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TYPHOID ILEAL
PERFORATION
DR BASHIR YUNUS
DEPT OF SURGERY
AKTH
9/1/2013
INTRODUCTION
The most common surgical complication of
typhoid fever. Remains a problem in
developing countries due to gros...
EPIDEMIOLOGY
Global incidence of typhoid fever is 21million
cases annually with 1-4% mortality
predominantly in 5-15years....
PATHOGENESIS
 The infection is caused by the
bacteria, Salmonella typhi (a gram-negative
rod found only in humans), and r...
PATHO… CT
 By the 2nd week, organisms are mopped
up from the circulation by the
reticuloendothelial system esp. the kuffe...
PATHO….CT
 The organisms are also released into the bile
through which they reach the intestine.
Invade the previously se...
PATHOLOGY
 ULCERS; shallow irregular oval ulcers disposed
longitudinally on the antimesenteric border of
the ileum esp. t...
CLINICAL FEATURES
 History of fever, 2-3weeks preceding the
onset of abdominal pain.
 Abdominal pain
 ± hematochezia pr...
GENERAL EX
 Depending on the stage of the illness
 Very ill patient
 Dehydrated
 Pale
 Pyrexia
 Wasted
9/1/2013
CVS
 Tachypnea
 Hypotension
 shock
9/1/2013
CHEST
 respiratory function is compromised by
chest infection, which is worsened by the
marked abdominal distention(if pr...
ABDOMEN
 Generalized tenderness
 Rebound tenderness
 Guarding
 Rigidity
 Diminish or absent bowel sounds
 Tenderness...
INVESTIGATIONS
The diagnosis of is often clinical, based on
Hx, features of peritonitis and investigations are
done to
 s...
 Serum electrolytes, urea, and creatinine:
↓K⁺ (Hypokalaemia is a troublesome problem),
↓Na⁺,↓Cl⁻,↓HCO₃⁻,↑Urea
 Complete...
Plain radiography:
 Chest and upper abdomen (erect film):
Some patients with intestinal perforation
present evidence of a...
 Full abdomen (erect and supine):
The intestines may show dilatation and
oedematous walls. Patients who are too sick
for ...
 Microbiological cultures:
Blood and urine, as well as an operative
specimen of intraperitoneal fluid/pus, are
cultured t...
RESUSCITATION
 Correction of fluid and electrolyte deficits:
 Nasogastric decompression
 Urethral catheter:
 Reversal ...
DEFINITIVE TREATMENT
The definitive treatment for intestinal
perforation is operative to evacuate faecal
contamination and...
SIMPLE CLOSURE
 single perforation,
 if perforations are far apart
 if the number of perforations are so numerous
that ...
RESECTION & ANASTOMOSIS
 Large solitary perforation
 Multiple perforation in close vicinity to each other.
 Adjacent bo...
ILEOSTOMY
 The perforation (if single) or the proximal
and distal ends (following segmental
resection) of the intestine a...
POST OP MGT
 Strict fluid and electrolyte mgt
 The chosen antibiotic regime(base on result of
culture) is continued post...
POST OPERATIVE
COMPLICATIONS
 Prolonged ileus
 Surgical site infection
 Abdominal wound dehiscence
 Anastomotic leakag...
 Reperforation
 Hypoproteinaemia
 Pleural effusion
 Transient psychosis
9/1/2013
PROGNOSIS
 Age of patient
 Duration of perforation before surgery
 Degree of fluid and electrolyte correction
 GI hemo...
CONCLUSION
Typhoid perforation is a challenging
surgical condition especially in
developing countries. Prompt
diagnosis, a...
REFERENCES
 Emmanuel .A Ameh., Paediatric Surgery;A
comprehensive text for Africa.
 E.A Badoe.,Principle and practice of...
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Typhoid ileal perforation

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Typhoid ileal perforation

  1. 1. TYPHOID ILEAL PERFORATION DR BASHIR YUNUS DEPT OF SURGERY AKTH 9/1/2013
  2. 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. 9/1/2013
  3. 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. 9/1/2013
  4. 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. 9/1/2013
  5. 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. 9/1/2013
  6. 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. 9/1/2013
  7. 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. 9/1/2013
  8. 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. 9/1/2013
  9. 9. GENERAL EX  Depending on the stage of the illness  Very ill patient  Dehydrated  Pale  Pyrexia  Wasted 9/1/2013
  10. 10. CVS  Tachypnea  Hypotension  shock 9/1/2013
  11. 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 9/1/2013
  12. 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. 9/1/2013
  13. 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. 9/1/2013
  14. 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. 9/1/2013
  15. 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. 9/1/2013
  16. 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. 9/1/2013
  17. 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. 9/1/2013
  18. 18. RESUSCITATION  Correction of fluid and electrolyte deficits:  Nasogastric decompression  Urethral catheter:  Reversal of hypoxia  Blood transfusion:  Antibiotic therapy: 9/1/2013
  19. 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 9/1/2013
  20. 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 9/1/2013
  21. 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). 9/1/2013
  22. 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. 9/1/2013
  23. 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 9/1/2013
  24. 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 9/1/2013
  25. 25.  Reperforation  Hypoproteinaemia  Pleural effusion  Transient psychosis 9/1/2013
  26. 26. PROGNOSIS  Age of patient  Duration of perforation before surgery  Degree of fluid and electrolyte correction  GI hemorrhage  Number of perforation 9/1/2013
  27. 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. 9/1/2013
  28. 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. 9/1/2013

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