This presentation discusses the management of the most common complication of typhoid fever.

1. DISCUSS THE MANAGEMENT OF
TYPHOID ILEAL PERFORATION(TIP)
DR ALIYU ABUBAKAR ABUBAKAR
Department of Surgery
FMC Azare, Bauchi State.
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2. SYNOPSIS
• INTRODUCTION
• STATEMENT ON SURGICAL IMPORTANCE
• EPIDEMIOLOGY
• RELEVANT ANATOMY
• AETIOLOGY
• PATHOGENESIS/PATHOLOGY
• MANAGEMENT:
• RESUSCITATION
• HISTORY
• EXAMINATION
• INVESTIGATIONS
• DEFINITIVE TREATMENT
• COMPLICATIONS
• PREVENTION
• PROGNOSIS
• DIFFERENTIAL DIAGNOSIS
• CURRENT/FUTURE TRENDS
• CONCLUSION
• RECOMMENDATION
• REFERENCES
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3. INTRODUCTION¹̛ ²̛ ³
• Typhoid fever is a common infection causing public health challenges in the
developing world.
• Lack of portable water, poor sanitation, open defecation, unsanitary well
• Typhoid intestinal perforation(most common surgical problem), causes
significant morbidity and mortality mainly due to late presentation.
• Others surgical complications: hepatic/splenic abscess, splenic rupture,
cholecystitis (±rupture, empyema), osteomyelitis, abscesses, pleural
effusion, orchitis, pancreatitis etc.
• Surgery is the gold standard treatment option after adequate resuscitation
and appropriate antibiotic cover.
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4. STATEMENT ON SURGICAL IMPORTANCE
• Being a common surgical condition in tropical and subtropical
countries, including Nigeria, the surgical intern, medical officer or
resident must at least be equipped to diagnose and optimize patient
for definitive treatment.
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5. EPIDEMILOGY 1/3³
• Globally, estimated incidence is 21million(most in the developing
world) cases annually with 1-4% mortality (WHO). Predominant age is
5-15yrs.
• Children account for over 50% of cases of typhoid intestinal
perforation (TIP).
• Perforation rate about 10% in children which increases with age to
about 30% by 12yrs.
• Children M:F is equal; adults M>F
• Has higher incidence in rainy season.³ May be low in some regions. ¹
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6. EPIDEMILOGY 2/3¹
• B. T. Ugwu et al, Surgery Dept, JUTH, North central, Nigeria, 10yr retrospective study
(1994-2003).
• One hundred and one patients with TIP; 49% children; 78% in low socio-economic status;
peak incidence 78% (Nov-March, dry season); M:F 1.9:1; mean age 19yrs; mean
hospitalization period 18days.
• Number of perforation was 167; most (72.2%) had single perforation; four involved large
bowel and appendix
• Mortality:13.9%, mostly children; prolonged perforation-surgery interval(>72hrs),
jaundice, convulsion, ASA V, fecal peritonitis, re-exploration for early intraperitoneal
complication.
• Morbidity:65.3%, mostly children, perforation surgery interval 24-72hrs, hematochezia
and multiple perforations.
• Moribund patients fared better when operated under LA with adequate analgesia.
• Least traumatic procedure=best results
• Better chances of survival: children who lived up to 5 days; adults 10 days.
• Peak incidence between November and March (dry season in Nigeria).
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7. EPIDEMILOGY 3/3²
• A. A. Shehe et al, surgery department, AKTH, retrospective 2012-2015.
• Forty seven patients, most (68.1%) were males; M:F 2.13:1; age range 15-55yrs;
mean age: 17yrs;
• Vast majority (87.2%) had single perforation; mortality 8.5%.
• Wedge excision and simple repair (95.7%)
• SSI 55.3% (Superficial 19.1%, deep 12.8%, organ/space 24,3%).
• Wound dehiscence 14.9% (superficial 2.1%, total 12.8%).
• Median duration of hospital stay 16days (4-101days).
• Mortality 8.5%; median interval between surgery and death was 19.5days (3-26
days); attributable to septic shock.
