Typhoid Fever

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enteric fever, typhoid fever, surgical complications

enteric fever, typhoid fever, surgical complications

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  • 1. TYPHOID Surgical Complications *DR. MANSOOR KHAN 28 th Oct, 2009 * Resident Surgical “C”, KTH, Peshawar
  • 2. Salmonella a formidable killer! TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications
  • 3. “ Potentially fatal, multi-systemic illness caused primarily by Salmonella typhi and paratyphi ”
  • 4. Typhoid---ancient Greek Typhos, smoke or cloud that was believed to cause disease or madness
  • 5. S. typhi, a major human pathogen for thousands of years , thriving in conditions of poor sanitation , crowding , and social chaos
  • 6. 430–426 B.C. Killed 1/3 of the population of Athens , including their leader Pericles . The power shifted from Athens to Sparta . 2006 study detected DNA sequences similar salmonella
  • 7. Antonius Musa A Roman physician who achieved fame by treating the emperor Augustus with cold baths when he contracted typhoid
  • 8. Thomas Willis (1621-1675) The first description of epidemic Typhoid in 1659
  • 9. Carl Joseph Eberth (1835-1926) Discoverer of the typhoid bacillus in 1880
  • 10. Georges Fernand Isidor Widal (1862-1929) Demonstrated specific agglutinins in the blood of Typhoid patient in 1896---- “ The Widal Reaction”
  • 11. History of typhoid epidemics
  • 12. DISTRIBUTION
  • 13. Infects roughly 21.6 million people each year * International Estimate Ramsden AE, Mota LJ, Münter S, Shorte SL, Holden DW. The SPI-2 type III secretion system restricts motility of Salmonella-containing vacuoles. Cell
  • 14. Kills 200,000 people each year * International Estimate Ramsden AE, Mota LJ, Münter S, Shorte SL, Holden DW. The SPI-2 type III secretion system restricts motility of Salmonella-containing vacuoles. Cell
  • 15. 62% of these occurring in Asia and 35% in Africa * International Estimate * Taylor TE, Strickland GT. Malaria. In: Strickland GT, ed. Hunter’s Tropical Medicine and Emerging Infectious Diseases. 8th ed. Philadelphia: WB Saunders, 2000:614-43.
  • 16. Highest in Pakistan & India in Asian countries (451.7 per 100,000) * WHO Estimate * Bull World Health Organ vol.86 no.4 Genebra Apr. 2008
  • 17. S P R E A D
  • 18. TYPHOID BLACK HAND
  • 19. Best prevention Scrub of them off your hands Best prevention Scrub them off your hands
  • 20.  
  • 21. Bacteria are better scientists than we are War of survival—they are working out very hard
  • 22. RISK FACTORS
  • 23. S. typhi are able to survive a stomach pH as low as 1.5 . Antacids , (H2 blockers), PPI’s, gastrectomy, facilitate S typhi infection TYPHOID FEVER RISK FACTORS
  • 24. Contaminated food, House hold with Cases, Inadequate hand washing, , drinking unpurified water, and living without a toilet Environmental/behavioral risk factors TYPHOID FEVER RISK FACTORS
  • 25. PRESENTATION Incubation period is 7-14 days
  • 26. FIRST WEEK TEMPERATURE PATTERN
  • 27. Diffuse abdominal pain , Inflamed Peyer patches narrow the lumen-- Constipation . Dry cough, dull frontal headache , delirium, increasingly Stupor & malaise FIRST WEEK OTHER SYMPTOMS
  • 28. Rose spots , blanching, truncal, maculopapules usually 1-4 cm wide, < 5 in number; these generally resolve within 2-5 days ( bacterial emboli to the dermis ) FIRST WEEK OTHER SYMPTOMS
  • 29. Distended abdomen, Soft splenomegaly , Relative bradycardia & dicrotic pulse (double beat, the second beat weaker than the first) SECOND WEEK
  • 30. Patient may descend into the typhoid state- --apathy, confusion, and even psychosis THIRD WEEK TYPHOID STATE
  • 31. Necrotic Peyer patches, bowel perforation, Peritonitis, intestinal hemorrhage may cause death THIRD WEEK Week of complications
  • 32. Fever, mental state, and abdominal distension slowly improve over a few days, complications may still occur in surviving untreated individuals FOURTH WEEK WEEK OF CONVALESCENCE
  • 33. COMPLICATIONS Immunity, antacids, vaccination, previous exposure, virulence, inoculum, choice of antibiotics
  • 34. GENERAL COMPLICATIONS
  • 35. Bilateral Salmonella typhi breast abscess unmarried 35-year-old female without any predisposing conditions Singh S, Pandya Y, Rathod J, Trivedi S. Bilateral breast abscess: A rare complication of enteric fever. Indian J Med Microbiol [serial online] 2009 [cited 2009 Oct 16];27:69-70. Available from:  http://www.ijmm.org/text.asp?2009/27/1/69/45176
  • 36. MEDICAL COMPLICATIONS
  • 37. MAJOR SURGICAL COMPLICATIONS
  • 38. MAJOR SURGICAL COMPLICATIONS
  • 39. Morbidity 55.4% mortality 28.5 % INTESTINAL PERFORATIONS 5% of people with typhoid fever experience this complication DS00538 April 10, 2008© 1998-2009 Mayo Foundation for Medical Education and Research (MFMER). Typhoid enteric perforation, Dr Y. Akgun *, B. Bac, S. Boylu, N. Aban, I. Tacyildiz, British Journal of Surgery Volume 82 Issue 11,  Pages 1512 - 1515 Published Online: 8 Dec 2005
