Introduction► Typhoid fever is caused by gram –ve organism salmonella typhi also called as typhoid bacillus.► Most common in developing countries in tropics► Poor hygiene and inadequate sanitary condition attributed to entry of organism into GIT.► Surgical importance of disease is because of perforation of typhoid ulcer.
Pathology► Organisms enter into GIT through ingestion of contaminated foods and water.► In GIT organism colonize the peyer’s patches of terminal ileum causing the hyperplasia of lymphoid follicles followed by necrosis and ulceration► Microscopic picture show erythrophagocytosis with histiocytes proliferation► Ulcer may lead to perforation or bleeding if pt left untreated or inadequately treated.► Bowl may perforate several sites including large bowl also.
Clinical Features & Diagnosis► The patient present in or has recently visited an endemic areas has persistent high temperature for 2 – 3 weeks.► The pt may be toxic with abdominal distension from paralytic ileus.► Pt may have melena due to hemorrhage from typhoid ulcer, can lead to hypovolemia► Positive blood & stool culture confirm the nature of infection and exclude malaria.► Widal test also used to detect the presence of agglutinins to O & H antigens of salmonella typhi► After second week signs of peritonitis usually denote perforation confirmed by presence of free gas seen on x- ray.
Other Test To detect specific & sensitive marker of typhoid fever► Practical and cheep kits are available for rapid detection need no special expertise or equipment are 1- Multi-Test Dip-S-Ticks to detect IgG 2- Tubex to detect IgM 3- TyphiDot to detect IgG & IgM► These tests are particularly valuable when blood culture are negative (due to self medication or pre-hospital treatment with antibiotics).► These test mostly used when facilities for other test not available.
Treatment► Resuscitate with IV fluid and antibiotics in ICU to stabilize patient condition.► Cephalosporin, metronidazole & gentamicin are used in combination.► Despite of potential side effects such as aplastic anemia of chloramphenical is still used in developing countries.► Laprotomy then carried out.
Surgery► Commonest site of perforation is terminal ileum► Most appropriate surgical option depend upon general condition of the patients, the site of perforation, number of perforation & degree of peritoneal soiling.► Closure of perforation after freshening the edges, wedges resection of ulcer area and closure,► Resection of bowl area with or without anastomosis► Closure of perforation and side-to-side anastomosis► Iliostomy or colostomy where the perforated bowl is exteriorised after refashioning the edges► After closing of ilial perforating area, surgeon should also look for other sites of perforation or necrotic patches► Peritoneal lavage is essential, peritoneum should be closed and wound should be open for delayed primary or secondary intention.