• Peritoneal aspirate volume >1000ml strongly associated with post operative
fistula.
• Postoperative fistula occurrence was significantly associated with postoperative
mortality.
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8. LOCAL DATA:• Total surgeries 29/08/19 to 29/01/20 (5months)=362 (GS, Urology, orthopedics, ophthalmology, ENT)
• TIP:72 (19.9%)
TABLE 1: Surgical emergencies in general surgery
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Emergency No. of cases Percentage (%)
TIP 72 56.3
Appendix related 10 14.1
Gastric perforation 4 3.1
ECF 7 5.5
Intestinal obstruction 12 9.3
Perforating abdominal injury 4 3.1
TB peritonitis 3 2.3
Others: burst abd, volvulus 8 6.3

9. RELEVANT ANATOMY 1/2
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10. RELEVANT ANATOMY 2/2
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• Wall: mucosa, submucosa, muscularis and serosa.
• Payer’s patches: more in the ileum; aggregation of lymphoid tissue in the mucosa around the
antimesenteric border.

11. ETIOLOGY¹²
• Salmonella enterica serovar typhi (formerly known as salmonella typhi) is
the main cause of typhoid/enteric fever.
• A pathogenic gram negative aerobic bacilli specific to humans; feco-orally
transmitted; insidious clinical course; long incubation period (median 5-9
days); systemic infection; chronic infection/carrier state; life-threatening
complications.
• Others: some strains of non-typhoidal salmonella (NTS) which includes
salmonella paratyphi A, B and C; rapid onset; short incubation period (12-
72hrs); brief duration (<10days); gastroenteritis localized to intestines and
mesenteric lymph nodes (immunocompetent pts).
• salmonella typhi is most common strain associated with TIP
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12. PATHOGENESIS/PATHOLOGY 1/3⁴
• Week 1:
• Ingestion of contaminated food/water; bacilli evade stomach acidity
• Bacteria in small intestine; multiply locally
• Pass through Peyer’s patches into blood stream (initial bacteremia; detectable in
blood) then spreads to organs.
• Sensitization of the lymphoid tissue.
• Week 2:
• Bacilli taken from circulation into the reticuloendothelial syst esp liver Kuffer cells;
multiply; necrosis of RE cells and release into circulation and bile.
• Bacteria secreted in bile; gall bladder wall: cholecystitis, empyema, rupture,
chronic carrier state.
• Invasion Payer’s patches (previously sensitized); multiply; passed in stool
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13. PATHOGENESIS/PATHOLOGY 2/3⁴
• Week 3:
• Hypersensitivity in Payer’s patches; swelling,
mucosal/submucosal/muscular layers congestion.
• Blockage of capillaries; necrosis; ulceration; bleeding/perforation.
• Salmonella bacilli may be detectable in urine.
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14. PATHOGENESIS/PATHOLOGY 3/3⁴
• ULCERS: shallow, irregular, oval, longitudinally oriented,
antimesenteric border, terminal ileum.
• Perforation : small or wide; most are single and within 45cm of
terminal ileum. Reported: jejunum, transverse colon, cecum.
• Histologically: tissue infiltrates around the perforation by
lymphocytes, macrophages and few neutrophils.
• Typhoid cells: macrophages ingesting RBCs.
• At the serosal level: acute inflammatory changes; neutrophil
predominace.
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15. MANAGEMENT
• Resuscitation
• History
• Examination
• Investigations
• Definitive treatment
• Complications
• Prevention
• Prognosis
• Differential diagnosis
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16. RESUSCITATION
• Nil per oral (NPO)
• Three tubes: IV canular, Nasogastric tube and urethral catheter.
