TYPHOID

PERFORATION
Presented by Dr Ajayi A. O.
OUTLINE

■ INTRODUCTION
■ BRIEF HISTORY
■ PATHOGENESIS
■ CLINICAL SIGNS AND SYPMTOMS
■ LAB INVESTIGATION
■ MEDICAL MANAGEMENT
■ SURGICAL MANAGEMENT
INTRODUCTION

■ TYPHOID DISEASE
■ Complication of enteric fever of surgical importance are still common in most tropical
countries:
■ 1. many patients seek help late with with abuse of chemotherapy
■ 2. Chloramphenicol despite Rapidly curative, has been gradually phased out
■ Typhoid disease may prove to be a diagnosis challenge as it can present as acute
appendicitis , progress to acute intestinal haemorrhage, simulate acute meningitis cause
acute abdomen with perforation and fanaliy in convalescence continue to smoulder as
an orchitis, chronic cholecystits, arthritis or osteomylitis
■ TYPHOID PERFORATION
■ It an important complication of enteric fever in many tropical countries where reported incidence
rises up to about 20% of adult cases. it accounts for 40-50% of deaths in typhoid and is also
responsible for up to 20% of cases of peritonitis excluding salpingitis.
■ classical form the perforation occurs in the third week of the illness . In tropical countries early
perforation is the rule usually at the end of the first week of illness. The high incidence of typhoid
perforation in some localities has not been explained. In- creased salmonella virulence and
decreased host resistance have both been considered.
■ In late perforation eply some endemic areas the perforations occur in the first week when the blood
cultures are positive and the Widal tests negative. Most patients are between 5 and 40 and only 5%
are over 40; a third are in the second decade. The male : female ratio of 3: 1 is a reflection of the
sex incidence of enteric fever.
CLINICAL SIGNS AND SYPMTOMS

■ . Typhoid Perforation
■ i) The patient has usually been ill for some days with general malaise, headache, fever
and diarrhoea and occasion- ally he is in hospital with typhoid fever.
■ ii) There is then a sudden onset of abdominal pain most marked in the lower abdomen.
■ iii) The abdomen is usually moderately distended with generalized tenderness and
guarding or rigidity which may be most marked in the lower abdomen or right lower
abdomen.
■ iv) A plain X-ray of the abdomen may show gas under the diaphragm. Often times
typhoid perforation &d acute appendicitis can only be differentiated at operation.
Pathogenesis

■ Typhoid fever affects the haemopoietic system and espe- cially the Peyer's patches of the ileum,
abdominal nodes and spleen. The lymphoid follicles of the intestine and the subjacent submucous
and muscular layers are at first congested and swollen with hyperplastic plasma cells and
mononuclears. Blockage of their capillaries leads to their necrosis and development of shallow
ulcers which because of the disposition and site of the follicles are irregularly oval in shape, are
found longitudinally directed on the anti-mensenteric border and are most abundant towards the
terminal ileum
■ Seperation of the slough may lead to severe hemorrhage or perforation of the wall. The perforation
may be small or wide, up to 2.5cm.
■ Perforation are multiple in 20% of patient and most are within 45cm of the ileo-caecal junction.
■ Perforation leads to ilea content with bacteria E. coli leak into the peritoneal cavity causing
generalized peritonitis
Signs and symptoms

■ It is dependent on recognition of the clinical syndrome with a minimum of

confirmatory investigation. The diagnosis of enteric fever may be difficult enough but
to establish that perforation has occurred may be even more exacting, Patients present
with:
■ Headache, joint pain, high fever and associated abdominal pain.
■ Signs of abdominal tenderness and gurding or rigidity. However this classical signs
maybe abscent due to extreme Toxaemia.
■ The first indication of perforation can be doughy and tender or discovery of free fluid in
the peritoneum
Signs and symptoms

■ Vomiting or increase rate of vomiting occur at the first incidence of perforation

■ Bowel sound may be absent but this sign is not. May be of little importance as there is
some degree of ileus in toxic typhoid patient
■ Present of reduce liver dullness may be notice due to typanitic percussion node
■ The four quadrant peritonea1 tap is often rewarding in doubtful cases by yielding a
confirmatory bile-stained peritoneal fluid.
LAB INVESTIGATION

■ Diagnostic X-rays of the abdomen may show Gas under the diaphragm can only be
expected in 80% of cases.
■ Diagnosis of perforation is usually difficult in two categories of patients.
(a) a small group of patients who perforate under medical care and
(b) patients with protracted illness reaching hospital several days after perforation.
In the former group the signs of perforation are in abeyance because of the insidious
development of perforation; in the latter group gross abdominal distention overshadows the
other signs of perforation.
Principles of management

■ treatment was essentially non-operative consisting of

1. maintenance of fluid and electrolyte therapy
2. initial resuscitative measures with specific chemotherapy,
3. adequate parenteral nutrition
4. other supportive measures.