DR BASHIR YUNUS
DEPT OF SURGERY
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
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.
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
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.
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.
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.
History of fever, 2-3weeks preceding the
onset of abdominal pain.
± hematochezia prior to onset of pain
Diarrhea or constipation.
± jaundice may be a complaint.
Depending on the stage of the illness
Very ill patient
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
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.
The diagnosis of is often clinical, based on
Hx, features of peritonitis and investigations are
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
Serum electrolytes, urea, and creatinine:
↓K⁺ (Hypokalaemia is a troublesome problem),
Complete blood count:
anaemia. , leucocytosis and neutrophilia
Blood grouping and cross matching:
For correcting anaemia or intraoperative use.
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
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.
Blood and urine, as well as an operative
specimen of intraperitoneal fluid/pus, are
cultured to identify
the Salmonella organism and any
Correction of fluid and electrolyte deficits:
Reversal of hypoxia
The definitive treatment for intestinal
perforation is operative to evacuate faecal
contamination and prevent further
LAPAROTOMY + SURGICAL OPTIONS;
Simple closure of perforations
Segmental resection of affected intestine
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
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).
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
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
Surgical site infection
Abdominal wound dehiscence
Anastomotic leakage or complete
breakdown of the anastomosis
Adhesion intestinal obstruction
Age of patient
Duration of perforation before surgery
Degree of fluid and electrolyte correction
Number of perforation
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.
Emmanuel .A Ameh., Paediatric Surgery;A
comprehensive text for Africa.
E.A Badoe.,Principle and practice of
surgery; Including pathology in the tropics.
Indian journal of clinical practice,
Vol.12,No.10, March 2002.
Nelson Awori., Primay surgery Vol. 1online