• Fluid and electrolyte deficit correction + maintenance; K⁺
• Correction of anemia (PCV before fluid resuscitation may show
hemoconcentration)
• Antibiotics therapy:³
oQuinolone + Metronidazole
oThird generation Cephalosporin + Metronidazole
oAmoxicillin + Gentamycin + Metronidazole
oChloramphenicol + Gentamycin + Metronidazole
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17. HISTORY 1/2¹
CLASS DESCRIPTION NO. OF PATIENTS PERCENTAGE (%)
I Professional and business
men
2 1.9
II Lesser professional,
traders and teachers
3 2.9
III N Skilled non-manual e.g.
clerical staff
6 5.9
III M Skilled manual e.g.
electricians, lorry drivers
11 10.9
IV Semi-skilled manual e.g.
machine operators, farm
workers
33 32.7
V Unskilled manual to the
unemployed e.g. laborers
46 45.5
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• Biodata: age, sex, occupation
• TABLE 2: Registrar general British social classification¹

18. HISTORY 2/2¹
PARAMETER NO. OF PATIENTS PERCENTAGE (%)
Fever 101 100
Abdominal pain 101 100
Abdominal distension 93 92
Vomiting 89 88
Haematochezia 26 25.7
Dehydration 73 72
Pallor 11 10.8
Feculent gastric aspirate 15 14.9
Jaundice 10 9.9
Convulsion 6 5.9
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• Fever: typically 2-3 weeks preceding abdominal pain/distension
• TABLE 3: percentage occurrence of symptoms¹

19. EXAMINATION 1/2 ⁴
• General exam: often very ill, dehydrated (may be in shock), pale,
fever, wasted.
• Abdomen:
oDistended, minimal/nil MWR
oTenderness, rebound tenderness, guarding, rigidity
oPalpable Rt hypocondrial mass suggests an enlarged gall bladder
oDiminish/absent bowel sounds
oDRE: Rectovesical/rectouterine pouch fullness, tenderness
oBlood may be seen examining finger
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20. EXAMINATION 2/2 ⁴
• CVS: tachycardia, hypotension, shock
• RESP:
o Resp distress, tachypnoeic,
o Diaphragmatic splinting; acidosis; pneumonia
o Crepitations: pneumonia
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21. INVESTIGATIONS 1/3 ⁴
• Diagnosis can be made clinically with a high level of accuracy based
on clinical symptoms.
• Investigations may be done to:
• Support diagnosis
• Identify derangements/deficits
• Ascertain fitness for surgery
• Taking blood samples taking may be delayed until patient is
adequately resuscitated, well hydrated and making adequate urine.
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22. INVESTIGATIONS 2/3 ⁴
• Serum electrolytes, urea and creatinine: ↓K⁺, ↓HCO₃⁻, ↑Urea
• FBC: anemia, leukocytosis, neutropenia
• Blood GXM: pre-, intra- or post-op transfusion
• Plain radiograph:
oChest + upper abdomen; full abdomen.
oAir under the diaphragm (erect view); 55% of children.
oDilated loops; oedematous walls (supine view).
oLethargic patients: leteral decubitus; check for air under the anterior abd wall.
oPneumoperitonium is commonly seen but absence does not exclude
perforation.
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23. INVESTIGATIONS 3/3 ⁴
• Microbiological culture and sensitivity:
oBlood, stool and urine.
oIntraperitoneal collection/pus.
oTo identify salmonella organism or any superimposed infections.
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24. DEFINITIVE TREATMENT 1/5³
• Aim: repair perforation, evacuate peritoneal fecal contamination and
peritoneal lavage
• Laparoromy + surgical option
1. Simple repair
2. Segmental resection and anastomosis
3. Enterostomy (ileostomy)
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25. DEFINITIVE TREATMENT 2/5³
• SIMPLE REPAIR:
oSingle perforation; multiple perforation wide apart; numerous perforation
when resection can lead to short gut.
oEdge of perforation is excised and sent to the lab for histology.
oSimple closure with single or double layers.
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26. DEFINITIVE TREATMENT 3/5³
• RESECTION AND ANASTOMOSIS:
oMultiple perforations in close vicinity to each other
oFriable adjacent bowel/near perforation
oResection margin should be healthy
oA limited right hemicolectomy may be necessary if the most distal perforation
is within 3cm to ileocecal junction (ICJ)
oResected segment is sent to the lab for histology
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27. DEFINITIVE TREATMENT 4/5³
• ILEOSTOMY:
• Patient too sick or extensive intestinal oedema; simple closure or
anastomosis is unsafe
• Perforation or resected segments exteriorized as a stoma
• Reversal: 8-12wks; when oedema has subsided, patient nutritionally
stable and fit for surgery.