  • 40. Ileum especially distal ileum , jejunum usually does not perforate in typhoid, usually happens in the third week
  • 41. MECHANISM OF INTESTINAL PERFORATION Intestinal peyer’s patches
  • 42. 2 or 3 weeks hx of disease, with suddenly worsening of pain & general conditions , Tenderness starts in his right lower quadrant, spreads and eventually becomes generalized, Guarding , (seldom the board-like rigidity) Erect film, shows gas Under diaphragm (50% positive) lateral decubitus film, shows gas under his abdominal wall The bradycardia and leucopenia of typhoid may occasionally mask the tachycardia and leucocytosis of peritonitis PRESENTATIN PERFORATION
  • 43. PATIENT PERFORATION
  • 44. If peritonitis seems to be localized , signs confined to only part abdomen, general condition is good , patient not deteriorating , consider non-operative treatment . If signs of generalized peritonitis, do a laparotomy CONSERVATIVE SURGICAL VS
  • 45. “ Suck and drip” Resuscitation, antibiotics, pass a NG-tube, Monitor abdominal tenderness, pulse, temperature, white blood count. If any of these rise, suspect that peritonitis is extending, so take an erect X-ray film of his abdomen CONSERVATIVE MANAGEMENT
  • 46. MDR-area MDR+NAR-area MEDICATION TREATMENT WHO RECOMMENDATIONS
  • 47. Do not forget to cover anaerobes and gram negative bacteria along with salmonella
  • 48. Operate as early as possible , Do as much as necessory & as little as possible SURGICAL MANAGEMENT PREPARATION Adequately resuscitate, Maintain good urine output, pass nasogastric tube down, Start chemotherapy.
  • 49. *Agbakwuru EA, Adesunkanmi AR, Fadiora SO, Olayinka OS, Aderonmu AO, Ogundoyin OO et al A review of typhoid perforation in a rural African hospital. West African Journal of Medicine 2003; 22(1):22-25. (13 kb) Abstract only Surgery Steps
  • 50. Surgery Steps
  • 51. Surgery Steps
  • 52. Surgery Steps
  • 53. CLOSE THE ABDOMEN Completely Without drains Drains are counter productive Surgery Steps
  • 54. POSTOPERATIVELY
    • Fever usually subsides in 4 or 5 days
    • Nourish patient as early as possible
    • ICU care and monitoring
    • Continue chemotherapy 14days
  • 55. S P E C I M E N S John Hunter (1728-1793)
  • 56. INTESTINAL HEMORRHAGE Occurs in 10-20 per cent of the cases
  • 57. Intestinal bleeding is often marked by a sudden drop in blood pressure and shock, followed by the appearance of blood in stool Hemorrhage presentation
  • 58. replace the blood loses. Bleeding usually stops spontaneously Only operate if bleeding is persistent, or alarmingly INTESTINAL HEMORRHAGE
  • 59. Surgery Intestinal Hemorrhage
  • 60. TYPHOID CHOLECYSTITIS
  • 61. Occurs in 1-2% of cases *According to Indian study 8% More common in children Antibiotic resistance & virulence of bacteria *M.L. Kulkarni, SJ. Rego, Department of Pediatrics, J.J.M. Medical College, Davangere 577 004. Acute Acalculous Cholecystitis TYPHOID
  • 62. *Thickened gall bladder wall, sonographic Murphy's sign, pericholicystic collection in the absence of gall stones *Subha Rao SD, LewinS, Shetty B, et al. Acute acalculous cholecystitis in typhoid fever. Indian Pediatr 1992, 29: 1431-1435. Acute Acalculous Cholecystitis TYPHOID
  • 63. Unlike other AACs, antibiotic therapy is the recommended treatment for Typhoid AAC Acute Acalculous Cholecystitis TYPHOID
  • 64. Chronic Cholecystitis (Carriers) TYPHOID Excretes bacteria in stools for more > 1 year1-4% of non-treated infected patients become chronic carriers Patients with cholelithiasis, biliary anomalies, females, Salmonella can be cultured from stools, duodenal aspirate, gall stones
  • 65. Mary Mallon (September 23, 1869 – November 11, 1938) Forcibly quarantined twice, she infected 47 people , three of whom died . She died in quarantine.
  • 66. Biliary anomalies, stones--requires cholecystectomy + antibiotics 4-6 weeks antibiotic treatment Chronic Cholecystitis TYPHOID
  • 67. MAJOR SURGICAL COMPLICATIONS
  • 68. MAJOR SURGICAL COMPLICATIONS
  • 69. Typhoid Enteric Perforation: Prognostic Factors an Experience with 76 Patients J Ayub Med Coll AbottabadJan - Mar 2000;12(1):49-52.Department of Surgery, Khyber Teaching hospital, Peshawar
  • 70.  
  • 71. Arkadiy Stavrovskiy , Typhoid. 1932 Oil on canvas
  • 72. OIL ON CANVAS
  • 73. Ty21a —Oral live attenuated vaccine
  • 74. Vi-CPS — parenteral vaccine
  • 75. Good food handling & water sewage treatment can eliminate typhoid Prompt anntibiotic therapy can save many lives—take it a serious job Severe vomiting, diarrhoea & abdominal distension--- complicated, admit them & give IV antibiotics and support Prognosis of complications depends on the time-lapse b/w onset & treatment TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications TYPHOID Surgical Complications take home message killer salmonella formidable
  • 76. w w w . s l i d e s h a r e . c o m