, My nine [64.1%] patients presented 25-72 hours after severe abdominal pain [Group B] and twenty one patients [23%] presented after 72 hours [Group C]. Mortality was highest among group C patients [8/21 ;38%], while the mortality among the late presenters [Group B] was 10.2% [6/59]. There r was no mortality in the early presenters [Group A]. Overall mortality was 15.2% [14/92]. The average perforation operation interval in survivors was 44.2 hours as compared to average of non-survivors- 63.9 hours [p <0.01]. Prolonged presentation time leads to a high mortality rate. Once intestinal perforation occurs, early recognition, early referral and aggressive management could decrease the high mortality

Typhoid fever and viral hepatitis.

Feco-oral route is the most common mode of transmission for both enteric fever and hepatitis A and E, and thus infection by these agents may occur concurrently especially in tropical endemic areas like India. In this scenario, there occurs a diagnostic dilemma with respect to differentiation from 'typhoid hepatitis', the hepatic manifestations of typhoid fever. We herein present such a case and discuss pertinent issues.

Enteric fever with suspected intestinal perforation and incidental renal cell carcinoma--a case report.

Enteric fever presents with protean manifestations, at times eluding the treating physician. We report the case of a 19-year-old woman whose clinical presentation suggested enteric fever, however, autopsy revealed occult renal cell carcinoma. We emphasise here, the need to investigate non-infective causes of pyrexia.

Typhoid myopathy or typhoid hepatitis: a matter of debate.

PURPOSE: The aim of the present study was to evaluate the major source of increased serum enzyme level in typhoid fever and to determine the most relevant clinical entity, hepatitis or myopathy, during typhoid fever. METHODS: A total of 118 subjects proved to have typhoid fever were evaluated for serum enzymes such as transaminases, alkaline phosphatase, lactate dehydrogenase (LDH) and creatinine kinase (CK); and their relation with each other, clinical symptoms and serum bilirubin were evaluated by regression methods. RESULTS: Hepatomegaly was revealed in 14% of the cases and was correlated with elevated serum biliribin (5.05 +/- 13.03 mg/dL in hepatomegalic subjects). Alanine aminotransferase (ALT) and CK were elevated in 22 and 60% of the cases, respectively. Correlation coefficient of CK with aspartate aminotransferase (AST) and LDH was R2 = 0.68 and 0.75, respectively, which were higher than that of ALT with that two enzymes. CONCLUSIONS: In conclusion, elevation of serum enzymes in typhoid is mostly of muscular origin.

Salmonella enterica serotype Typhi from a case of breast abscess.

Enteric fever is an acute systemic febrile infection caused by Salmonella enterica serotype Typhi. Breast abscess due to S. typhi infection is a rare sequelae. We report here a classical case of Salmonella typhi infection in a rare clinical form of a breast abscess in a non-lactating immuno-compromised female.

Splenic abscess as a complication of enteric fever.

A rare and unrecognized complication of enteric fever is splenic abscess. We report two cases of childhood enteric fever complicated by splenic abscess (one solitary and the other multiple).

Reaparición de formas graves de tifoidea: a propósito de un caso de sangrado masivo gastrointestinal / Reappearance of serious forms of typhoid: about a case of gastrointestinal massive bled

Reportamos el caso de un paciente que fue admitido por presentar un cuadro de enterorragia masiva luego de 10 días de evolución, caracterizado por fiebre persistente, cefalea global y dolor abdominal, el cual no respondió al tratamiento médico con antibióticos, transfusiones y resucitación con fluidos, requiriendo intervención quirúrgica de emergencia. Se realizó una resección intestinal con anastomosis primaria, controlando así el sangrado. Se documentó la infección con S. tiphy en los hemocultivos y en la histopatología. En América Latina esta complicación de fiebre tifoidea fue común hasta inicios de la década del 90, antes de la epidemia del cólera. Este tipo de complicación ha sido raramente vista en los últimos 15 años.

A case of a patient is reported who was admitted with massive intestinal haemorrhaging after 10 days of medical discomfort, characterized by persistent fever, headache and abdominal pain. The patient did not respond to medical treatment: antibiotics, blood transfusions and fluid replacement and required emergency surgical intervention. Intestinal resection with primary anastomosis was performed, controlling the bleeding. Following the testing of blood cultures and histopathological study infection by theS.tiphy bacteria was recorded by testing. In Latin America this strain of typhoid fever was common until the beginning of the 90´s, before the cholera epidemic and has rarely been seen in the past 15 years.

Role of proximal Tube Enterostomy in fire management of typhoid enteric perforation

Typhoid perforation continues to have significant morbidity and mortality. A variety of surgical procedures like primary repair, wedge resection, intestinal resection, ileostomy and hemicolectomy reflect lack of consensus among surgeons. Complications like wound dehiscence, burst abdomen, intra-abdominal abscesses and fecal fistula continue to be unacceptably high. Currently for solitary perforation primary repair is the most acceptable technique whereas for multiple perforations ileostomy is used. Tube enterostomy as an adjunct to primary repair in both solitary and multiple perforations is presented in an attempt to reduce above mentioned postop complications