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28. DEFINITIVE TREATMENT 5/5
• Peritoneal lavage with copious amount of warm normal saline (principle of
dilution of contamination).
• Lavage with povidone iodine solution.¹⁰
• Drain, mentioned in some studies, may be placed. Not recommended routinely.²
• Mass closure of rectus sheath; Nylon 1.²
• Skin closure; interrupted stitches; Nylon 2/0,²
• Skin closure may be delayed in a situation of significant anterior abdominal wall
oedema; 3 days if no wound infection.³
• Skin oedema:↑wound infection, wound dehiscence and burst abdomen.³
• Gross fecal contamination/frank puss: pack with saline soaked abdominal packs;
1⁰ closure deferred until 48-72hrs; may allow secondary bowel inspection (to
repair missed perforations or reperforations).³
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29. ANESTHESIA OPTIONS¹
• General anesthesia + endotracheal tube for more clinically stable
patients.
• Analgesia + local infiltration + hyperoxygenation for moribund
patients.
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30. POST OPERATIVE CARE
• Close monitoring of vitals.
• Strict fluid management; keep input/output chart; electrolytes maintenance.
• Adequate analgesia: PCM/PENTAZOCINE; staggered dosing.
• Continue parenteral antibiotics until fever subsides; culture result may warrant change
• Post op PCV, EUCr (24hrs).
• Wound inspection 2nd day; then daily dressing.
• Commencement of graded oral sips if bowel activity returns(pass flatus/stool, bowel
sounds auscultated); remove NG tube/urethral catheter.
• Encourage early ambulation
• Good nutrition after commencement of oral intake.
• Stitch removal.
• Stoma care.
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31. POST OPERATIVE COMPLICATIONS
• SUREGERY: hemorrhage, bowel injury or viscera
• ANESTHESIA: intubation; laryngeal/vocal cords injury; chest infection.
• PRIMARY DIAGNOSIS:
o Prolonged ileus
o SSI
o Wound dehiscence
o Anastomotic leak or breakdown
o Reperforation
o Enterocutaneus fistula (ECF)
o Intraperitoneal abscess
o Hypoproteinemia
o Adhesive intestinal obstruction
o Malnutrition/hypoproteinemia
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32. PREVENTION 1/2⁹
1. PRIMARY: targeted at general population with special attention to
healthy individuals.
a. General health promotion: to prevent onset of illness through healt education,
sanitation, personal and food hygiene, adequate portable water, curtail open
defecation.
b. Specific prophylaxis: typhoid vaccination
2. SECONDARY: targeted at sick individuals
• Early diagnosis and treatment to prevent further damage and spread.
3. TERTIARY: treatment of complication
a. Limiting damage: surgical intervention for TIP
b. Rehabilitation: e.g. nutritional rehabilitation extremely sick and malnourished
patients after surgical intervention; prior to ileostomy reversal
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33. PREVENTION 2/2⁶
• Vaccination:
oOlder, parenteral whole-cell vaccine resulted in significant local and systemic
infections
oNewer vaccines:
1. Parenteral capsule polysaccharide vaccine; confers immunity 7-10days of inoculation;
booster dose in 3yrs.
2. Oral live attenuated vaccine; multiple doses required; moderately immunogenic.
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34. PROGNOSIS
GOOD PROGNOSTIC FACTORS POOR PROGNOSTIC FACTORS
1. Early presentation
2. Initial antibiotic treatment
3. Short perforation-surgery interval
4. Simple closure
5. Long post-op days(children 5, adults 10)
1. Multiple perforations
2. Copious peritoneal collection(>1000mls)
3. Gross fecal contamination
4. Abscess collection
5. End-to-end anastomosis
6. Development of fistula
7. Burst abdomen
8. Re-exploration
9. Convulsion
10. Jaundice
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TABLE 3: Prognostic factors in TIP

35. DIFFERENTIALS
• Mainly are the causes of generalized peritonitis
oGastric perforation ( PUDx, Gastric Ca)
oDuodenal perforation (PUDx)
oPerforated appendix
oSealed TIP
oBowel ischemia: volvulus, intussusception,
oTB peritonitis
oDisseminated malignancy: liver
oSpontaneous bacterial peritonitis
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36. FOLLOW UP
• 2wks, 4-6wks, 3months
• Op-site inspection
• Incisional hernia
• MCS for chronic carrier state: stool/bone marrow
• Optimization of nutritional status: weight; serum proteins.
• Prepare for: ileostomy reversal, incisional hernia repair.
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37. RECOMMENDATION
• Restoration of hydration status before sample collection.
• Patient optimization before surgery.
• Surgery under local infiltration + adequate analgesia +
hyperoxygenation for moribund patients.
• Delay primary skin closure when significant skin oedema present
• Putting drain in selected patients (frank puss in the peritoneum)
• Center based studies.
• Ensure recording of all operated patients in the operation register.
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38. CURRENT/FUTURE TRENDS¹¹
• Progress in the last five decades has provided opportunities for the
patient with patient with once dreaded TIP to recover from the
disease.
• Mortality however, continues to be high in the West African sub-
region because of suboptimal quality of care.
• Future investments must center on prevention of typhoid fever and
perforation because they are achievable, cheaper and safer than cure.
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39. CONCLUSION
• TIP, most dreaded surgical complication of the infection, is diagnosed
clinically based on fever, abdominal pain/distension and
demonstrable peritonitis, surgery is the definitive treatment after
adequate resuscitation and appropriate antibiotics cover.
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40. APPRECIATION
• PRAISE IS DUE TO THE ALMIGHTY FOR ALL THE INNUMERABLE
BLESSINGS ESPECIALLY OF HEALTH, WEALTH AND KNOWLEDGE.
• SPECIAL APPRECIATION TO DR SANI ABDULLAHI GIADE
• DR AYINDE AYOBAMI MUSLIU
• DR UMAR ALHAJI INUWA
• THANK YOU ALL FOR LISTENING
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41. REFERENCES
1. B.T. Ugwu, S.J. Yiltok, A.T. Kidmas, A.S. Opaluwa, Typhoid intestinal perforation in North central Nigeria,
online.
2. Abdurrahman A. S., LJC Anyanwu, Aminu M. M., Abubakar B. M., Stephen K. O, Typhoid intestinal
perforation: analysis of the outcome of surgical treatment in kano, Nigeria. amhsjournal.org
3. Emmanuel A. Ameh., Paeditric Surgery; A comprehensive text for Africa.
4. Bashir Yunus., Typhoid Ileal perforation, Surgery Department, AKTH, SlideShare ppt.
5. E. A. Badoe., Principle and practice of surgery including pathology in the tropics. 4th Ed.
6. Surgery in Africa-monthly review, typhoid fever
7. Nguyen Q.C., Paul E., Tran Tan Khoa, A clinical, Microbiological and Pathological study of intestinal
perforation associated with typhoid fever, online.
8. Abdurrahman Onen, Ali Ihsan Dukucu, Factors effecting morbidity in typhoid intestinal perforation in
children, online.
9. Adetokumbo O. Lucas, Herbert M. Gilles, a short textbook of public health medicine for the tropics.
10. Bapat RD, Supe A N, Sathe M J. Management of small bowel perforation with intra- and post-operative
lavages with povidone iodine (A prospective study). J Postgrad Med [serial online] 1983 [cited 2020 Jan
29];29:29-33. Available from: http//www.ipgonline.com/text.asp?1983/29/1/29/5559
11. AY Ukwenya, A Ahmad, ES Garba, Progress in management of typhoid perforation, Department of
surgery, Ahmadu Bello University Teaching hospital, Zaria, Annals of African Medicine.
12. Manuella R, Paul Wilson R, Sebastian E, Andreas JB, Clinical pathogenesis of typhoid fever, Review
Article, Department of Medical Microbiology, School of Medicine, University of California at Davis, USA.
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